Safety Quiz

The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother?

Complete the hospital identification procedure with mother and infant. The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

What is the main advantage of using a floor stock system?

A nurse can implement medication orders quickly A floor stock system enables a nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

Which client statement indicates the need for further teaching about percutaneous umbilical blood sampling (PUBS) to assess fetal hemoglobin and hematocrit?

"I will lie on my back in a cylinder-type machine." With PUBS, the client is scanned with an ultrasound, and a spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant. The client will not be placed in a cylindrical unit; this type of unit is used for magnetic resonance imaging. Transient fetal bradycardia is possible following this procedure. PUBS may be used for a fetal blood transfusion. With PUBS, the client is scanned with a linear-array ultrasound placed in a sterile glove, and a 25-gauge spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant.

Safety Quiz Question 3: The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. The client asks, "Can my spouse visit me?" Which response is correct?

"Yes, as long as your spouse wears a mask and stays at least 3 feet (1 meter) away from you." The client's family can visit and must use personal protective equipment (PPE). PPE should be worn when entering the room for all interactions that may involve contact droplet precautions with the client and potentially contaminated areas in the client's environment. Keep visitors 3 feet (1 meter) from the infected person. The client is not going to infect the community because the interaction is occurring in the health care setting. The spouse can visit using PPE as long as the spouse stays 3 feet (1 meter) from the client. PPE are provided to protect anyone visiting including hospital personnel.

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease?

Signs of kernicterus Neonates with an Rh and ABO incompatibility are likely to develop severe jaundice as a result of rising bilirubin. If bilirubin levels are high enough to cross the blood-brain barrier (usually 20 mg and higher), the neonate is at serious risk for neurologic impairment caused by permanent cell damage (kernicterus). Other findings in hemolytic disease include lethargy or irritability, poor feeding patterns, including vomiting, and possible weight loss of greater than 10%.

Safety Quiz Question 1: Of all possible nursing interventions to break the chain of infection, which is the most effective?

practicing hand hygiene Practicing hand hygiene is the most effective way to help prevent the spread of organisms. Nurses need to focus on this simple procedure that can interrupt the cycle of infection.

A woman who is in the second trimester of her first pregnancy has been experiencing frequent headaches and has sought advice from her nurse practitioner about safe treatment options. What analgesic can the nurse most safely recommend?

Acetaminophen Acetaminophen is the analgesic of choice during pregnancy.

Safety Quiz Question 5: Which of the following statements about glove use and hand hygiene is true?

Artificial fingernails should not be worn by staff involved in direct patient care. The CDC Guideline for Hand Hygiene in Health-Care Settings (2002) specifies that healthcare personnel involved in patient care should not wear artificial nails because they are more likely to be associated with higher bacterial counts.

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.

A client who is 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?

Dehydration Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis.

A nurse is monitoring the effectiveness of a client's drug therapy. When should the nurse obtain a blood sample to measure the trough drug level?

Immediately before administering the next dose Measuring the blood drug concentration helps the nurse determine whether the dosing has achieved the therapeutic goal. To measure the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose.

Safety Quiz Question 4: The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?

Open a new sterile dressing kit The nurse's next action is to obtain a new sterile dressing kit before continuing with the dressing change procedure. Continuing the dressing change without obtaining a new kit would increase the client's risk for infection. The client's hands do not need to be cleansed after touching the contents of the kit, and it would be inappropriate to restrain the client's hands (unless the client is unaware of the event or has trouble remembering what is occurring).

What information must a medication order include?

Physician's signature A medication order must include a physician's signature. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions aren't components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

Which of the following is a disadvantage to using the IV route of administration for analgesics?

Short duration Disadvantages of using the IV route for analgesic administration include short duration, the occurrence of possible respiratory depression, and that careful dosage calculations are needed. Intramuscular analgesics have a slower entry into the bloodstream.

Safety Quiz Question 2: The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?

Stop and obtain appropriate PPE. The nurse should stop the task and obtain the appropriate protective wear. Protective equipment should be left outside of the room so that it can be donned prior to entering. Completing the task without the appropriate equipment can contaminate the nurse, which can lead to cross-contamination on the unit. Asking a colleague to finish the task is inappropriate.

When a hospitalized client requires contact precautions, which responses is necessary?

The client should be placed in a private room when possible. When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed, doors do not need to be closed, and a room with negative air pressure is not required.

Which of these age groups has the highest actual rate of death from drowning?

Toddlers Toddlers and older adolescents have the highest actual rate of death from drowning.

Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?

absence of any seizure activity during the first 48 hours The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

A client is taking spironolactone to control her hypertension. Her serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess her:

electrocardiogram (ECG) results. Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action?

Turning the client from side to side, using the logroll technique To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.

A physician writes a medication order for meperidine 500 mg. The nurse's appropriate action would be to:

clarify the order with the physician. The nurse must call the physician to clarify the order because meperidine 500 mg isn't a safe dosage, and the physician's order is incomplete. The order doesn't include a route or frequency of administration. It isn't appropriate for the nurse to administer an unsafe dosage to the client. The nurse should clarify the order with the physician, not with the pharmacist or another nurse.

The nurse recognizes older adults require lower doses of anesthetic agents due to:

decreased lean tissue mass. Lower doses of anesthetic agents are required in older adults, as they have decreased lean tissue mass, decreased tissue elasticity, and decreased liver mass. Bone mass is unrelated to doses of anesthesia.

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should wear gloves when

providing mouth care. Standard precautions stipulate that a health care worker wear gloves when contact with a client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. Maintaining strict isolation isn't needed because human immunodeficiency virus (HIV) is spread by contact with contaminated blood or body fluids, which can be avoided by following standard precautions. A private room wouldn't provide barrier protection, which is needed for standard precautions. Providing routine blood pressure, entering the room, or delivering the food tray is not necessary unless anticipating splashing of blood or body fluids.

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?

Allow unnecessary personnel to enter the OR environment. The circulating nurse restricts the admittance of unnecessary personnel in the OR environment.

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed." The nurse should instruct the client to use the call button when she needs to use the bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity. If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings are accurate. Inserting a catheter without a physician's order or not allowing the client to get out of bed isn't acceptable nursing practice.

A 2-year-old has been prescribed an antibiotic as part of treatment. What should the nurse consider to minimize the adverse effects?

Altering the dosage of the drug according to the child's age Adverse effects of some drugs are more severe and more likely to occur in children due to their immature body systems. Drug receptor sensitivity varies with age. It may be increased or decreased for certain drugs. This variability may promote adverse effects and may necessitate lower or higher drug dosages than would normally be expected. For example, tetracycline administered to a child between the age of 4 months and 8 years will stain the permanent teeth.

After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom she's assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?

Ask the student to provide a photo ID for comparison with the names on the assignment sheet. Most facilities require photo identification to maintain security and confidentiality. Allowing a student without an ID to have supervised access to a medication record doesn't protect client information. Contacting the instructor by phone doesn't verify the student's identity.

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.

A geriatric client is observed smoking a cigarette and lowering the oxygen nasal prongs away from the nostrils. Which is the priority action of the nurse?

Remind the client to avoid smoking during oxygen therapy There is a highly flammable risk when cigarettes are lit and smoked near oxygen therapy. Both the clients and guests should be advised and reminded not to smoke when oxygen therapy is present. Although tobacco chewing would lessen the flammable risk, this product is infrequently available. The nurse should discuss smoking habits and the interest to quit smoking cigarettes with the client. If the client expresses interest in a smoking cessation program or, even, the nicotine treatments, then it would be appropriate for the nurse to request a smoking cessation prescription from the physician. However, the nurse should always consider and discuss the client's preferences and coping mechanisms rather than institutionally pressuring or assimilating the client to stop smoking. Finally, while every client will die one day from medical diseases or accidents, the nurse must recognize the flammable risk the client is generating to him- or herself, those around them, and the surrounding environment. The nurse has a moral responsibility to remind the client of the flammable risks of mixing oxygen with cigarette smoking.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing. A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

When administering medication, the nurse ensures client safety by following the rights of medication administration. Identify the "rights of medication administration." Select all that apply.

Right client Right medication Right dose Right time Right route A nurse must always implement safe nursing practices when administering medications. Following the rights of medication administration helps protect the client from medication errors. Safe procedure includes confirming the right client, dose, medication, time, and route. Confirming the room number does not guarantee that the right client will receive the correct medication.

A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate:

drug dependence. Hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness are classic symptoms of drug dependency that usually appear within the first 24 hours after birth. Sepsis is indicated by temperature instability and tachycardia. Hepatitis will manifest as jaundice. Hypothermia, muscle twitching, diaphoresis, and respiratory distress may be signs of hypoglycemia.

A client is admitted to the emergency department with sneezing and coughing. The client is in the triage area, waiting to be seen by a health care provider (HCP). To prevent spread of infection to others in the area and to the health care staff, the nurse should:

give the client a surgical mask to wear. In order to prevent infections in hospitals, the nurse institutes measures to contain respiratory secretions in symptomatic clients. The nurse gives the client a mask to wear, and tissues; the nurse instructs the client to dispose of used tissues in a no-touch receptacle. It is not necessary to place the client in isolation. It is not appropriate to ask others to move away from the client, but the nurse can ask the client to keep 3 feet away from others in the waiting room, if there is room. The nurse instructs the client to perform hand hygiene after blowing his nose or touching his nose or face, but doing so is not a prerequisite for being examined by the HCP. The nurse and HCP also use hand hygiene practices when caring for this client.