PassPoint Questions
The nurse is preparing to administer an injection from an ampoule. To avoid injury, how should the nurse open the ampoule? A. Using a pad, break ampoule away from the body. B. Wearing gloves, break ampoule toward the body. C. Use a syringe without the needle attached to withdraw the medication. D. Ask the patient care technician to open the ampoule.
B. Wearing gloves, break ampoule toward the body. Explanation: Using a pad and breaking the ampoule away from the nurse protects the nurse from cutting from the sharp edge of the broken ampoule. Gloves are thin and can easily be cut by a broken glass. Using a syringe without a needle puts the nurse's fingers in direct contact with the broken glass. Asking the technician to open the ampoule without the proper technique puts the technician at risk of injury.
Which communicable disease requires isolating infected children from pregnant women? A. pertussis B. roseola C. rubella D. varicella
C. rubella Explanation: Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Pertussis, roseola, and varicella don't have any teratogenic effects on a fetus.
A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? A. "You could have gotten it by using I.V. drugs." B. "You must have received an infected blood transfusion." C. "You probably got it by engaging in unprotected sex." D. "You may have eaten contaminated restaurant food."
D. "You may have eaten contaminated restaurant food." Explanation: Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.
A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? A. Report the incident to the nursing regulatory agency. B. Complete an adverse drug reaction (ADR) report. C. Anticipate suspension from the facility due to the error. D. Report the incident to risk management.
D. Report the incident to risk management. Explanation: The incident should be reported to risk management in order to evaluate care, and determine potential risks or system problems that contributed to the error. This type of error will not be reported to the nursing regulatory agency, or result in the nurse's suspension. Some facilities track the number of errors made by a nurse, or that occur on a particular unit, in order to provide appropriate education, and to improve the nursing process. Adverse drug reaction forms are used to report a client's reaction to a medication, not errors.
A nurse is reviewing information about immunizations with a new mother. The nurse determines that the woman has an understanding of the information based on which client statement about active immunity? A. "Although it is only temporary, this immunity develops rapidly." B. "Antibodies in my blood are transmitted to my baby." C. "Direct exposure by a vaccine or disease leads to this type of immunity." D. "I can give it to my baby when I give him my breast milk."
C. "Direct exposure by a vaccine or disease leads to this type of immunity." Explanation: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but is temporary. Passive immunity may be transferred from mother to neonate.
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? A. ineffective coping B. hopelessness C. risk for injury D. disturbed personal identity
C. risk of injury Explanation: This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation. Although ineffective coping, hopelessness, and disturbed personal identity also are appropriate diagnoses, the client's safety takes highest priority. The nurse should take immediate action to protect the client from injury.
Several large boxes of supplies need to be relocated to another room on a client care area. Which action should be taken to prevent the staff from experiencing back injuries when moving these supplies? A. Break the boxes into smaller and lighter loads. B. Pull the boxes across the floor to the new location. C. Stack the boxes so more can be moved at one time. D. Push the boxes across the floor with the legs to the new location.
A. Break the boxes into smaller and lighter loads. Explanation: When needing to move large loads of boxes or heavy items, the loads should be broken into smaller loads. Loads should be limited to 35 pounds (16 kg). Pulling the boxes places strain on the lower back. Stacking the boxes so that more can be moved at one time increases the risk of a back injury. Pushing the boxes places strain on the arms and lower back.
To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this? A. By swabbing the labia minora from front to back B. By cleaning the labia minora from back to front C. By cleaning the labia majora from back to front D. By swabbing the entire perineal area
A. By swabbing the labia minora from front to back Explanation: The client should swab the labia minora from front to back, using one swab for each wipe, because this technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because this increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back — not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water.
A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus? A. sputum B. feces C. blood D. urine
B. feces Explanation: The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? A. Chickenpox B. Impetigo C. Measles D. Cholera
C. Measles Explanation: Measles warrants respiratory isolation, which aims to prevent disease transmission primarily over short distances through the air (droplet transmission). Other infections necessitating respiratory isolation include epiglottitis or pneumonia caused by Haemophilus influenzae, erythema infectiosum, meningitis caused by H. influenzae or meningococci, meningococcal pneumonia, meningococcemia, mumps, and pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and cholera, enteric isolation.
The nurse is caring for a client on an oncology unit who is refusing further chemotherapy treatment after the rationale for the treatment has been clearly explained. What is the nurse's best action? A. Support the client's decision and hold all treatments. B. Continue to provide treatment because it will benefit the client. C. Involve the client's family for encouragement to continue treatment. D. Tell the client that it is wrong not to accept treatment.
A. Support the client's decision and hold all treatments. Explanation: Supporting the client's decision is in concert with the ethical principle of autonomy. The other options violate autonomy and privacy of the client.
Which I.M. injection site might the nurse use for a 2-year-old child? A. Ventrogluteal muscle B. Pectoral muscle C. Femoral muscle D. Deltoid muscle
A. Ventrogluteal muscle Explanation: When administering an I.M. injection to a 2-year-old child, the nurse might select the ventrogluteal muscle if the muscle is well developed. However, the preferred site is the vastus lateralis. The pectoral, femoral, and deltoid muscles aren't appropriate injection sites for a child.
A nurse must obtain the blood pressure of a client in airborne isolation. Which method is best to prevent transmission of infection to other clients by the equipment? A. dispose of the equipment after each use B. wear gloves while handling the equipment C. use the equipment only with other clients in airborne isolation D. leave the equipment in the room for use only with that client
D. leave the equipment in the room for use only with that client
A nurse is caring for a client who is admitted to the hospital with a bowel obstruction. Which nursing action requires the use of sterile gloves? A. inserting a urinary catheter B. performing oral suctioning C. changing an oxygen system D. drawing blood for laboratory testing
A. inserting a urinary catheter Explanation: Inserting an indwelling urinary catheter is the only sterile procedure listed here. Gloves are not necessary when changing an oxygen system. The nurse should wear nonsterile gloves when drawing blood and performing oral suctioning.
The mother of a child with chickenpox (varicella) asks the nurse when her child may return to school. The nurse responds correctly by telling the mother that the child can return: A. when the fever has resolved. B. 24 hours after the appearance of the rash. C. when all of the lesions are crusted over. D. after the child receives the first dose of diphenhydramine.
C. when all of the lesions are crusted over. Explanation: The period of communicability for chickenpox begins 1 to 2 days before the appearance of the body rash and continues until all skin lesions have crusted over. The child may return to school after this period.
On entering the room of a client with chronic obstructive pulmonary disease (COPD), the nurse observes that the client is receiving oxygen at 4 L/minute by way of a nasal cannula. The nurse's next action should be based on which statement? A. "The flow rate is too high." B. "The flow rate is too low." C. "The flow rate is correct." D. "The client shouldn't receive oxygen."
A. "The flow rate is too high." Explanation: The administration of oxygen at 1 to 2 L/ minute by way of a nasal cannula is recommended for clients with COPD; therefore, a rate of 4 L/minute is too high. The normal mechanism that stimulates breathing is a rise in blood carbon dioxide. Clients with COPD retain blood carbon dioxide, so their mechanism for stimulating breathing is a low blood oxygen level. High levels of oxygen may cause hypoventilation and apnea. Oxygen delivered at 1 to 2 L/ minute should aid in oxygenation without causing hypoventilation. Oxygen therapy is the only therapy that has been demonstrated to be life-preserving for clients with COPD.
A nurse admits an older adult client with a history of osteoporosis experiencing a right wrist and hip fracture after a fall. Which intervention by the nurse is priority? A. Administer opioid analgesics as prescribed. B. Assist with activities of daily living. C. Give the client water as requested. D. Obtain data regarding skin integrity.
A. Administer opioid analgesics as prescribed. Explanation: Relieving pain and making the client more comfortable should have priority. Water should not be administered unless cleared by the surgeon in case the client requires surgery. Obtaining data regarding skin integrity and assisting with activities of daily living are important but not the priority at this time.
An 8-year-old child is brought to the clinic with watery eyes and clear nasal drainage that has lasted more than 10 days, without fever. The nurse observes that the child has dark circles under the eyes and a crease above the tip of the nose. Which intervention should be the nurse's priority? A. Collect data about potential environmental allergy triggers. B. Prepare to administer amoxicillin 25 mg/kg. P.O. every 12 hours. C. Prepare to administer trivalent inactivated influenza vaccine 0.5 mL P.O. D. Prepare the child for sinus x-rays.
A. Collect data about potential environmental allergy triggers. Explanation: Cold symptoms that last longer than 10 days without fever, dark circles under the eyes (from increased blood flow near the sinuses), and a crease near the tip of the nose (from upward nose wiping) are all signs and symptoms of perennial allergic rhinitis. The nurse's priority is to collect data about potential indoor and outdoor environmental allergen triggers. Amoxicillin is used to treat bacterial infections, not allergies. Additionally the nurse will not prepare medication for administration without the appropriate orders from the health care provider. Influenza vaccination is indicated annually. Sinus x-rays may be necessary to check for structural abnormalities, but they are not the priority at this time.
A client is admitted with diarrhea and dehydration. A stool culture shows Clostridium difficile. The nurse should institute which isolation precaution for this client? A. Contact B. Standard C. Airborne D. Droplet
A. Contact Explanation: The nurse should institute contact precautions for the client with Clostridium difficile infection because the microorganism can be transmitted by direct contact or indirect contact with environmental surfaces. Standard precautions should be used with every client when contact with blood or other body fluids is likely. Airborne precautions are necessary for clients known or suspected infection with microorganisms transmitted by airborne droplet nuclei, such as tuberculosis. Droplet precautions are used for clients infected with microorganisms contained in large droplets, such as influenza.
The nurse is assisting a client with cerebrovascular accident (CVA) with feeding. Which nursing action(s) promote(s) safety when feeding the client? Select all that apply. A. Have the client in a sitting position. B. Elevate the head of the bed. C. Position the client on the right side. D. Chat with the client while the client is eating. E. Check the mouth after feeding.
A. Have the client in a sitting position. B. Elevate the head of the bed. E. Check the mouth after feeding.
A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation? A. Isolation is not required at this time. B. Immediate isolation in a private room is required . C. Isolation would be required 10 days after exposure. D. Isolation would be required 12 days after exposure.
A. Isolation is not required at this time. Explanation: The incubation period for varicella (chickenpox) is 2 to 3 weeks, usually 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of a breakout. A person is infectious from 1 day before eruption of lesions to 6 days after the vesicles have formed crusts.
A nurse needs to administer prescribed medications to a client with heart failure. Prior to administering the medications, what actions should the nurse take? Select all that apply. A. Perform handwashing. B. Hold all the medications until the primary health care provider has examined the client. C. Check the client's medical record number and name on the identification bracelet. D. Check the client's allergies in the medical record, and verify them with the client. E. Ask the client if there are any medications that will be refused.
A. Perform handwashing. C. Check the client's medical record number and name on the identification bracelet. D. Check the client's allergies in the medical record, and verify them with the client. Explanation: To verify a client's identity, the nurse should read the identification bracelet and check at least two client identifiers, such as the name and medical record number. Handwashing is always performed prior to preparing medications for administration. The primary health care provider does not need to have examined the client before administration of previously prescribed medications. While clients have the right to refuse a medication, this is not something the nurse would ask the client in advance.
What is the nurse's most important intervention for a client having a tonic-clonic seizure? A. Protect the client from further injury B. Time the duration of the seizure C. Note the origin of seizure activity D. Insert a padded tongue blade to prevent the client from biting his tongue
A. Protect the client from further injury Explanation: protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.
A nurse is planning care for a client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A? A. fecal contamination and oral ingestion B. exposure to contaminated blood C. sexual activity with an infected partner D. sharing a contaminated needle or syringe
A. fecal contamination and oral ingestion Explanation: Hepatitis A is predominantly transmitted by the ingestion of fecal contaminated food. Transmission is more likely to occur with poor hygiene, crowded conditions, and poor sanitation. Hepatitis B and C are transmitted via exposure to contaminated blood and blood products; such exposure can occur during sexual activity with an infected partner or by sharing contaminated needles or syringes.
Several children at a day care center have been infected with hepatitis A virus. Which instruction reinforced by the nurse would reduce the risk of spreading hepatitis A to other children and staff members? A. hand washing after diaper changes B. isolation of the sick children C. using masks during contact with children D. sterilization of all eating utensils
A. hand washing after diaper changes Explanation: Children in day care centers are at risk of hepatitis A infection, which is transmitted via the fecal-oral route due to poor hand hygiene practices and poor sanitation. Isolation of sick children, use of masks during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection.
A school-age child begins to have a seizure while walking to the bathroom after an appendectomy. The nearby staff do not have the child's medical history. What is the nurse's first action? A. Notify the health care provider. B. Position the child on the side. C. Administer diazepam. D. Call a rapid response team.
B. Position the child on the side. Explanation: The child should first be eased to the floor and turned to the side to prevent aspiration. Notifying the health care provider will not be the first action or calling a rapid response team is not the immediate action, because the child's safety is of primary importance. Diazepam would be administered only if it had been ordered, but the nurse does not have that information at this time.
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis? A. Hold the neonate loosely and gently. B. Support the neonate's head and back with the forearm. C. Use one hand to support the neonate's head. D. Strap the neonate into the bath basin.
B. Support the neonate's head and back with the forearm. Explanation: To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with her forearm. A loose hold may increase the risk of dropping the neonate. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.
A nurse is caring for a client with a diagnosis of dissociative identity disorder (DID). Which client behavior should the nurse identify as a safety risk? A. The client experiences periods of lost time. B. The client expresses a desire to do self harm. C. The client expresses gladness to be in the unit. D. The client is hearing loud voices.
B. The client expresses a desire to do self harm. Explanation: The nurse needs to initiate safety precautions to prevent self-harm. The sensation of lost periods of time is not a safety issue. Being glad to be in the unit indicates a feeling of security. The client with DID hearing voices does not indicate a psychotic episode.
The health care practitioner uses nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes are ruptured, the nurse expects the paper will turn which color? A. pink B. blue C. yellow D. green
B. blue Explanation: Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink.
A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to A. bananas. B. latex. C. kiwi fruit. D. color dyes.
B. latex. Explanation: If a child is sensitive to bananas, kiwi fruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.
After completing a course on infection control, a licensed practical nurse (LPN) demonstrates knowledge of the use of standard precautions based on which statement? A. "Standard precautions should be implemented at the nurse's discretion, as the need arises." B. "Routine care activities may transmit human immunodeficiency virus (HIV), regardless of precautions." C. "Standard precautions are mandatory for use with all client care." D. "Standard precautions include measures related to transmission-based precautions.
C. "Standard precautions are mandatory for use with all client care." Explanation: The Centers for Disease Control and Prevention requires the use of standard precautions, which protect against blood and body fluid transmission of potential infective organisms, for all client care, and are not at the nurse's discretion. Routine care activities do not facilitate transmission of HIV. Transmission-based precautions, such as airborne precautions or droplet precautions, are used in addition to standard precautions against the spread of highly transmissible pathogens.
An 8-year-old client has tested positive for West Nile virus infection. The nurse suspects the client has the severe form of the disease when she recognizes which signs and symptoms? A. Fever, rash, and malaise B. Anorexia, nausea, and vomiting C. Fever, muscle weakness, and change in mental status D. Fever, lymphadenopathy, and rash
C. Fever, muscle weakness, and change in mental status Explanation: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise, anorexia, nausea and vomiting, and lymphadenopathy suggest the mild form of West Nile virus infection.
A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention? A. Have the parent give the child syrup of ipecac. B. Tell the parent to get the child to drink a glass of milk. C. Give the parent instructions on how to call poison control. D. Determine whether the parent knows cardiopulmonary resuscitation (CPR).
C. Give the parent instructions on how to call poison control. Explanation: The parent should call poison control and ask what immediate steps should be taken to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.
A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution? A. Ask if the client is really allergic to the medication. B. Give the medication as ordered by the NP. C. Hold the medication until speaking with the NP. D. Call the pharmacist and discuss a substitution for the medication.
C. Hold the medication until speaking with the NP. Explanation: The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.
A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse? A. Break the transfer down into smaller steps. B. Apply a back belt before beginning the transfer. C. Obtain an assistive device to help with the transfer. D. Recommend the client remain in bed until strength returns.
C. Obtain an assistive device to help with the transfer. Explanation: If any healthcare provider is required to lift more than 35 pounds (16 kg) of a client's weight, the client should be considered fully dependent and assistive devices should be used for the transfer. Breaking the transfer down into smaller steps will not help if the client is unable to assist. A back belt has not been proven effective in preventing injuries. Additional bedrest will cause the client to become further weak and debilitated.
A client begins to experience alcoholic hallucinosis. Which appropriate nursing intervention does the nurse implement at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes
C. Providing a quiet environment and administering medication as needed and prescribed Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or herself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.
While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action? A. Administer the medication immediately and chart it as given on time. B. Report the error and request a private meeting with the unit manager. C. Report the error, complete the proper paperwork, and meet with the unit manager. D. Contact the physician and follow their instructions.
C. Report the error, complete the proper paperwork, and meet with the unit manager. Explanation: Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, the nurse must still report the error and complete the proper paperwork. The nurse should contact the physician and follow their instructions, but shouldn't bypass proper protocol.
When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next? A. Rinse their eyes with water, record the incident on the client's chart, and see Employee Health. B. Wash their hands, complete an incident report, and see a physician as soon as possible. C. Rinse their eyes with water, report the incident, and go to Employee Health. D. Rinse their eyes, contact Employee Health and document their findings.
C. Rinse their eyes with water, report the incident, and go to Employee Health. Explanation: Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their may allow viral transmission through contact with the mucous membranes.
A nurse is reinforcing education with parents on how to reduce the spread of impetigo. What should the nurse encourage the parents to do? A. Teach children to cover mouths and noses when they sneeze. B. Arrange for their children to be immunized against impetigo. C. Teach children the importance of proper hand washing. D. Isolate a child with impetigo from other members of the family.
C. Teach children the importance of proper hand washing. Explanation: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing will not prevent its spread. Currently, no vaccine exists to prevent a child from contracting impetigo. Isolating a child with impetigo is unnecessary
A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority? A. Have three staff members present, one to restrain each side of the client's body and one for the head. B. Tie restraints securely to the side rails. C. Use an organized, efficient team approach to apply and secure the restraints. D. Secure restraints to the bed with knots to prevent the client from escaping.
C. Use an organized, efficient team approach to apply and secure the restraints. Explanation: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots.
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: A. develops rapidly and is temporary. B. occurs by antibody transmission. C. results from exposure of an antigen through immunization or disease contact. D. may be transferred by mother to neonate.
C. results from exposure of an antigen through immunization or disease contact. Explanation: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it's temporary. Passive immunity may be transferred by mother to neonate.
A nurse is assisting with planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety? A. Apply a restraining vest to keep the client from getting out of bed. B. Orient the client to the room so the client can find the way to the bathroom. C. Lower the side rails so the client can get out of bed more easily. D. Place the call bell within the client's reach and ensure the client knows how to use it.
D. Place the call bell within the client's reach and ensure the client knows how to use it. Explanation: To reduce the risk of injury and falls in a client with both eyes patched, the nurse should place the call bell within reach and instruct the client how to use it. Because the client is alert and oriented, applying a restraint to keep the client in bed is inappropriate. If activity prescriptions allow limited ambulation, such as to the bathroom, the nurse should explain the importance of calling for assistance when getting out of bed. When the client is in bed, the side rails should be raised for safety.
The nurse is caring for a preschool child just diagnosed with impetigo. What is the most important action the nurse should take to prevent the spread of impetigo to others? A. Cover the area. B. Isolate the child at home. C. Apply an antibacterial ointment. D. Teach child and family good handwashing techniques.
D. Teach child and family good handwashing techniques. Explanation: Handwashing is the most important action that a nurse or client can take to prevent the spread of infection. Covering the area or applying an antibacterial ointment does not stop the spread of infection, nor does isolating the child.
