NURS418 - Module 4 DB NCLEX Questions
The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation c. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury
C rationale A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection.
Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and a mask or face shield
4 Rationale: Splashes of body secretions can occur when provid ing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precau tions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary. Test-Taking Strategy: Focus on the subject, protective items needed to perform colostomy care. Also, note the words contact precautions. Visualize care for this client to determine the necessary items required for self-protection I This will direct you to the correct option.
Which of the following is the FIRST priority in preventing infections when providing care for a client? a. Handwashing b. Wearing gloves c. Using a barrier between client's furniture and nurse's bag d. Wearing gowns and goggles
Answer & Rationale: The answer is A. Handwashing is the most effective way to avoid the spread of pathogens. Our hands contain many microorganisms that we don't see. It is the common mode of transmission for many infections, such as the common cold. B, C, and D are all measures that could prevent infections, but it is not the FIRST action a nurse should do. Nurses should always wash their hands or use an alcohol based sanitizer if permitted, when entering and exiting a patient's room. It is also important to teach familiy and visitors the importance of hand hygiene as well.
Which of the following is the FIRST priority in preventing infections when providing care for a client? a. Handwashing b. Wearing gloves c. Using a barrier between client's furniture and nurse's bag d. Wearing gowns and goggles.
Answer & Rationale: The answer is A. Handwashing is the most effective way to avoid the spread of pathogens. Our hands contain many microorganisms that we don't see. It is the common mode of transmission for many infections, such as the common cold. B, C, and D are all measures that could prevent infections, but it is not the FIRST action a nurse should do. Nurses should always wash their hands or use an alcohol based sanitizer if permitted, when entering and exiting a patient's room. It is also important to teach familiy and visitors the importance of hand hygiene as well
Which patients should be placed in droplet precautions? (SELECT ALL THAT APPLY) A. A 5 year old patient with Chicken Pox. B. A 36 year old patient with Pertussis. C. A 25 year old patient with Scarlet Fever. D. A 56 year old patient with Tuberculosis. E. A 69 year old patient with Streptococcal Pharyngitis. F. A 89 year old patient with C. Diff.
Answer and Rationale: Answers: B, C, E. Rationale -Patients with Pertussis (Whooping Cough), Scarlet Fever, and Streptococcal Pharyngitis are to be placed in droplet precautions. Patients with TB are to placed in airborne precautions while a patient with Chicken Pox should be place in both airborne and contact precautions. Patients with C. Diff are to be placed in contact precautions. Remember that Droplet transmission occurs when a pathogen is spread with a spray or splash of infectious microorganisms which can occur with coughing and sneezing for example. Airborne transmission occurs when the pathogen is carried in dust or droplets in the air. Measles is an example of a virus that is transmitted with the airborne mode of transmission.
The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1.A pregnant woman who exclaims, "My baby is not moving." 2.A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."
Answer-1, Rationale: A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.
A 76-year-old client lives alone at home. Which of the following is the highest priority question for his home health nurse to ask regarding his safety? A."Do you use soft glow light bulbs in your front room lamps?" B." At what temperature is your thermostat set?" C."Why don't you consider selling your two-story home and buying a house without stairs?" D."Do any of your medications cause you to be physically unsteady?"
Answer: - D Rationale - Some medications cause dizziness, and it is always good to know the side effect of the patient's medication. The patient/ caregiver must be aware to avoid falls and further injuries.
The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.
Answer: 2 Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.
The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients' clothing and have them shower. 4. Assume the clients have been decontaminated at the plant.
Answer: 3 Rationale: In most situations this is the first step, but with a potential chemical or biological exposure, the first step must be the safety of the hospital; therefore, the client must be decontaminated. This is the second step in the decontamination process. This is the first step. Depending on the type of exposure, this step alone can remove a large portion of exposure. This assumption could cost many people in the hospital staff, as well as clients, their lives.
The nurse caring for a confused patient with an IV catheter. The patient habitually tugs at the IV tubing with his left hand and has almost dislodged it. What is the LEAST amount of restraint that will still maintain the patient's safety? A. Safety "mitt" for the left hand. B. 2-point restraints on the arms only. C. Safety "mitts" for both hands. D. 4-point restraints for maximum safety.
Answer: A Rationale: A safety "mitt" still allows for movement of the arm but negates the patient's ability to grasp the IV tubing and disrupt it. This is the least restrictive method that will still maintain patient safety.
The nurse reviews the use of incident reports with a novice nurse. Which example requires an incident report to be completed? (Select all that apply) A. The health care provider prescribes ampicillin 900mg, the client is administered 1000mg. B. Vancomycin hydrochloride is infusing via a peripheral IV line, and the IV site becomes red and swollen. C. Famotidine is scheduled to be administered at 0900, and the client receives famotidine at 1130 due to pharmacy delay. D. A left knee arthroscopy is scheduled, but a right knee arthroscopy is performed E. An unlicensed assistive personell (UAP) falls due to a liquid spill on the floor
Answer: A, B, C, D, E. Rationales A. Too much ampicillin was given, an incident report should be completed, a patient may be harmed B. the IV site has become red and swollen, this should be report, file and incident report C. Famotidine medication was not administered in a timely manner, an incident report needs to be completed because this could impact patient's progress D. An incident report is required for surgery performed on a wrong extremity, affects patient's health directly. E. UAP falling results in injury, even when there is no injury, an incident report is required.
A nurse manager is reviewing guidelines for preventing injury with staff nurses. which of the following instructions should the nurse manager include? (select all that apply) A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements during lifting and moving clients E. take a break from repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles.
Answer: A, B, D. To reduce the risk of injury, at least 2 staff members should reposition clients. Twisting the spine or bending at the waist (flexion) increases the risk for injury. Using smooth movements instead of sudden or jerky muscle movements helps prevent injury.
The joint commission issues a guidelines regarding the use of restraints. In which case is a restraint properly used? A) the nurse positions a pt. in a supine position prior to applying wrist restraints. B) the nurse ensures that two fingers can be inserted between the restraint and the patient's ankle. C) the nurse applies a cloth restraint to the L hand of a patient with an IV catheter in the R wrist. D) the nurse ties an elbow restraint to the raised side rail of a patient's bed.
Answer: B - nurse ensures that two fingers can be inserted between the restraint and the patient's ankle. Rationale: The nurse should be able to place two fingers between the restraint and patient's ankle to ensure that the restraint is not too tight affecting circulation or impairing skin integrity. Placing a patient supine with restraints may cause them to aspirate. Placing a cloth restrint on the L hand when the IV is on the R does not protect the tubing. Securing a patient's restraint to the side rail may injure the patient when the side rail is pulled down.
The nurse plans to educate the patient on how to ensure home safety. Which modes of teaching will be effective to the client that is strictly Spanish-speaking? (SATA) A. English-written home safety instructions B. Spanish translated written home safety instructions C. Documents with photos of common household safety items D. A list local important emergency phone numbers
Answer: B, C, D Rationale: English written documents will require further translation. All the other options will be much easier in understanding.
A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe aspects of this procedure? Select all that apply a. An incident report is used as disciplinary action against staff members. b. An incident report is used as a means of identifying risks. c. An incident report is used for quality control. d. The facility manager completes the incident report. e. An incident report makes facts available in case litigation occurs. f. Filing of an incident report should be documented in the patient record.
Answer: B, C, E Answer A is not correct because that would deter nurses and staff members from reporting an incident report. B and C is correct because incident reports are used to identify trends and weaknesses that researchers can develop new protocols to prevent these kinds of incidents in the future. D is incorrect because the nurse needs to complete the incident report. E is correct because an incident report should include as much information possible about the incident in case it needs to be presented in court. F is incorrect because an incident report is not documented in the patient record since it is kept confidential.
A nurse is caring for a morbidly obese patient with limited mobility. The patient needs to be moved to a chair by the side of the bed. How should the nurse proceed in an ideal situation? A- Find the strongest tech to help and the two will attempt to move the patient. B- The nurse should put a gait belt on the patient to aid in the transfer. C- The nurse should use a mechanical lift to move the patient. D- The nurse should clock out and call it a day.
Answer: C Rational: A patient who is morbidly obese with limited mobility should be moved with a mechanical lift for the safety of all involved.
In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents? A. Being aware of the signs and symptoms of potential agents of bioterrorism B. Making ethical decisions regarding exposing self to potentially lethal substances C. Being aware of the agency's emergency response plan D. Being aware of what and how to report to the Centers for Disease Control and Prevention
Answer: C Rationale: In disaster preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities, and mechanisms of reporting. Emergency preparedness encompasses diverse fields within the hospital and regional settings.
Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. A. Hire only competent nurses. B. Improve the nurse's ability to multitask C. Establish a reporting system for "near misses." D. Communicate effectively E. Create a culture of trust
Answers: C, D, E Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. By reviewing this information, the system can be reviewed to make adjustments in preventing these near misses. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. A & B are inappropriate answers. Even a competent nurse can make medication errors.
A client with a fractured hip needs to be transferred to the radiology unit for an x-ray. Which of the following actions should the RN take first to transfer the client? A. Ask the client's significant other to transfer them. B. Lower the client's bed to the lowest setting. C. Assess the client's strength and mobility. D. Arrange the stretcher next to the client's bed.
Correct Answer: C. Assess the client's strength and mobility. Rationale: C is the correct answer because assessment is the first step in the nursing process. By assessing the client's strength and mobility, the RN is able to decide which method of transfer would put the patient at least risk for harm and would also utilize the client's strength and mobility to assist with the transfer so that it is also not straining to the RN. A is incorrect because it is the RN's responsibility to transfer the client. B and D are incorrect because the RN needs to assess the client before determining how they will transfer the client.