Content areas: Safety, Skills, and Cultural Awareness

A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel to clean up the blood spill is incorrect? 1 Uses tongs to collect any broken glass 2 Wears gloves for the cleaning procedure 3 Blots up the spill with a face cloth or cloth towel 4 Disinfects the area of the blood spill with a dilute bleach solution

Blots up the spill with a face cloth or cloth towel Rationale: The unlicensed assistive personnel (UAP) should blot the spill with an absorbent disposable material, such as paper towels or terry wipes but not with a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or an agency-approved product.

An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information? 1 "I should not wear my contact lenses." 2 "New contact lenses should be obtained." 3 "My old contact lenses should be discarded." 4 "My contact lenses can be worn if they are cleaned properly."

"My contact lenses can be worn if they are cleaned properly." Rationale: If the adolescent wears contact lenses, he should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.

A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? 1 Directly observed therapy 2 More medication instructions 3 Involvement of the family in teaching 4 Reinforcement by the health care provider

Directly observed therapy Rationale: Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. Ultimately the client may be required to have directly observed therapy to reduce the risk to the public. This involves having a responsible person actually observe the client taking the medication each day.

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions? 1 Droplet precautions 2 Enteric precautions 3 Contact precautions 4 Protective isolation

Droplet precautions Rationale: Droplet precautions are required for a client with mycoplasmal pneumonia because this type of pneumonia is transmitted by droplet nuclei larger than 5 mm. The nurse wears a mask while in the client's room. Enteric precautions are necessary when exposure from feces is likely; gloves are necessary and possibly a gown and face shield if splashes are expected to occur. Contact precautions are implemented when exposure to contaminated material, such as wound drainage, can occur and requires the use of gloves and possibly a gown. Protective isolation is instituted when it is necessary to protect the client from others.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. At which frequency should the nurse plan to check the IV sites of these clients? Every hour Every 2 hours Every 3 hours Every 4 hours

Every hour Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV may be checked even more frequently, depending on whether medication also is being infused. The time periods in options 2, 3, and 4 are too infrequent. In addition, agency policy and procedures are always followed regarding care to an IV site.

An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? 1 Prayer 2 Magnetic therapy 3 Foods considered to be yin 4 Foods considered to be yang

Foods considered to be yin Rationale: In the Asian American culture, health is believed to be a state of physical and spiritual harmony with nature and a balance between positive and negative energy forces (yin and yang). Yin foods are cold and yang foods are hot. Cold (YIN) foods are eaten when one has a hot illness (fever), and hot (YANG) foods are eaten when one has a cold illness. Options 1 and 2 are not health practices specifically associated with the Asian American culture or the yin and yang theory.

The nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has had blood-tinged sputum with previous suctioning. The nurse plans to use which item as part of standard precautions for this client? 1 Gloves, gown, and mask 2 Gown, mask, and protective eyewear 3 Gloves, gown, and protective eyewear 4 Gloves, gown, mask, and protective eyewear

Gown, mask, and protective eyewear Rationale: Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During procedures that aerosolize blood, the nurse wears a mask and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with splashes of secretions or blood.

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question? 1 Ibuprofen by oral route 2 Morphine sulfate by intravenous route 3 Tramadol hydrochloride by oral route 4 Meperidine hydrochloride by intramuscular route

Meperidine hydrochloride (Demerol) by intramuscular route Rationale: Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal antiinflammatory medication and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it should be used only short term and is not recommended for use in older clients.

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate? 1 Naloxone 2 Promethazine 3 Atropine sulfate 4 Protamine sulfate

Naloxone Rationale: Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin.

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1 Palpation and clubbing 2 Percussion and vibration 3 Hyperoxygenation and suctioning 4 Administer a bronchodilator and monitor peak flow

Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions.

The nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next? 1 Stop the IV infusion. 2 Obtain a prescription for a chest x-ray. 3 Notify the health care provider. 4 Apply cold compresses to the insertion site.

Stop the IV infusion. Rationale: The assessment indicates that infiltration of the IV solution has occurred, and the infusion must be stopped immediately to prevent further infiltration of the chemotherapy fluid. The nurse next notifies the health care provider (HCP) of the occurrence. The HCP needs to prescribe the treatment for the insertion site. There is no useful reason for doing a chest x-ray.

The nurse is caring for a Native American client and notices that the client has been mostly silent. What is the best action for the nurse to take? 1 Ask the client's family to communicate for the client. 2 Remember to make eye contact with the client when communicating. 3 Accept it because this behavior is normal and makes the client feel comfortable. 4 Realize that you are unable to communicate effectively and have another staff member care for the client.

Accept it because this behavior is normal and makes the client feel comfortable. Rationale: This behavior is normal because many Native Americans are comfortable with silence. The remaining options are inappropriate interpretations of the client's behavior.

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? 1 Use a ⅝-inch needle for the injection. 2 Apply prolonged pressure to the IM site after the injection. 3 Apply a 4 × 4 pressure dressing at the IM site after the injection. 4 Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.

Apply prolonged pressure to the IM site after the injection. Rationale: Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an IM injection will lessen the chance of having an increase of bleeding into the tissue. It is not necessary to apply a pressure dressing to the IM site of injection. A ⅝-inch needle is not an appropriate size needle for an IM injection. The heparin infusion is not decreased before an injection, and the rate is not adjusted unless specifically prescribed by a health care provider (HCP).

The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation? 1 Offer the client a cup of coffee. 2 Get a cup of coffee and join the conversation. 3 Ask the nurse to refrain from eating and drinking in that area. 4 Appreciate what a wonderful therapeutic relationship this nurse and client have.

Ask the nurse to refrain from eating and drinking in that area. Rationale: A potential complication with hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), their families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate hand washing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. The nurse should ask the second nurse to stop eating and drinking in the work area.

The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation? 1 Obtain a dust pan and mop to sweep up the syringe. 2 Call the housekeeping department to pick up the syringe. 3 Carefully pick up the syringe from the floor and gently recap the needle. 4 Carefully pick up the syringe from the floor and dispose of it in a sharps container.

Carefully pick up the syringe from the floor and dispose of it in a sharps container. Rationale: Used syringes should always be placed in a sharps container immediately after use to avoid injury to anyone. A syringe should not be swept up because this action poses an additional risk of needle stick. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes should not be recapped because of the risk of getting pricked with a contaminated needle.

A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy? 1 Constipation because of the location of the epidural catheter 2 Dislodgment of the epidural catheter because the catheter is not sutured in place 3 Permanent lower motor weakness because of the proximity of the catheter to the sciatic nerve 4 Chronic addiction to the epidural medication because epidural analgesia is a more powerful means of pain relief than patient-controlled analgesia therapy

Dislodgment of the epidural catheter because the catheter is not sutured in place Rationale: Epidural analgesia (also known as peridural or extradural analgesia) refers to the instillation of a pain-blocking agent into the epidural space. Complications that occur with epidural analgesia are directly related to catheter placement, catheter maintenance, and the type of analgesia. Epidural catheters are not sutured in position and must be taped in place to help prevent dislodgment. Low concentrations of medications are used to avoid any sensory and motor deficits that can accompany epidural analgesia. Constipation and chronic addiction are not specific complications of epidural analgesia.

A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? 1 Encourage the client to drink only thin liquids. 2 Teach the client to examine his oral mucosa monthly. 3 Teach the client to speak slowly and enunciate clearly. 4 Encourage the client to use artificial saliva to manage dryness.

Encourage the client to use artificial saliva to manage dryness. Rationale: Epithelial cells are destroyed by radiation involving the head and neck. Inflammation and ulceration occur because of the rapid cell destruction, impairing normal saliva excretion and distribution. Artificial saliva aids in preventing further damage by lubricating the affected area. A client with difficulty swallowing should avoid drinking thin liquids because of the increased risk of aspiration resulting from epiglottis dysfunction related to radiation therapy. Examining the oral mucosa is a preventive maintenance intervention to alert the client to changes in the mucosa, but this should be done daily, not monthly. The client with dysphagia has difficulty swallowing, not difficulty speaking; therefore, teaching the client to speak slowly and to enunciate clearly would provide no health benefit for the impairment in swallowing.

The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is appropriate to prevent these disorders from developing? 1 Restricting fluids 2 Placing a pillow under the knees 3 Encouraging active range-of-motion exercises 4 Applying a heating pad to the lower extremities

Encouraging active range-of-motion exercises Rationale: Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

A home care nurse is assigned to visit a Hispanic-American client to perform an admission assessment. On the initial meeting with the client, the nurse should plan to incorporate which social custom? 1 Avoid touching the client. 2 Greet the client with a handshake. 3 Smile and use humor throughout the entire admission assessment. 4 Avoid using affirmative nods during the conversations with the client.

Greet the client with a handshake. Rationale: To demonstrate respect, compassion, and understanding, health care providers (HCPs) should greet Hispanic American clients with a handshake. On establishing rapport, providers may further demonstrate approval and respect through touch, smiling, and affirmative nods of the head. Because of the diversity of dialects and the nuances of language, use of culturally congruent use of humor is difficult to accomplish and therefore should be avoided.

A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client? 1 Walker 2 Slider board 3 Raised toilet seat 4 Adaptive eating utensils

Walker Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to a stretcher or wheelchair. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications, that are contraindicated for use with ibuprofen? Select all that apply. 1 Warfarin 2 Glimepiride 3 Amlodipine 4 Simvastatin 5 Hydrochlorothiazide

Warfarin Glimepiride Amlodipine Rationale: Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen can amplify the effects of anticoagulants such as warfarin; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination is contraindicated. Although concurrent use of NSAIDs can result in an antagonistic effect with antihypertensives, it is not a contraindication and the medications can still be taken together; it may be advisable to closely monitor the blood pressure while NSAIDs are being taken, especially in elderly clients. There is no known interaction between ibuprofen and simvastatin.