NUR 190 EAQ - Safety and Infection Control
A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required?
"I have to take his blood pressure every day in the arm with the fistula."
A nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk for spreading the disease when the client makes which statement?
"I should wash my hands frequently."
While assessing an older adult with decreased perception of touch, the nurse provides instructions to the client to reduce the risk associated with falling. Which statements made by the nurse are beneficial to the client? Select all that apply.
"Look where your feet are placed while walking." "Wear shoes that give good support while walking." "If you are unable to change your position frequently request assistance."
Which actions contribute to the transmission of human immunodeficiency virus (HIV) infection from an infected to a healthy person? Select all that apply.
-Having sexual intercourse -Receiving blood transfusions
What should an older client be instructed to do to ensure antibody-mediated immunity? Select all that apply.
-Obtain a shingles vaccination. -Receive a tetanus booster injection. -Obtain the pneumococcal vaccination. -Receive an annual influenza vaccination.
The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority? Select all that apply.
-Stroke -Active hemorrhage -Respiratory distress
Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do? Select all that apply.
-Use a soft toothbrush. -Read the ingredients in over-the-counter drugs before taking them.
Which toddler-age client has reached a height in which it is no longer safe to sleep in a crib?
36 inches.
A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal when the patient is at home, the nurse should instruct the client to place used insulin syringes where?
A plastic liquid detergent bottle with a screw-top lid.
A primary healthcare provider prescribes carboprost to be administered to a postpartum client with intractable vaginal bleeding. Which prior condition noted in the client's history should alert the nurse to question this prescription?
History of asthma.
Which is the first antibody formed after exposure to an antigen?
IgM.
A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action?
Immobilizing the child's spine to limit additional injury.
The nurse is providing education about the use of restraints to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?
Prevent an adult client from getting up at night when there is insufficient staffing on the unit.
A nurse is caring for clients with various health problems. These problems include scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis. What common factor linking these diseases should the nurse consider?
Result from streptococcal infections that enter via the upper respiratory tract.
Which is the priority topic when advising the parents of a toddler-age client regarding the selection of toys?
Safety.
A nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. What is the purpose of these precautions?
They keep the child away from uninfected people.
How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction?
Replace the top linen and only the necessary bottom linen.
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene to prevent these behaviors from causing the other clients to feel what?
Angry.
Suicide precautions are ordered for a newly admitted client. What is the most therapeutic way to provide these precautions?
Assigning a staff member to be with the client at all times.
When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?
Clean gloves.
A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?
Complete the entire course of antibiotic therapy.
A woman receiving treatment with topiramate gives birth to a newborn with a cleft lip and cleft palate. Which Food Drug Administration (FDA) Pregnancy Risk category of pregnancy does the drug belong?
D.
What nursing intervention should be implemented routinely after a client has a vacuum aspiration abortion?
Encouraging the client to take the prescribed antibiotic medication.
When a 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. What is the most important measure for the nurse to take?
Having the visitor step outside the room.
A nurse is preparing a teaching plan for a client with syphilis. The nurse includes that syphilis is not considered contagious in which stage?
Tertiary stage.
A nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. The nurse teaches the parents that this gait was chosen because of what?
It provides for equal but partial weight bearing on each limb.
A client with cervical cancer is to undergo a course of internal radiation. The client returns to her lead-lined room on the oncology unit with an indwelling urinary catheter and a vaginal applicator in place. Once the primary healthcare provider has loaded the applicator with the radiation source, what should the nurse's plan of care include?
Leaving the urinary catheter undisturbed.
A client with pulmonary tuberculosis is being treated at home. What does the nurse instruct the client to do in order to help control the spread of the disease?
Open the windows frequently to allow air to circulate throughout the house.
A pregnant client asks a nurse for information about toxoplasmosis during pregnancy. What should the nurse teach the client about how to prevent the transmission of toxoplasmosis?
Pork and beef should be cooked well before being eaten.
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. What is this known as?
Proximate cause.
A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do?
Remove the sterile drape from its package by lifting it by the corners.
When two nurses are getting an older adult out of bed, the client reports feeling lightheaded. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do?
Sit on the edge of the bed while they hold the client upright.
A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately?
Small amount of yellowish green oozing.
The nurse is teaching a parent group about adolescent adherence to the immunization schedule. What complication of mumps will the nurse include in the teaching?
Sterility.
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?
Using a back-and-forth motion while cleaning the wound.
A nurse is caring for a 9-year-old child who is undergoing chemotherapy to treat leukemia. What is the priority nursing action?
Using techniques to minimize risk of infection.