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the nurse receives a report on a newly admitted client who is positive for clostridium difficile. which category of isolation would the nurse implement for this client?

contact used for direct client or environmental contact with blood or bodily fluid from an infected client

during an acquired immunodeficiency syndrome (AIDS) education class, a client states, "Vaseline works great when I use condoms." Which conclusion about the clients knowledge of condom use can the nurse draw from this statement?

ignorance about correct condom us vaseline breaks down integrity and will increase the risk for condom failure

which strategy to warm affected areas during a vasoconstrictive episode in a client with Raynaud disease would the nurse find concerning?

immersion in hot water sensation in this type of disease is diminished. the area with immersed in hot water could result in a burn injury

when leaving for a lunch break, the primary nurse shares that the client is prescribed morphine for pain as needed (PRN0.which action would the covering nurse take first when the client complains of a pain level of 8 on a pain scale of 1-10?

verify the pain medication prescription in the clinical record the nurse must verify the accuracy of the prescription

which action would the nurse take when the blood pressure of a client who has acquired immunodeficiency syndrome (AIDS)?

wash the hands thoroughly sufficient, b/c this procedure does not involve contact with blood or secretions, no additional protections is indicated

a nurse teaches an adolescent undergoing chemotherapy about the need for special mouth care bc of the potential for oral lesions. which statement indicates to the nurse that the instructions have been understood?

"I can us foam-tipped applicators to wipe my teeth and gums." it will not damage the oral mucosa

a father requests information on how to care for his Childs severe diaper rash. which statement made by the Childs father indicates a need for additional teaching?

"I direct a heat lamp at the buttocks" heat lamps are not used bc of the potential for burns

when caring for a client in the third trimester of pregnancy with a history of MI, which statement made by the client would the nurse the most

"I have been using cough drops to try and get rid of my cough"

which action would the nurse implement when caring for a client with pruritus to protect the client from injury?

1.apply topical anesthetics 2.apply lotion after bathing 3.administer corticosteriods 4.add bath oil to the bath water 5.teach the client stress management techniques 6.instruct the client to avoid alcohol, tea, and coffee

which intervention would the nurse institute to keep a client with Guillain-barré syndrome safe from injury?

1.inspect the skin 2.keep the bed in low position 3.use a moisture chamber for the eyes 4.raise rails while the client is in bed 5.put call light within reach for the client

a new mother asks the nurse whether she may wash her baby in a tub after they go home. what is the nurses best response?

"babies can be bathed in a tub after the cord has fallen off" tub bathing before then increases the risk for infection by way of the moist umbilical stub

which response by the nurse is appropriate when a client with tuberculosis asks about the communicability of the disease?

"untreated active tuberculosis is communicable"

which response would the nurse give a client with herpes simplex who is on viral therapy and asks if they can pass the infection on to others?

"you can still transmit the infection even if you are on antiviral therapy and have no lesions"

which principle would the nurse use to prevent an error when taking the BP of a client with hypertension?

1. position the arm on the surface at the level of the heart 2.sit the client in a chair with feet resting on the floor 3.determine the systolic pressure first by palpation 4.use a cuff whose bladder encircles at least 80% of the clients arm 5.compare BP readings in both arms while the client is lying down, standing, and sitting

when providing discharge instructions to a client with type 1 diabetes mellitus on sharps disposal, the nurse would instruct the client to place used insulin syringes where?

a plastic liquid detergent bottle with a screw-top lid

which sign would alert the nurse to apply a black band to a victim if a bomb blast?

a severe head injury and a need for artificial ventilation a black tag would be given to victims of a disaster who are expected to die indicates a low chance of survival

which ppe is most essential when changing the bed linens of a client with a wound draining seropurulent secretions?

clean gloves protects hands and wrists from microorganisms in the linens

which intervention would the nurse include in a 3 week old infants plan of care after surgery to repair a cleft lip?

cleansing the suture line to prevent infection

a client in active labor reports to the nurse that she had a chlamydial infection at her last clinical visit. she also states that she stopped taking the antibiotic after 3 days bc she "felt better". which prescription from the HCP does the nurse expect?

administration of antibiotics before delivery a maternal chlamydial infection is transmitted to the newborn during passage through the birth canal; therefore, administration of antibiotics before delivers is necessary

A nurse is caring for a newborn with myelomeningocele. which would immediate nursing care for this infant include?

applying sterile, moist non adherent dressings to the sac prevents drying and breakage of the sac

Which action is appropriate of a nurse who observes a client rushing down the hall of the mental health unit, rapidly tapping their fingers against the wall?

approaching the client in a nonthreatening manner to determine the cause of the agitation helps the agitated client gain self-control

which nursing action is most important when using elbow restraints on a confused client to prevent the client from pulling out a nasogastric tube?

assess the clients condition every hour a restraint impedes the movement of a client; therefore, a clients condition needs to be assessed every hour

which instruction would the nurse give yo a client experiencing orthostatic hypotension to reduce the risk for falls?

avoid hot baths or showers they may fillet blood vessels and cause dizziness on standing

which is the most highly sensitive time within the developing embryo for the risk for malformation related to environmental teratogens?

cleft palate at 8 weeks' gestation

which client should be treated immediately according to the disaster triage tag system

client A - RED tag

which statement would be an appropriate response by the nurse when coworkers inquire about test results of a friend being cared by the nurse?

decline to discuss the friends medical condition all client health info. in this situation is confidential, regardless of the relationship of the employee to the client

which prescription would the nurse clarify with the HCP?

erythropoietin 6000 subcutaneously TIW "TIW"= 3x a week an unacceptable abbreviation, can be mistaken for 3x a day or 2x weekly

which nursing action is inappropriate while caring for different clients after a disaster?

evacuating injured and uninjured ppl from a danger area done by firefighter and other disaster-trained emergency personnel

which legal term best describe a hospital refusing to allow the discharge of a newborn until the parents pay part of the hospital bill?

false imprisonment the hospital is threatening to keep the infant; therefore, false imprisionment is threatened. false imprisionment is restraining or confining a person w/o a clinical reason

which postpartum complication would the nurse monitor for in a client with hydramnios

hemorrhage

a tapwater enema is prescribes for a 6 month old infant with suspected Hirschsprung disease. which rationale causes the nurse to question this prescription?

it could cause a fluid and electrolyte imbalance tapwater enemas are hypotonic and are contraindicated; they may cause increased absorption of fluid through the bowel and may upset the balance of fluid in the body

Which nursing action is most appropriate when caring for a client who is legally blind and is admitted to the hospital for surgery?

keep the furniture in the same location in the room promotes safety and independence

which legal principle is most likely to be applied when a nurse fails to act in a reasonable, prudent manner?

malpractice

which position would the nurse tell parents is the safest position for infants to sleep?

on the back, lying flat lying flat on the back poses the lowest risk for SIDS.

which assessment would be reported to the RN caring for a client with hemophilia experiencing a bleeding episode?

pain level a client with hemophilia in the midst of a bleeding episode experiences extreme pain. pain level allows the client to be quickly transitioned to oral opioids and then to nonopioid pain medication

a client being treated for influenza A (H1N1) is scheduled for a CT scan. which precaution would the nurse take to ensure client and visitor safety during transport?

place a surgical mask on the client nurses should provide influenza patients with surgical masks to wear for source control and tissues to contain secretions when outside of their room. special precautions such as face masks should be taken to decrease the risk for further outbreak

which action would the nurse take to ensure proper body mechanics when working with another nurse to move a client who one-sided weakness up in bed?

positioning the nurses on either side of the bed with their feet apart, gathering the pull sheets close to the client, turning toward the head of the bed, and them moving the client minimizes stress on muscles, joints, ligament, and tendons

a nurse is caring for a 13 year old child who has an external fixation device on a leg. which goal is the nurse's priority when providing pin care?

preventing infection pin sites provide a direct avenue for organisms into the bone

which term describes the link between the harm suffered by a client and the nurse negligence?

proximate cause legal concept meaning that a client must prove that the nurses actions contributed or caused the clients injury

which level of maslow's hierarchy of needs is the nurse addressing when teaching a client how to us the call bell/call light system?

safety a call bell system enables the client to communicate with the staff and supports safety and security, which is a second-level need

which test result should a nurse review to determine if the antibiotic prescribed for the client will be effective?

sensitivity test infected body fluids are tested to determine the antibiotics to which the organism is particularly sensitive or resistant(sensitivity)

which role describes the American Red Cross in emergency nursing after a community disaster?

setting up shelters for clients who have lost their homes

which position would the nurse encourage the client who has been prescribed bed rest fir mild preeclampsia to maintain?

side lying improve venous return to the heart and increases stroke volume and cardiac output

which action would the nurse advise an older client to take who reports feeling light-headed when getting out of bed?

sit on the edge of the bed while holding the client upright sitting allows the nurse to support the client until orthostatic hypotension subsides

which instruction would the nurse include in the accident prevention teaching for a 3 month old infant?

test the temperature of water before bathing excessive high temperatures can damage the delicate skin of an infant

which action provides evidence that a family member is effectively managing the care for a homebound client with a percutaneous endoscopic gastrostomy (PEG) tube?

the head of the bed remains elevated after the feeding prevents aspiration and promote digestion

which principle would legally apply when a nurse discovers burns due to incorrect setting of a heating pad?

the nurse could be held liable for the injury that occurred

why is it important for a newly admitted client with worsening preeclampsia to be placed in a non stimulating environment?

the probability of tonic-clonic seizures is reduced

which organism would the nurse explain commonly causes protozoal infections in clients with acquires immunodeficiency syndrome (AIDS)?

toxoplasmosis protozoal infection in the AIDS client and an AIDS-defining condition in adults