PN NCLEX EVOLVE: Safety Q's

A client who is recovering from a brain attack (stroke) has residual dysphagia. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

Given the client thin liquids Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned. Liquids should be thickened to avoid aspiration. Food is placed on the unaffected side of the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which action?

Check the placement of the tube Rationale: Before administering the feeding, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. In order to prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Formulas are administered at room temperature. Options 2 and 4 are not directly related to the subject of the question.

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and Gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with body fluids, such as wound drainage, diarrhea, or ileostomy or colostomy drainage. Masks are not required unless droplet or airborne precautions are necessary.

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that the client needs further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible Rationale: The oxygen concentrator is kept slightly away from the walls and corners to permit adequate airflow. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use. This could result in fire and injury to the client. Therefore, a straight razor is used for shaving. The client should follow the oxygen prescription exactly and should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include keeping the source out of direct sunlight; having telephone numbers for the health care provider, nurse, and oxygen vendor available; and teaching the client signs and symptoms requiring emergency care.

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Water pad Rationale: The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client's weight on the device. These include foam, water, gel, or alternating air pads. A plastic-lined pad absorbs moisture but provides no pressure relief. A pillow provides cushion but does not redistribute weight equally. An air ring relieves pressure in some spots but causes pressure in others by its design.

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000/mm3. Based on this laboratory result, which action should the nurse include in the plan of care?

using a soft toothbrush for mouth care Rationale: If a child is severely thrombocytopenic, with a platelet count less than 20,000/mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. Additionally, suppositories and rectal temperatures are avoided. The incorrect options relate to the prevention of infection rather than bleeding.

The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which statement by the client indicates adequate understanding of cold therapy treatment?

I should wrap the frozen ice pack in a warm towel to help adjust to the cold. Rationale: Cold therapy should be used for only 15 to 20 minutes 2 or 3 times a day. The client needs to be instructed not to place ice directly between the skin and a firm surface. The weight of the body and the low temperature of the ice may produce ischemia. The skin should be checked for signs of injury. The frozen ice pack is taken from the freezer and should be wrapped in a warm towel to help the client adjust to the cold

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container Rationale: The correct procedure for needle disposal is to discard uncapped needles and sharps in a hard-walled, puncture-resistant, leak-proof container immediately after use. Discarding the uncapped needle and attached syringe in a designated sharps container prevents injury to the client and health care personnel. Recapping needles increases the risk of needle-stick injury. Options 1, 3, and 4 are unsafe actions.

The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the client tells the nurse that a space heater is used to heat the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater need to be placed at least 3 feet from anything that can burn Rationale: Space heaters need to be used appropriately because they present a great risk of fire. A space heater needs to be placed at least 3 feet from anything that can burn. Placing a heater in a hallway does not guarantee that it will be 3 feet from anything that can burn. A low setting does not reduce the risk of fire. A space heater can be used in an apartment if there is ample space and safety precautions are followed.

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide (Lasix), penicillin (Nafcillin) and ibuprofen (Motrin). He has received ibuprofen (Motrin) twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total pts. (moderate risk) Rationale: Score the fall risk as follows: Age: 1 point; Fall History: none; Elimination: none; Medication: on one high fall-risk: diuretic, furosemide (Lasix): 3 points; Patient Care Equipment: 3 points (3 or more present: IV infusion, indwelling catheter, sequential compression devices (SCD); Mobility: 2 points (requires supervision for mobility); Cognition: none. Total: 9 points

The registered nurse (RN) tells a licensed practical nurse (LPN) that the health care provider has prescribed a hypotonic intravenous (IV) solution for a client. Which IV solution should the LPN obtain for administration to the client?

0.45% saline Rationale: Five percent dextrose in water is an isotonic solution; 10% dextrose in water and 5% dextrose in 0.9% saline are hypertonic solutions; 0.45% saline is hypotonic and is probably the only hypotonic solution used in clinical situations. Distilled water is another example of a hypotonic solution. Hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution.

Home History Help Calculator Review ModeQuestion 25 of 25 Previous ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse determines that the client understands the proper fitting of the crutches when he states that which amount of space should be between the axilla and the top crutch pad?

1 1/2 to 2 inches Rationale: The client should have a distance of 1½ to 2 inches between the axilla and the top of the crutch pad to prevent injury to the brachial nerve plexus while maintaining proper support. This measurement should be taken with the client holding the crutches with the elbows bent at a 30-degree angle. The other options are incorrect.

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

DO you have a history of seizure? How long have you been using ginkgo? DO you have a history of clotting disorder? Have you been diagnosed with diabetes mellitus? Rationale: Clients with a history of seizures should not use this supplement because it may increase the frequency of seizure activity. Asking how long the client has been taking the supplement is an appropriate question. Ginkgo has been shown to affect clotting time. Diabetics should not use this supplement because it may affect glucose levels. Ginkgo is taken by mouth; it is not applied as a cream.

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

I need to be sure to place my cup of coffee on the counter Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove and to turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. Option 3 does not reflect an adequate understanding of the principles of safety.

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should avoid which action when performing this procedure?

Placing suction on the catheter while introducing the catheter into the tracheostomy tube Rationale: Suction is not placed on the catheter when the catheter is introduced into the tracheostomy tube. Suction draws out oxygen, and placing suction on the catheter at this time could traumatize tracheal tissue. The remaining options are appropriate components of the plan of care for suctioning.

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

Provide adequate lighting Ensure that frequently used items are easily accessible, Have the bedside stand and over bed tray table within reach Rationale: One action is to provide adequate lighting. Ensure that frequently used items, such as the telephone, eyeglasses, or other personal belongings, are easily accessible. Place bedside table and overbed table within reach. Restraints should not be used because they can cause the client to become more agitated. Leaving both side rails down on the bed of an older client increases the risk of falling, especially if the client will be reaching down to obtain a needed item.

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe delivery of the oxygen the nurse should avoid which action?

Secures the oxygen tubing to the client's bottom sheet. Rationale: If the tubing is attached to the client's bed linen, it will become dislodged from the nares whenever the client moves. The tubing should have sufficient slack and be secured to the client's clothes. Keeping the humidification jar filled will help prevent the client from breathing dehumidified oxygen. The nares should be checked frequently because oxygen will dry the nasal mucosa. Oxygen is a medication and its prescription should be verified every shift to ensure the correct rate.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The health care provider visits and prescribes restraints if needed. Which action is appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

Socialize with the restrained client. Remove the restraint and perform range of motion activity Reapply the restraint after assisting the client to the bathroom Rationale: The skill of applying restraints can be delegated to the UAP whom the nurse knows is competent in caring for a client with restraints. The nurse is responsible to document the mental status of the client necessitating the restraints. The nurse must determine the appropriate type of restraint and frequency of position change. The UAP may perform care including meeting mobility, hydration, nutrition, elimination, and socialization needs and removing and reapplying restraints under the direction of the nurse.

The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location should the nurse select to administer the medication?

Vastus lateralis muscle Rationale: The vastus lateralis muscle is the best choice for all age groups and should always be used in children younger than 3 years of age. The ventrogluteal muscle is safe for children older than 18 months because it is free of major blood vessels and nerves. The dorsogluteal muscle develops with walking, so it should not be used until the child has been walking for at least 1 year. The deltoid muscle is not used for children because the small muscle mass cannot hold large volumes of medication or medications that must be injected deep into the muscle mass.

The nurse is administering intramuscular iron to an assigned client. The nurse should take which action to avoid skin staining around the injection site?

se a Z-track method for administration Rationale: Proper technique for administering iron by the intramuscular route includes using a Z-track technique and changing the needle after drawing it up, but before the medication is given. The medication should be given in the upper outer quadrant of the buttock, and not in an exposed area such as the arms or thighs. The site should not be massaged after injection.

The nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further teaching

I need to refer to medication As CANDY only when really necessary Rationale: Home safety measures are very important to prevent unnecessary childhood poisoning or death. Toxic substances should be labeled with green poison stickers and placed in a locked area out of reach of children. The poison control center telephone number should be visible near all telephones. Medications should be stored in childproof containers. Medicine should never be referred to as "candy." This could tempt a child to try to eat it when the parents are not in the immediate vicinity.

The nurse plans to admit a client who has seizure precautions prescribed. Which pieces of equipment should be available at the client's bedside in the hospital room? Select all that apply.

Clean Gloves Oxygen with nasal cannula setup Suction machine with oral catheter Rationale: Seizure precautions are interventions prescribed for clients at high risk of having a seizure. This involves keeping equipment at the client's bedside to protect and attend quickly to the needs of the client during a seizure. Clean gloves, oxygen with a nasal cannula setup, and a suction machine with oral catheter should be at the client's bedside. A defibrillator is not used to stop seizures. Limb restraints and padded tongue blades are strictly contraindicated for use during a seizure. Clients should not be restrained and should have their body parts, especially the head, protected from injury during a seizure. Nothing should be placed in the mouth when the teeth are clenched because this will lead to injury. An oral airway or biteblock could be inserted if the nurse recognizes in advance that a client will have a tonic-clonic seizure.

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which action by the client shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?

The client adjust the setting downward slightly. Rationale: The client applies a transcutaneous electrical nerve stimulation unit by placing two electrodes on the skin and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block painful stimuli has been reached. The volume is then reduced slightly until no further discomfort occurs. The other options are incorrect.

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours Rationale: Restraints should be completely removed for a brief period at least every 2 hours, and this action should be documented in the nurse's notes. The color of the extremity should be noted, and the pulse should be assessed. The client should be asked to move the extremity, or range-of-motion exercises should be performed. Agency guidelines regarding the use of restraints should always be followed.

The nurse is reinforcing instructions to a client with chronic vertigo. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home Rationale: The client should keep the home environment free of clutter for general safety. The client should remove throw rugs because the effort of trying to regain balance after slipping could trigger the onset of vertigo. The client with chronic vertigo should avoid all driving and should use public transportation because the sudden movements could begin an attack. The client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture.