HESI Module 6

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. Immune Urinary Lymphatic Respiratory (Lungs) Gastrointestinal Integumentary System (Skin)

Respiratory Gastrointestinal Integumentary

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precautions does the nurse understand are most appropriate to help ensure the safety of this client? Select all that apply. 1. Switching injection sites 2. Doubling the dose of anticoagulant 3. Applying a pressure bandage to the site after each IM injection 4. Applying prolonged pressure to the sites of the IM and SC injections 5. Decreasing the sizes of the needles used for the IM and SC injections

1. Switching injection sites 4. Applying prolonged pressure to the sites of the IM and SC injections

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of signs/symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply. 1. "Change positions slowly." 2. "Remove clutter from your home." 3. "Use public transportation as much as possible." 4. "Drive your car only if you're not feeling dizzy." 5. "Turn your head slowly when someone speaks to you."

1. "Change positions slowly." 2. "Remove clutter from your home."

A nurse performs an evaluation to determine whether a client's home is electrically safe. Which finding indicates the need for further investigation and intervention? 1. Wiring for the television runs under the carpet. 2. Electrical cords are free of frayed and damaged wires. 3. Electrical kitchen appliances are located away from the sink. 4. A safety-type extension cord is secured to the floor with electrical tape.

1. Wiring for the television runs under the carpet

In which of the following situations would the nurse use this type of restraint (see figure-mitts)? Select all that apply. 1. To secure the shoulders and the waist 2. To immobilize a client's arm and shoulders 3. To prevent the client from getting out of bed 4. To prevent dislodgment of an intravenous line 5. To prevent the client from turning from side to side 6. To prevent the use of the hands while allowing free arm movement

4. To prevent dislodgment of an intravenous line 6. To prevent the use of the hands while allowing free arm movement

A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? 1. Planning to have the nuclear scan performed at the bedside 2. Asking the technicians in the nuclear scan department to wear masks 3. Placing a surgical mask on the client for transport and for contact with other individuals 4. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued

3. Placing a surgical mask on the client for transport and for contact with other individuals

A home health nurse is performing an assessment of a client's skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client? 1. Putting on a pair of gloves 2. Donning a mask and gloves 3. Putting on a gown and gloves 4. Avoiding sitting on the client's furniture

3. Putting on a gown and gloves

A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply. 1. The assistant leans forward when turning a client in bed. 2. The assistant positions a box that is to be lifted between his knees. 3. The assistant turns his back to change position while moving a client. 4. The assistant keeps the object to be moved as close to his body as possible. 5. The assistant helps a client requiring total care into a chair without additional assistance.

2. The assistant positions a box that is to be lifted between his knees 4. The assistant keeps the object to be moved as close to his body as possible.

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? 1. Confining the fire 2. Extinguishing the fire 3. Activating the fire alarm 4. Running for the fire extinguisher

3. Activating the fire alarm

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. 1. The client's temperature 2. The client's 24-hour urine output 3. Skin integrity of the restrained body part 4. The procedure used in applying the restraint 5. The date and time of application of the restraint 6. Circulatory and neurovascular status of the restrained extremities

3. Skin integrity of the restrained body part 4. The procedure used in applying the restraint 5. The date and time of application of the restraint 6. Circulatory and neurovascular status of the restrained extremities

The nurse plans to wear this protective mask (see figure-surgical mask) when caring for clients with certain disorders. What are these disorders? Select all that apply. 1. Scabies 2. Hepatitis A 3. Tuberculosis 4. Pharyngeal diphtheria 5. Streptococcal pharyngitis 6. Meningococcal pneumonia

4. Pharyngeal diphtheria 5. Streptococcal pharyngitis 6. Meningococcal pneumonia

An older client in a long-term care facility is at risk for injury because of confusion. Which of the following devices would be the best choice to help prevent injury while the client is in bed? (Pictures- restraints)

Bed alarm option

A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? Select all that apply. 1. Mask 2. Gown 3. Gloves 4. Face shield 5. Shoe protectors

Gown Gloves Face shield

A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. 1. Fresh apple 2. Raw celery 3. Italian bread 4. Tossed salad 5. Baked chicken 6. Well-cooked cheeseburger

3. Italian bread 5. Baked chicken 6. Well-cooked cheeseburger

A teenage client returns to the gynecological (GYN) clinic for a follow-up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching? 1. "I finished all the antibiotic, just like you said." 2. "I know you won't tell my parents that I'm sick." 3. "I always make sure my boyfriend uses a condom." 4. "My boyfriend doesn't have to come in for treatment."

4. "My boyfriend doesn't have to come in for treatment."

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. 1. Keeping bedside table surfaces clean and dry 2. Placing tissues and soiled dressings in paper bags 3. Changing dressings that become wet or soiled 4. Placing capped needles and syringes in puncture-resistant containers 5. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin 6. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

1. Keeping bedside table surfaces clean and dry 3. Changing dressings that become wet or soiled 5. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin 6. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

A nurse, assessing a client's readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply. 1. "I live in a single-story house." 2. "I don't have any nightlights in the house." 3. "I've removed the scatter rugs from the house." 4. "I keep my personal items within reach when I sit in my easy chair." 5. "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

2. "I don't have any nightlights in the house." 5. "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. 1. Keep visitors to a minimum 2. Acknowledge the client's feelings 3. Provide information about hospital routines 4. Put the client in a room far from the nurses' station 5. Keep the door open and the room lights on at all times 6. Allow the client to have as many choices regarding his care as possible

2. Acknowledge the client's feelings 3. Provide information about hospital routines 6. Allow the client to have as many choices regarding his care as possible

A nurse educator is providing in-service sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. 1. The use of latex gloves 2. The use of shielded needles 3. The use of recessed needles 4. The use of needleless devices 5. Disposal of needles in special puncture-resistant containers

2. The use of shielded needles 3. The use of recessed needles 4. The use of needleless devices 5. Disposal of needles in special puncture-resistant containers

A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply. 1. Increased lens accommodation 2. Transmission of hot impulses is delayed. 3. The client's peripheral vision is decreased. 4. The client complains of frequent nocturia. 5. High-frequency hearing tones are perceptible. 6. Voluntary and autonomic reflexes are slowed.

2. Transmission of hot impulses is delayed. 3. The client's peripheral vision is decreased. 4. The client complains of frequent nocturia. 6. Voluntary and autonomic reflexes are slowed.

According to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, what are the components of actions in the mitigation phase? Select all that apply. 1. Actions taken to return to normal after the disaster 2. Putting disaster-planning services into action 3. Actions that can prevent the occurrence of a disaster 4. Measures that can reduce a disaster's damaging effects 5. Actions that plan for rescue, evacuation, and care of disaster victims 6. Determining available resources for the care of infants, older clients, the disabled, and people with chronic health problems

3. Actions that can prevent the occurrence of a disaster 4. Measures that can reduce a disaster's damaging effects 6. Determining available resources for the care of infants, older clients, the disabled, and people with chronic health problems

A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10-car wreck on the interstate will be brought to the ED. How does the nurse manager initially manage this situation? 1. Telling EMS to take the victims to another hospital 2. Closing the emergency department temporarily to incoming clients 3. Calling the nursing supervisor to discuss activation of the disaster plan 4. Demanding that the nurses from the night shift stay until all of the victims have been treated

3. Calling the nursing supervisor to discuss activation of the disaster plan

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. This client has a tendency to be forgetful. Which items in the home increase the client's risk for injury? Select all that apply. 1. A nightlight in the bathroom 2. Elevated toilet seat with armrests 3. Cooking equipment such as a stove 4. Smoke and carbon monoxide detectors 5. Common household objects such as door mats 6. A water heater thermostat adjusted to a low setting

3. Cooking equipment such as a stove 5. Common household objects such as door mats

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? 1. Initial 2. Primary 3. Tertiary 4. Secondary

3. Tertiary

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. 1. Anthrax is never fatal. 2. No vaccine to prevent anthrax is available. 3. Anthrax can be transmitted from person to person. 4. A blood test is available for the detection of anthrax. 5. One way that anthrax can be contracted is through the skin.

4. A blood test is available for the detection of anthrax. 5. One way that anthrax can be contracted is through the skin.

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive? Belt Wrist Elbow Ambularm

4. Ambularm

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. What is the most appropriate initial action for the nurse to take? 1. Implementing a child safety program 2. Planning a focused child safety program 3. Performing an analysis of health problems related to child safety 4. Determining the appropriateness of the planned health activity

4. Determining the appropriateness of the planned health activity

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? 1. Staying secluded in the bedroom 2. Wearing an oxygen mask at all times 3. Keeping the house closed up to minimize the spread of disease 4. Disposing of contaminated tissues in a container with a leak-proof bag

4. Disposing of contaminated tissues in a container with a leak-proof bag

What is an example of the nurse using surgical asepsis? 1. Applying a gown and gloves 2. Handling hazardous and infectious materials 3. Reducing the number of organisms and preventing their spread 4. Maintaining objects and areas free from pathogenic microorganisms

4. Maintaining objects and areas free from pathogenic microorganisms

A nurse giving a client a bed bath drops the towel on the floor. What should the nurse do? 1. Use a bath blanket as a towel 2. Borrow a towel from the client's roommate 3. Wash his/her hands, pick up the towel, and shake the towel out 4. Wash his/her hands and go to the linen room to obtain another towel

4. Wash his/her hands and go to the linen room to obtain another towel

Which event would require a nurse to complete and file an incident report? 1. A client has a seizure. 2. The nurse determines that a client would benefit from the use of a walker to ambulate. 3. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. 4. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment

4. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client understands the directions? Select all that apply. 1. "I need to follow the oxygen prescription exactly." 2. "I can use my electric razor while I'm using oxygen." 3. "I have to keep the oxygen concentrator out of direct sunlight." 4. "I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner." 5. "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator."

1. "I need to follow the oxygen prescription exactly." 3. "I have to keep the oxygen concentrator out of direct sunlight." 5. "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator."

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line-related sepsis is diagnosed. What does the nurse interpret the meaning of this infection? Select all that apply. 1. A nosocomial infection 2. An iatrogenic infection 3. A result of bacterial colonization 4. A community-acquired infection 5. A healthcare-associated infection 6. A hospital-acquired infection

1. A nosocomial infection 5. A healthcare-associated infection 6. A hospital-acquired infection

An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply. 1. A victim with a limb amputation 2. A victim with burns of both arms 3. A victim who is alert but complaining of loss of vision 4. A victim who is dazed and staggering around the other victims 5. A victim who has sustained minor bruising of an arm and the lower legs

1. A victim with a limb amputation 4. A victim who is dazed and staggering around the other victims

A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. 1. A victim with respiratory distress 2. A victim with a fractured humerus 3. A victim with partial amputation of the foot 4. A victim with a forehead laceration that is not bleeding 5. A victim with multiple nonbleeding bruises of the arms and legs

1. A victim with respiratory distress 3. A victim with partial amputation of the foot

A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk? Select all that apply. 1. Assess the client's visual acuity 2. Observe the client's gait and posture 3. Evaluate the client's muscle strength 4. Look for any hazards in the home environment 5. Ask a family member to move in with the client until her recovery is complete 6. Request that the client transfer to an assisted living environment for at least 1 month

1. Assess the client's visual acuity 2. Observe the client's gait and posture 3. Evaluate the client's muscle strength 4. Look for any hazards in the home environment

The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. What should the nurse instruct the mother to do immediately? 1. Call a poison control center 2. Administer an excessive amount of fluids to induce vomiting 3. Call an ambulance to bring the child to the emergency department 4. Leave a message on the primary health care provider's answering service about the incident

1. Call a poison control center

A nurse is preparing a sterile field to change a client's sterile dressing. What are some sterile techniques the nurse must adhere to? Select all that apply. 1. Do not turn your back to the sterile field at any time. 2. A half-inch border of the sterile field is considered contaminated. 3. Cuff the top of the disposable paper bag, and place it within reach of the work area. 4. Maintain the sterile field and gloved hands above the level of the waist. 5. Make sure to use sterile gloves when opening up sterile gauze packages to place on the sterile field.

1. Do not turn your back to the sterile field at any time. 4. Maintain the sterile field and gloved hands above the level of the waist.

A community health nurse is asked to assist in developing a community disaster plan identified by Federal Emergency Management Agency (FEMA). The nurse knows that the preparedness phase of the plan includes what components? Select all that apply. 1. Evacuation 2. Planning for rescue 3. Caring for disaster victims 4. Training of disaster personnel 5. Putting disaster planning services into action 6. Actions to prevent the occurrence of a disaster or reduce the damaging effects

1. Evacuation 2. Planning for rescue 3. Caring for disaster victims 4. Training of disaster personnel

Which of the following actions are in keeping with the principles of standard precautions? Select all that apply. 1. Handwashing between client contacts 2. Cleaning of blood spills with soap and warm water 3. Discarding needles in puncture-resistant containers 4. Handwashing before removal of a pair of soiled gloves 5. Wearing a face shield as a part of the protective garb during a wound irrigation 6. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

1. Handwashing between client contacts 3. Discarding needles in puncture-resistant containers 5. Wearing a face shield as a part of the protective garb during a wound irrigation 6. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. 1. Have a first aid kit available. 2. Have a firearm or other weapon available. 3. Plan a meeting place for family members. 4. Obtain a 1-day supply of water (1 gallon per person). 5. Have an adequate supply of prescription medications. 6. Have a battery-operated radio and a flashlight and batteries available.

1. Have a first aid kit available 3. Plan a meeting place for family members 5. Have an adequate supply of prescription medications. 6. Have a battery-operated radio and a flashlight and batteries available.

Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. 1. Saving vomitus for laboratory analysis 2. Placing the client in the supine position 3. Determining the type and amount of substance ingested 4. Removing any visible materials from the nose and mouth 5. Inducing vomiting if a household cleaner has been ingested 6. Assessing the client's airway patency, breathing, and circulation

1. Saving vomitus for laboratory analysis 3. Determining the type and amount of substance ingested 4. Removing any visible materials from the nose and mouth 6. Assessing the client's airway patency, breathing, and circulation

Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. 1. The client becomes agitated. 2. The skin under the restraint is red. 3. The client's left hand is pale and cold. 4. The client verbalizes the reason for the restraints. 5. The client is unable to reach the gastrostomy tube with his hands. 6. The client slips his hand from its restraint and pulls at his gastrostomy tube.

1. The client becomes agitated. 2. The skin under the restraint is red. 3. The client's left hand is pale and cold. 6. The client slips his hand from its restraint and pulls at his gastrostomy tube.

At the beginning of the 7 am-3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L), notifies the primary health care provider, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply. 1. The primary health care provider was contacted. 2. The blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L). 3. An IV solution of 5% dextrose in water was infusing at 7 am. 4. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. 5. A 5% dextrose in water solution is not usually prescribed for clients with diabetes, and the solution was changed immediately on its discovery.

1. The primary health care provider was contacted. 2. The blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L). 3. An IV solution of 5% dextrose in water was infusing at 7 am.

A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply. 1. Untacked rugs on the stairs 2. Small rugs in the living room 3. Carpet on stairs secured with tacks 4. Clothes hamper at the end of the hallway 5. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

1. Untacked rugs on the stairs 2. Small rugs in the living room 5. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. 1. Using tongs to collect any broken glass 2. Wearing gloves for the cleanup procedure 3. Placing the pieces of broken glass in a plastic bag 4. Blotting up the spill with a face cloth or cloth towel 5. Disinfecting the area of the blood spill with a dilute bleach solution

1. Using tongs to collect any broken glass 2. Wearing gloves for the cleanup procedure 5. Disinfecting the area of the blood spill with a dilute bleach solution

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. 1. Wear a lead shield when in the client's room. 2. Limit visits from family to 60 minutes per day. 3. Wear a dosimeter film badge when in the client's room. 4. Allow children to visit the client as long as they are at least 12 years old. 5. Keep all bed linens and dressings in the client's room until the implant is removed

1. Wear a lead shield when in the client's room. 3. Wear a dosimeter film badge when in the client's room 5. Keep all bed linens and dressings in the client's room until the implant is removed

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? Select all that apply. 1. Enteric 2. Inhalation 3. Direct contact 4. Gastrointestinal 5. Through open wounds 6. Handling of contaminated materials

2. Inhalation 3. Direct contact 6. Handling of contaminated materials

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3 (0.5 x 109/L). Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply. 1. Providing a soft toothbrush for oral care 2. Monitoring the client's oral temperature 3. Maintaining sterile occlusion of intravenous (IV) catheters 4. Requiring the client to use an electric shaver rather than a razor 5. Performing meticulous skin decontamination before venipuncture 6. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure

2. Monitoring the client's oral temperature 3. Maintaining sterile occlusion of intravenous (IV) catheters 5. Performing meticulous skin decontamination before venipuncture

A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. 1. Holding the pair of sterile forceps below waist level area 2. Positioning the sterile field so that it remains in full view 3. Reaching across the sterile field to pick up a sterile gauze 4. Leaving the room to obtain a bottle of sterile normal saline solution 5. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand 6.Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

2. Positioning the sterile field so that it remains in full view 5. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand 6.Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? Select all that apply. 1. Declaring a disaster 2. Providing disaster relief 3. Activating disaster medical assistant teams 4. Developing a federal disaster response plan 5. Identifying and training personnel for disaster response 6. Educating the public about ways to prepare for disasters

2. Providing disaster relief 5. Identifying and training personnel for disaster response 6. Educating the public about ways to prepare for disasters

A client with paraplegia has spasticity of the leg muscles. Which nursing interventions should be included in the plan of care for this client? Select all that apply. 1. The use of restraints to immobilize the limbs 2. Range-of-motion exercises of the affected limbs 3. An as-needed prescription for a muscle relaxant 4. Removal of potentially harmful objects near the client 5. The use of padding against the client's legs when the client is sitting in a wheelchair

2. Range-of-motion exercises of the affected limbs 3. An as-needed prescription for a muscle relaxant 4. Removal of potentially harmful objects near the client 5. The use of padding against the client's legs when the client is sitting in a wheelchair

A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request? 1. Remove both restraints 2. Remove a restraint from one extremity 3. Tell the mother that the restraints may not be removed 4. Loosen the restraints after telling the mother that they may not be removed

2. Remove a restraint from one extremity

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is most important? 1. The religious affiliation or church of preference 2. The names of close friends and family members 3. What medications have been prescribed and what the client knows about his or her side effects 4. The name of the person from whom the client contracted TB, so that the person may be reported for follow-up care

2. The names of close friends and family members

After discussing the use of restraints with a client and family, the primary health care provider has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. 1. The restraints are applied tightly. 2. The restraints are being released every 2 hours. 3. A safety knot has been used to secure the restraints. 4. The restraints have been tied to the side rails of the bed. 5. The call light has been placed within reach of the client.

2. The restraints are being released every 2 hours. 3. A safety knot has been used to secure the restraints. 5. The call light has been placed within reach of the client

A registered nurse(RN)is watching as a new licensed practical nurse(LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely? 1. Gloves and mask 2. Gloves and gown 3. Gloves, gown, and face shield 4. Gown and protective eyewear

3. Gloves, gown, and face shield