Because I'm an Idiot
Which action, if performed by the nurse, is inappropriate while caring for different clients after a disaster? Teaching and supervising volunteers Providing on-site first aid and emergency care Evacuating injured and uninjured people from a danger area Correct answer Teaching clients about procedures that are needed for safety
After a disaster, evacuating the injured and uninjured people from the danger area and placing them in a safer place is done by firefighters and other disaster-trained emergency personnel. The nurse would not perform this action because they are not provided with specific rescue training. The nurse would teach and supervise volunteers to effectively perform during disasters. The nurse would provide on-site first aid treatment to the clients. The nurse would also perform the emergency care at the disaster site. Teaching the client about safety measures at home is appropriate.
Which instructions will the home health nurse include when teaching a client with peripheral artery disease? Select all that apply. "Avoid crossing your legs." Correct answer "Inspect your feet daily." Correct answer "Change positions slowly." "Do not use compression stockings." Correct answer "Avoid green leafy vegetables in your diet."
Crossing the legs and using compression stockings will restrict blood flow, so these actions should be avoided in clients with peripheral artery disease. Inspection of the feet is done daily to detect injury, infection, or skin breakdown. Changing position slowly is not necessary for clients with peripheral artery disease, although it is recommended for those on medications that cause orthostatic hypotension. Dark green leafy vegetables are avoided by clients who take warfarin.
Which factor that influences the spread of sexually transmitted infections (STIs) would the nurse include in a teaching session? Age Correct answer Drug abuse Correct answer Lack of education Correct answer Multiple sex partners Correct answer Absent or subtle symptoms Correct answer Limited access to health care Correct answer
Despite medical advances and public health efforts, STIs continue to be a serious public health problem in the United States. Factors that influence the spread of STIs include age (those younger than 30 years of age are at higher risk), drug abuse, lack of education, having multiple sex partners, the fact that these infections often have absent or subtle symptoms that are easily ignored, and limited access to health care.
Which parent teaching would the nurse provide for a 4-month-old infant with a spica cast? Obtain a specially designed car seat. Correct answer Keep diapers on to prevent soiling of the cast. Be sure to change the infant's position every 8 hours. Use the bar between the infant's legs to change positions.
Standard seat belts and car seats are not easily adapted for use by children in spica casts; specially designed devices are available to meet safety requirements. Other strategies in addition to diapers will be necessary to keep the cast clean. Changing the infant's position every 8 hours is inadequate; the position should be changed at least every 2 hours. Using the abduction bar to lift or turn the child can weaken the cast; the bar is designed to keep the hips in alignment.
Which nursing interventions are beneficial in the event of fire in the hospital? Opening the doors and windows Moving ambulatory clients in wheelchairs to a safe location Putting out the fire first and then removing the clients from fire area Asking ambulatory clients to help push wheelchair clients out of danger Correct answer Maintaining injured clients' respiratory status manually until removed from the fire area Correct answer
The nurse would ask ambulatory clients to help push wheelchair clients out of danger. The nurse would maintain the respiratory status of injured clients manually until they can be removed from the fire area. The nurse would close the doors and windows to try to contain the fire. The nurse would move the immobile clients from the fire area in a wheelchair or by stretcher.
The nursing staff used seclusion for a client due to behavior that placed other clients and staff at risk for harm. Which intervention would the nurse perform first when reintegrating the client into the unit? Document behaviors that occurred. Administer antipsychotic medication. Discuss behavior that necessitated seclusion. Correct answer Plan alternative methods to respond to stress.
When a client is allowed back into the unit after a period of seclusion, the first action the nurse would perform is to discuss the behavior that led to the client being placed in seclusion. This leads the client to identify triggers that caused the behavior. The nurse would administer medications as an alternative to seclusion. The nurse would document the behaviors that occurred after the client is placed in seclusion. After discussing the behaviors that caused the seclusion, the nurse would work with the client to develop different methods to use when responding to stress in the future.
When the fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen, which action would the nurse take to ensure the safety of the clients, staff, and family members? Select all that apply. Move immobile clients via stretcher. Correct answer Place ambulatory clients in wheelchairs. Turn off all sources of supplemental oxygen. Correct answer Provide manual respiratory support to critically ill clients. Correct answer Close all windows and doors and use an ABC fire extinguisher. Correct answer
When responding to a fire in a facility, the nurse would move immobile clients out of the area via stretchers. All sources of supplemental oxygen should be discontinued and manual respiratory support should be provided to critically ill clients. All windows and doors should be closed and an ABC fire extinguisher should be used to help contain the fire. Ambulatory clients should be asked to walk and not placed in wheelchairs.
Which characteristics of a bully would the nurse include in parental education? Defiant Correct answer Depressed Aggressive Correct answer Manipulative Correct answer Low self-esteem
Bullies are generally defiant toward adults, manipulative, and have aggressive attitudes. Children who are targeted for bullying often have internalizing characteristics such as depression and low self-esteem.
Which side effect would the nurse monitor for when administering a selective serotonin reuptake inhibitor (SSRI)? Anxiety Correct answer Nausea Correct answer Sedation Correct answer Restlessness Correct answer Suicidal ideation Correct answer Increased energy level Correct answer
Clients on SSRIs would be assessed for changes in attitude (anxiety, restlessness) and suicidal gestures. Depressed people may attempt suicide when taking antidepressants as a result of increased energy levels, which can lead to a renewed interest in suicide. Other side effects of SSRIs include nausea, sedation, dry mouth, vomiting, constipation, diarrhea, anorexia, differences in taste, headache, tremor, dizziness, weakness, fatigue, increased sweating, sexual dysfunction, visual disturbances, and urinary problems.
Oral care for a patient undergoing Chemo should include what process?
Cotton swabs may be used because they will not injure the mucous membranes. A mild toothpaste may be used because it will not injure the mucous membranes. A saline mouthwash is isotonic and will not injure the mucous membranes. Do not use: An electric toothbrush vigorously massages the gums; this may be irritating and could cause the gums to hemorrhage.
Which athletic safety equipment would the nurse recommend for a school-aged child? Select all that apply. Gloves Helmet Correct answer Padding Correct answer Eye shields Correct answer Mouth shields Correct answer
General safety equipment recommended for a school-aged child playing active sports includes a safety helmet, padding, eye shields, and mouth shields. Gloves are not necessary unless participating in a specific activity that requires them.
Which instructions would be included when teaching a client with hyperthyroidism who just had radioactive iodine to ablate thyroid tissue? Remain in the house. Avoid holding an infant. Correct answer Save urine in a lead-lined container. Refrain from using a bathroom used by others.
Infants are particularly sensitive to radioactivity; even the small amount emitted after treatment may affect infants. It is not necessary to avoid leaving the house as long as close proximity to others is avoided. Saving urine in a lead-lined container is not necessary; the same bathroom may be used by all members of the family, but the toilet should be flushed twice after use by the client. Refraining from using a bathroom used by others is not necessary.
A 2-year-old boy living on a farm is found to have a roundworm (Ascaris lumbricoides) infestation. The nurse teaches the mother about the transmission of these parasites. Which statement indicates that the mother needs further teaching? "The rest of the family won't need the medicine." "My little boy won't be able to play in the fields until he gets older." "We're going to have to wash everyone's bedding in soapy water every day." Correct answer "We're going to have to make sure vegetables are well cooked before we eat them."
It is not necessary to wash bedding daily because roundworm is not transmitted by fomites. Because the organism is not transmitted from person to person, the family does not have to be medicated. It is advisable to keep small children from playing in areas where there is dirt because young children explore their environment by putting their hands and objects in their mouths. Cooking vegetables should destroy the organism if it is present, so it is advisable.
The nurse is caring for a client who had head and neck surgery. Which complication will the nurse try to prevent by positioning the client's head in functional alignment after surgery? Cervical trauma Laryngeal spasm Laryngeal edema Wound dehiscence Correct answer
Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.
The nurse is teaching a group of college-age women the characteristics of a potential male batterer. Which signs would the nurse include? Select all that apply. High self-esteem Very assertive demeanor Especially good verbal skills Inability to empathize with others Correct answer Having a fluid view of gender roles Perception of self as "special" and deserving of special attention Correct answer
Male batterers are often unable to empathize with others and perceive themselves as "special" and deserving of special attention for being the provider or protector in relationships. Batterers usually have low self-esteem and deficits in assertiveness, as well as inadequate communication skills and a rigid view of gender stereotypes.
What diabetes medication is contraindicated in patients with renal insufficiency who will be having a CT with contrast and why?
Metformin because it will cause lactic acidosis when combined with CT contrast.
Which is correct regarding the safety of caffeinated beverages during pregnancy? High intake causes congenital disabilities. One 12-ounce cup of coffee per day is probably fine. Correct answer High consumption is often related to a decrease in birth weight. Correct answer Pregnant women should try to abstain from caffeine completely. Caffeine does not increase the risk for miscarriage, regardless of the amount consumed. There is no effect of caffeine on the fetus in the third trimester.
One 12-ounce cup of coffee per day is probably fine. A high intake of caffeine is often related to a decrease in birth weight. It does not cause congenital disabilities. All pregnant women do not need to abstain from caffeine completely; this is an individual choice. High intakes of caffeine during pregnancy might increase the risk of miscarriage. It is not true that a woman need not worry about caffeine intake once she has entered the third trimester; the recommendation remains no more than one 12-ounce cup daily.
When the nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. Which is the most important measure for the nurse to take at this time? Giving the infant to the mother Having the visitor step outside the room Correct answer Verifying the infant's and mother's identification bands Asking the visitor whether the coughing and sneezing are caused by a cold
Protection of newborns from unnecessary exposure to microorganisms is the priority. Giving the infant to the mother should not be done until the mother's and newborn's identification bands have been verified. Verifying the infant's and the mother's identification bands should be done after the visitor leaves the room. Asking the visitor whether the coughing and sneezing are caused by a cold is a discussion that should take place outside the room. The visitor should be asked to leave if indications of an infection are present.
Which screening would an nurse perform specifically for pregnant adolescents?
Routine screening for sexual assault and abuse is recommended for pregnant adolescents because pregnancy in minor adolescent girls can be the result of sexual assault and abuse. Screening for alcohol abuse, substance use, and occupational risks should be performed for all pregnant women, not specifically for pregnant adolescents.
Which is the nurse's priority action when caring for an obstetrical client experiencing eclampsia? Turn the head to one side. Correct answer Obtain the fetal heart rate. Administer magnesium sulfate. Prepare for an emergency delivery.
The airway should be kept patent by turning the client's head to one side or placing a pillow under the back or one shoulder if possible. Maternal stability is a priority. During eclampsia obtaining the fetal heart rate, administering magnesium sulfate, or preparing for an emergency delivery are not priority actions.
Which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis? Wear a mask during the procedure. Correct answer Clean the catheter exit site every day. Correct answer Maintain meticulous aseptic technique. Correct answer Wash your hands before the exchange. Correct answer Store supplies in a clean and dry location. Correct answer
The location of the peritoneal dialysis catheter makes it a direct portal to the peritoneum, which increases the client's risk for peritonitis. The nurse would ensure that the client understands the importance of preventing peritonitis when providing instructions on performing peritoneal dialysis. The client would be instructed to wear a mask during the procedure, especially when changing connector sets. The nurse would show the client how to properly clean the area around the catheter exit site and instruct that this be done every day to remove secretions. The client must be aware that meticulous aseptic technique throughout all phases of the exchange is essential. Proper hand-washing technique would be demonstrated and the client instructed on the importance of hand washing before the exchange. Supplies would be stored in a clean and dry place.
Which recommendation would the nurse provide a parent who asks when it is safe to transition a toddler from a crib to a bed? "Children can sleep in a bed safely when their height reaches 35 inches (89 cm)." Correct answer "Children are safe to sleep in a bed when they reach a weight of 25 pounds." "Children can sleep in a bed safely around the time they begin toilet training." "Children are safe to sleep in a bed when they are no longer waking up at night."
When children reach a height of 89 cm (35 inches), they should sleep in a bed rather than a crib. Weight, toilet training, or no longer waking at night are not determining factors for the safe transition from sleeping in the crib to a bed.
A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Bedwetting Thumb-sucking Difficulty consoling Correct answer Underdevelopment for age Correct answer Demands for physical closeness
Abused children may be difficult to console because they have not had positive past interpersonal experiences. Failure to thrive is often seen in abused children. It results from emotional stress as well as from neglect of physical needs. The task of nighttime bladder training may not be completed until 4 or 5 years of age, and sometimes even later. Thumb-sucking is not noteworthy because many children, not just those who are abused, continue to suck their thumbs for several years. Abused children do not seek physical closeness because their needs for comfort have not been met in the past.
Which education would the nurse provide about activated charcoal as a method of gastrointestinal decontamination in preschoolers who have ingested poison? "The use of activated charcoal may cause constipation and intestinal obstruction." Correct answer "Activated charcoal should always be administered through a nasogastric tube." "Activated charcoal should be administered within 2 hours of the poison ingestion." "Activated charcoal should be mixed with small amounts of chocolate milk or fruit syrup." Correct answer "Activated charcoal may be used in children who have ingested large amounts of quinine." Correct answer
Activated charcoal may be used for gastrointestinal decontamination in preschoolers who have ingested poison. However, its use may cause constipation and intestinal obstruction. To increase the child's acceptance of activated charcoal, the nurse should mix the activated charcoal with small amounts of chocolate milk or fruit syrup before administering the medication to the child. Children who have ingested large amounts of quinine can be administered activated charcoal. A nasogastric tube may be required to administer activated charcoal in small children; however, the nurse may serve activated charcoal orally through a straw by mixing it with chocolate milk or fruit syrup. Activated charcoal should be administered within 1 hour, not 2 hours, of the poison ingestion.
Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. Avoid eating from buffets. Correct answer Obtain annual flu vaccinations. Correct answer Perform regular hand hygiene. Correct answer Stay away from crowded areas. Correct answer Report a temperature greater than 100.5°F. Correct answer
Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment.
Which cause may produce abnormal uterine bleeding? Select all that apply. Hypothyroidism Correct answer Failure to ovulate Correct answer Bleeding disorders Correct answer Unidentified pregnancy Correct answer Use of oral contraceptives Correct answer Benign lesions of the uterus Correct answer
Common causes for any type of abnormal uterine bleeding include endocrine disorders like hypothyroidism; failure to ovulate or respond appropriately to ovulation hormones; bleeding disorders; pregnancy complications such as an unidentified pregnancy that is ending in spontaneous abortion; breakthrough bleeding, which may occur in the woman taking oral contraceptives; and lesions of the vagina, cervix, or uterus (benign or malignant).
Which action will the nurse perform to prevent pulmonary contamination when caring for victims of a dirty bomb? Administer pralidoxime chloride. Cover victims' noses and mouths. Correct answer Triage victims according to injuries. Quarantine the victims to one area.
Dirty bombs are composed of explosives and radioactive pellets. Radioactive dust and smoke can be inhaled and further spread. Therefore the initial action the nurse will take when treating clients exposed to a dirty bomb is to cover the victims' noses and mouths. Pralidoxime chloride is administered for chemical exposure. Prioritizing care by triaging victims is important, but does not prevent pulmonary contamination. Quarantining victims is done for communicable diseases not radiation exposure.
Which aspect of safe medication administration in the pediatric population does the nurse need to consider? Select all that apply. Medications can cause unanticipated side effects. Correct answer Dosing ranges are an important component in the process. Correct answer Many medications have not been tested in children. Correct answer Medication sensitivity in infants is the same as in adults. Some of the medications may be ineffective in children. Correct answer
Fully two-thirds of medications used in pediatrics have never been tested on children. As a result, complete understanding of the pharmacokinetics and both therapeutic and adverse effects in children may be lacking. As compared to adult dosing, pediatric dosing includes a component of safe dose ranges rather than a single, accepted dose. Some medications are, in fact, ineffective in children. Medication sensitivity in infants depends on many factors specific to their developmental phase and is not like medication sensitivity in adults.
During disaster response, which task is the responsibility of the medical command physician? Select all that apply. One, some, or all responses may be correct. Determine client acuity. Correct answer Assess required resources. Communicate with the media. Implement the emergency plan. Decide numbers of manageable casualties.
The responsibilities of the medical command physician include determining number, acuity, and resources required. The public information officer is the media liaison. The hospital incident commander implements the emergency plan.
Which steps are included in the emergency treatment of poisoning in a toddler? Assess the victim. Correct answer Identify the poison. Correct answer Terminate the exposure. Correct answer Provide gastric decontamination. Prevent poison absorption. Correct answer
The steps in the emergency treatment of poisoning in order are to assess the victim, terminate the exposure, identify the poison, and prevent poison absorption. Gastric decontamination is not a step in the emergency treatment of poisoning.
Which client assessment is triaged to nonurgent status by the emergency department nurse? Older adult male with purulent sputum Toddler with periods of unresponsiveness Middle-aged female with right scapular pain Teenager with ecchymosis and edema to the ankle Correct answer
The teenager with ecchymosis and edema to the ankle likely has a sprain, which is nonurgent. An older adult male with purulent sputum could have new onset of a respiratory infection such as pneumonia, which is urgent. The toddler with periods of unresponsiveness, which is life threatening, is triaged as emergent. The middle-aged female with right scapular pain has possible gastrointestinal- or gallbladder-related problems, which is urgent.
A client is receiving therapy that includes a radioactive sealed implant. Which nursing intervention would be implemented to protect against exposure to radiation? Wearing a dosimeter film badge at all times Limiting exposure to the client to 1 hour daily Using long-handled forceps to retrieve a dislodged implant Correct answer Ensuring that visitors maintain a minimum distance of 3 feet from the client
Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily.
