Prep-U Safety and Infection Control
Which instruction should a nurse include in an injury-prevention plan for a pregnant client?
"Take rest periods during the day." Explanation: The client should be instructed to avoid becoming fatigued and to take rest periods during the day. Fatigue can lead to injuries. The nurse should instruct the client to wear a seat belt below the tummy, not across it, and to position the steering wheel toward her chest, not her abdomen, to prevent injury to the fetus. Learning a new activity or sport while pregnant can lead to injury.
The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?
Contact the surgeon for clarification because this is not a complete order. Explanation: After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.
A nurse is administering a newly prescribed IV antibiotic to a client who suddenly develops wheezing and dyspnea. Which of the following is the nurse's priority action?
Discontinue the antibiotic infusion Explanation: The nurse should first discontinue the antibiotic because it is the most likely cause of the allergic reaction. Next, oxygen should be administered followed by administration of epinephrine and/or diphenhydramine as ordered.
A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access device. He's scheduled to receive amphotericin B I.V. Which action would be most appropriate for the nurse to take?
Tell a nursing assistant to stay with the client during the infusion. Explanation: The client needs the medication to combat the protozoal infection. Because he has been dislodging the I.V. access devices, a staff member should remain with him during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; appropriate nursing action allows for the drug's administration.
The nurse is reviewing the content of a prescription before giving it to a client. The nurse determines that the prescription is accurately written when which information is included on the prescription? Select all that apply.
healthcare provider signature frequency dose Explanation: Information needed on the perscription includes: the date, client name, medication (trade and generic name), dose, route, frequency, quantity, and signature of prescriber. The pharmacy name and telephone number of the client are not required.
Which of the following objects poses the most serious safety threat to a 2-year-old client in the hospital?
side rails in the halfway position Explanation: Side rails in the halfway position pose the biggest threat because the most common accidents in hospitals are falls. To prevent falls, the crib rails always should be raised and fastened securely unless an adult is at the bedside. Crayons and paper and a stuffed teddy bear are safe toys for a 2-year-old client. Although a mobile could pose a safety threat to this client, the threat is less serious than that posed by an incorrectly positioned side rail.
A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:
advance both crutches. Explanation: The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.
A client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, what should the nurse tell the client?
Any contaminated linens should be washed separately and then washed a second time, if necessary. Explanation: The client may excrete the chemotherapeutic agent for 48 hours or more after administration. Blood, emesis, and excretions may be considered contaminated during this time, and the client should not share a bathroom with children or pregnant women. Any contaminated linens or clothing should be washed separately and then washed a second time, if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste.
A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the morning medications, "That's not my pill! My pill is blue, not green." What should the nurse tell the client?
"I'll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color." Explanation: It is important for the nurse to listen to the client and respect his or her knowledge about the medication. In the other options, the nurse dismisses the client's concern or gives a possible explanation without checking out the specific situation. If the nurse has taken the wrong medication, the client can prevent a medication error, and if there has been a color change, the nurse can let the client know that information. In either case, helping a psychotic client deal with reality appropriately is therapeutic.
A nurse is caring for a client after a hemorrhoidectomy. Which of the following orders would the nurse question on the medical record?
Low-fiber diet Explanation: The nurse would question a low-fiber diet. Increased fluids and fiber would be encouraged to prevent constipation. Warm sitz baths would decrease rectal muscle spasms. A stool softener would be indicated to prevent straining.
Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which of the following statements indicates the primary reason for the nurse manager to perform an investigation to determine the causes of the two falls?
"I would like to establish the causes and trends related to client falls." Explanation: The analysis will identify variations in performance that cause or could cause the clients to fall. It will identify the answer to the question of "how can we prevent this from happening again?" It does not place blame on individuals; rather, it looks at systems and processes. The other answers do not support the definition of root cause analysis.
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.
The nurse is performing a surgical dressing change and drops a sterile gauze on the bedside table outside of the sterile dressing tray's field. What would be the most appropriate action of the nurse?
Discard the gauze and use another sterile piece. Explanation: The correct answer demonstrates that the nurse is aware of the contamination of the gauze and that it should not be used. The nurse must provide safe, competent, and ethical care. The other options are incorrect because using the contaminated gauze in any circumstance, especially when the nurse is aware of the risk to the client, would not be demonstrating safe and competent care.
A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of her car and beginning to approach the client's building, a group of men begin following and jeering at her. Which of the following is the nurse's best response to this situation?
Leave the area in her car, provided she can get to it safely. Explanation: The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove herself from the situation, provided this can be achieved without incurring further risk.
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 airborne isolation?
Measles Explanation: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?
Placing the client in respiratory isolation Explanation: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances.
A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?
airborne precautions Explanation: Transmission of SARS can be contained by airborne precautions that include an insolation room with negative pressure, use of N-95 respirator, and use of personal protective equipment. The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sufficient to prevent transmission. Reverse isolation (protection of the client) is not sufficient to prevent transmission.
A nurse observes a 10-month-old infant chewing on the security alarm attached to his identification bracelet. The nurse should:
distract the infant with a more appropriate toy. Explanation: Distraction with an appropriate chewing toy provides safety and is developmentally supportive. Removing the security device isn't appropriate; it must remain attached to the infant. Telling an infant not to chew on the security device isn't appropriate because chewing is typical behavior at the age of 10 months. Instructing the infant's parents about the safety hazard isn't the best response; doing so won't eliminate the immediate hazard and doesn't refocus the infant's attention.
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?
every 15 minutes Explanation: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.
A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
respiratory isolation Explanation: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the client's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.
When planning home care for a 3-year-old child with eczema, what should the nurse teach the mother to remove from the child's environment at home?
stuffed animals Explanation: For the child with eczema, which is commonly related to an allergic response, stuffed animals should be avoided because they tend to collect dust and are difficult to clean. Metal toy trucks, plastic figures, and wooden blocks are suitable toys for a 3-year-old child. They are easy to keep clean.
An emergency department nurse is awaiting the arrival of multiple persons exposed to botulism at the local shopping mall. What should the nurse do?
Activate the facility's emergency disaster plan. Explanation: The nurse should activate the facility's emergency disaster plan to ensure availability of sufficient personnel and supplies. The Centers for Disease Control and Prevention and local health departments are the designated agencies responsible for collaboration with hospital agencies regarding community biochemical exposures. The Public Health Agency of Canada and the the Department of Public Safety and Emergency Preparedness are the designated agencies responsible for disaster coordination in Canada and should notify all community agencies of the incident. The nurse must implement standard precautions, not contact precautions, to prevent botulism transmission from one person to another. It is not necessary to quarantine exposed individuals.
A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?
Apply cool water to the burned area. Explanation: To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.
A client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate?
Attach the ties of the restraints to the bedframe. Explanation: Restraints should be secured to the bedframe, not the siderails, to ensure that the siderails can be raised and lowered safely. Circulation checks, reevaluating need for restraints, and documentation should be done every 1 to 2 hours. Medical restraint prescriptions must be renewed and signed by a HCP every 24 hours
While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first?
Hang a new bag of D5W, and complete an incident report. Explanation: Maintenance of IV sites and systems includes regular assessment and rotation of the site and periodic changes of the dressing, solution, and tubing; these measures help prevent complications. The nurse should also observe the solution for discoloration, turbidity, and particulates. An IV solution is changed every 24 hours or as needed, and because the nurse noted an abnormal color, the nurse should change the bag of D5W and note this on an incident report. It is not necessary to verify this action with another nurse. Paging the HCP is not necessary; maintaining the IV and using the correct solutions is a nursing responsibility. Although the first action is to hang a new bag, hospital policy should be followed if there is a question as to whether there could have been an unknown substance in the bag that caused it to change color.
An 8-year-old child with juvenile idiopathic arthritis (JIA) is being admitted to the hospital for evaluation of progressively increasing symptoms. The child weighs 60 lb (27 kg) and is 50 inches (127 cm) tall. The nurse is reconciling the medications the parent brought from home with the medications prescribed. (See chart.) What should the nurse do?
Request a cetirizine prescription from the health care provider (HCP). Explanation: If the child was taking cetirizine for allergies, the nurse should contact the HCP for a prescription to continue the medication in the hospital. The provider should either prescribe the medication or provide a valid reason to discontinue its use. Advising the family to take a home supply of medications increases the risk of adverse reactions because the provider would be unaware of potential medication interactions. Many allergy medications that formerly required a prescription are now available over the counter, and because parents use them the nurse should be aware of the interactions and risks. The nurse does not need to question the methotrexate prescription as this medication is being added to treat the JIA.
The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence?
"How safe do you feel in your home?" Explanation: The act of screening for intimate partner violence is a key intervention to help open doors for at risk women to discuss ways to improve their safety and well-being. Asking clients how safe they feel in their home open is an open-ended, nonjudgmental way to elicit perceptions of safety. Asking if a partner is excited about a pregnancy is not a good screening question because many couples are not excited to learn of an unplanned pregnancy. However couples with healthy relationships eventually adjust. Having an arrest record and gun ownership do not automatically equate to having a history of violence.
The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?
Maintain a tidy environment around the child. Explanation: Visually impaired children explore their environment by feel. A tidy and organized environment can support this and promote the child's safety. It is a priority to make sure all items that could potentially injure the child are removed from the environment. This includes meal trays and supplies for procedures.
A nurse is helping a client move up in the bed. Which action maintains good body mechanics?
Having the client help himself as much as possible Explanation: When moving up in bed, the client's assistance will reduce strain on the nurse. The nurse may have to adjust the bed to a higher position, so it isn't possible to always keep the bed in a low position. However, the low position is preferred unless the client's medical condition contraindicates it. If the client folds his arms, he can't help pull or push himself up in the bed.
An infant is being admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant?
a private room Explanation: Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room.
A toddler receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would the nurse discourage for this child?
fresh strawberries Explanation: When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and vegetables may pose a health risk due to possible bacterial contamination. All other foods are either cooked or pasteurized and would not produce a health risk.
An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?
verify that the site, side, and level are marked. Explanation: As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.
A child who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond?
"Wear gloves when you're likely to come into contact with the child's blood or body fluids." Explanation: HIV is transmitted by blood and body fluids. Therefore, the nurse should respond by telling family members to wear gloves when anticipating contact with the child's blood or body fluids. Standard household methods for cleaning dishes and utensils are adequate, so the child needn't use disposable plates and utensils. To disinfect HIV-contaminated surfaces, the nurse should instruct the foster parents to use a solution of 1 part bleach to 10 parts water. The child may share toys; any toys that become soiled with the child's blood or body fluids should be disinfected with the bleach solution.
A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priory intervention?
Ask for additional information from the client. Explanation: The client experienced an event that needs follow up. The nurse should ask for additional information and from there determine what further action is needed. The nursing supervisor should be contacted after additional information is received. The hospital administrator does not need to be contacted.
A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?
Client's level of consciousness Explanation: A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.
Which activity should a nurse recommend to prevent foreign body aspiration in a child during meals?
Insist that the child remain seated while eating. Explanation: A child should remain seated while eating. The risk of aspiration increases if the child is running, jumping, or talking with food in his mouth. Television and toys are a dangerous distraction to toddlers and young children and should be avoided during meals. A child needs constant supervision and should be monitored while eating snacks and meals.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that she forgot to administer insulin to client with diabetes mellitus. She's made numerous errors in the past few weeks and is now afraid her job is in jeopardy. What is her best course of action?
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 her 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, she must still report the error and complete the proper paperwork. The nurse should contact the physician and follow his instructions, but she shouldn't bypass proper protocol.
Which type of restraint is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair?
elbow restraints Explanation: Recommended restraints for a child who has had palate surgery are elbow restraints. They minimize the limitation placed on the child but still prevent the child from injuring the repair with fingers and hands. A safety jacket or wrist or body restraints restrict the child unnecessarily.
Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply.
medical record number name band Explanation: A National Patient Safety Goal of The Joint Commission is to improve the accuracy of client identification; to attain that goal, health care personnel must use at least two client identifiers when providing care, treatment, or services. The medical record number and name as printed on the client's name band are appropriate identifiers. Because the client can change rooms and beds, these are not to be used as identifiers. Social security number is not used as an identifier for health care or treatment purposes.
A client experiencing neutropenia is in reverse isolation. When the client asks why the family has to wear a mask, which explanation is best?
"It is to protect you from outside infections introduced by others." Explanation: Neutropenia is an abnormally low level of neutrophils making the client susceptible to infections. Care needs to be provided to limit exposure to infections by both healthcare workers and family who are visiting. While it is true that reverse precautions are a standard of care prescribed by health care providers, this does not fully answer the client's question. Stating the goal of protecting the client from outside infections from all who encounter the client is the best explanation.
A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection?
practicing thorough hand washing Explanation: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.
X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?
"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." Explanation: When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.
The nurse is receiving an intubated client from the emergency room. What practices will the nurse follow during the start of the admission? Select all that apply.
Confirm client's name band. Match client's name in the electronic health record. Explanation: The intubated client will need to have a name band and the nurse will match the client's name in the electronic health record. The client will not be able to speak. The client belongings are not emergent and notification of security is not necessary.
A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?
Intradermal drugs diffuse more slowly. Explanation: Drugs administered intradermally (injected between the skin layers, just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapidly introducing an allergen could cause a life-threatening allergic reaction in a sensitive client. The ease of administration and client comfort are not principles taken into account when using intradermal injections for allergy testing.
A client is scheduled for a computed tomography (CT) of the chest with contrast media. Which of the following findings should the nurse report immediately to the healthcare provider?
The client is allergic to shellfish. Explanation: Allergy to shellfish can indicate an allergy to contrast media and needs to be reported to the healthcare provider. A CT scan is an open therefore claustrophobia should not be an issue. There is no caution with metal in a CT scan. Use of the inhaler is not contraindicated since the medication is rapidly absorbed.
A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss?
infection control Explanation: The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.
The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?
60, high risk Explanation: Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safety.
Which family member exposed to tuberculosis would be at highest risk for contracting the disease?
76-year-old grandmother Explanation: Elderly persons are believed to be at higher risk for contracting tuberculosis because of decreased immunocompetence. Other high-risk populations in the United States and Canada include the urban poor, clients with acquired immunodeficiency syndrome, and minority groups.
A nurse is preparing to administer a medication to a client and discovers that the seal on the vial is broken. What is the priority action by the nurse?
Contact the pharmacy for a new vial. Explanation: The nurse's best response is to send the medication back to the pharmacy and ask for a new one. The healthcare provider nor the supervisor will be able to obtain the medication. Do not administer the medication, the nurse does not know if the vial has been contaminated; do not obtain the medication from another client's drawer, this is unsafe, the dosage may not be the same.
A 7-year-old child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray?
fork Explanation: For a child with chorea-like movements, safety is of prime importance. Feeding the child may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with the tines.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?
Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:
is appropriate for the neonate. Explanation: The correct size covers the nose but not the eyes. The mask is too large if it covers the neonate's eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin.
When a client has a tearing of tissue with irregular wound edges, the nurse should document this as
laceration. Explanation: The nurse should document a tearing of tissue with irregular wound edges as a laceration. A contusion or a bruise is a closed wound caused by a blunt object resulting in bleeding in underlying tissue. An abrasion is a superficial wound from a rubbing or a scraping of the surface of the skin such as from a fall. Colonization is a wound containing microorganisms.
A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?
Restrain the client, as he is harmful to the other clients. Explanation: The nurse should restrain the client because he is potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client.
A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply.
Taking small steps with feet shoulder length apart when walking on wet surfaces. Removing clients from the area where a fire is reported. Using tongs to place a dislodged radioactive device in a lead container. Explanation: There are a number of situations that could compromise safety where an appropriate response will minimize risk. People should not walk under ladders, move unidentified objects during a bomb threat, or directly touch radiation sources. Clients should be safe before an employee starts to fight a fire. Wet conditions make footing slippery, so if it is necessary to walk on a wet surface the person should use a wide base of support and take small steps.
When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client?
a security window in the door or a room camera Explanation: When using seclusion, the safety of the client is paramount. Therefore, staff must be able to see the client in seclusion at all times, such as through a security window in the door or with a room camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is not critical for the client's safety. Having one staff member stay in a room alone with a potentially violent client is unsafe. A prescription for seclusion can be obtained before or after it is initiated.
The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement?
"I cannot wait to get home to my cat!" Explanation: The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's white blood cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods. Platelet production will be decreased, and the client will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of 100° F (37.8° C) or higher.
The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse?
Complete an incident report. Explanation: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.
A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?
Contact the physician and obtain necessary orders. Explanation: If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. Applying a wrist restraint instead of a vest restraint is inappropriate if a vest restraint is genuinely necessary. It would be inappropriate to delegate this aspect of care to a family member.
During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which of the following activities should the nurse perform after finishing the incident report?
Include the time and date of the incident. Explanation: The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the mistake should not be highlighted in the client's records. As the client report is a legal document, it should not contain the name of the nursing assistant.
An HIV-positive client discovers that his name is published in a report on HIV care prepared by his nurse. He strongly opposes this and files a lawsuit against the nurse. Which of the following offenses has this nurse committed?
Invasion of privacy. Explanation: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.
A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention?
Maintain the client on respiratory isolation Explanation: This client is showing signs and symptoms of active TB and, because of the productive cough, is highly contagious. He should be admitted to the hospital and placed in respiratory isolation. Three sputum cultures should be obtained to confirm the diagnosis.
While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next?
Open the client's airway. Explanation: The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be the necessary or appropriate action once the client's airway has been opened.
Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed?
Place the client in a high Fowler's position. Explanation: Many clients feel faint and weak when helped to ambulate for the first time after surgery. The client's circulatory system needs time to adjust to an upright position before the client is helped to a standing position. This is best done by placing the client in high Fowler's position in bed for a few minutes. After becoming accustomed to a sitting position, the client can then be helped to dangle the feet at the edge of the bed before ambulating. Although analgesics can promote comfort for the postoperative client, some can sedate the client and should not be given at the time the client is assisted out of bed. Having the client lie on the side of the bed or do leg exercises will not prepare the client to dangle the legs.
The nurse teaches a safety and accident prevention class to a group of third graders. Which preventive measure should the nurse stress during the first class?
car safety Explanation: Motor vehicle accidents are the most common cause of accidental injury and death in children ages 1 to 12 years. Measures should be emphasized that prevent accidents involving motor vehicles, bicycles, or motorized bikes. Therefore, car safety should be emphasized. This includes keeping children in a booster seat until they are 4 feet 9 inches (145 cm), which typically occurs between the ages of 8 and 12. After reaching that height, children must still ride in the backseat until they are older than 12 years of age. A seatbelt should be used anytime the child rides in a car. Burns are a major cause of accidental injury in children under 1 year of age to school age, and flame-retardant clothing would be an appropriate safety strategy. However, because burns are not the most common cause, this topic could be dealt with after discussing motor vehicle safety. Drowning is a major cause of accidental injury and death in school-aged children, and the use of life preservers is appropriate. However, because drowning is not the most common cause, this topic could be dealt with after discussing motor vehicle safety. Eye injuries do occur, but they are not the most common cause of accidental injury and death in children 1 to 12 years of age.
The nurse is ready to administer a partial fill of imipenem-cilastatin in the IV pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. The nurse should first:
determine when the client received the last dose of the imipenem-cilastatin. Explanation: The nurse should first determine whether the client received the last dose of imipenem-cilastatin. If the client did not receive the last dose, the nurse should notify the health care provider (HCP) that the client did not receive the dose, receive prescriptions, document, implement the prescriptions, and complete an incident report. The nurse should not automatically discard the partial fill of imipenem-cilastatin found at the client's bedside until further investigation is done. The nurse should recognize the cost of medications such as imipenem-cilastatin and consult the pharmacist after identifying information on the partial fill bag that was found. After verifying all information, the nurse can administer the new partial fill of imipenem-cilastatin so that the client can receive the antibiotic on time.
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct?
Making a copy of the incident report for the client Explanation: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the physician of the incident and the client's condition.
A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next?
Notify the physician and security immediately. Explanation: The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security because they're specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen, and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.
A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action?
Observe individuals in the area for large bags or oversized coats. Explanation: The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be a responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.
A client's blood pressure is elevated at 160/90 mm Hg. The health care provider (HCP) prescribed "clonidine 1 mg by mouth now." The nurse sent the prescription to pharmacy at 0710, but the medication still has not arrived at 0800. The nurse should do all except:
go to the pharmacy to obtain the drug. Explanation: Although the nurse needs to obtain and administer the medication as soon as possible, it is inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy and checking to see whether the medication was delivered. The drug may have been delivered to several appropriate spots on the unit, such as the client's drug bin, the transport system, or the delivery box. The nurse should assess the client's blood pressure to determine the immediacy of the condition for which the medication was prescribed.
A client found sitting on the floor of the bathroom in the day treatment clinic has moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at the lacerations. What is the most important action for the nurse to take next to the client?
Approach the client slowly while speaking in a calm voice, calling her by her name, and telling her that the nurse is there to help her. Explanation: Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that she is there to help, the nurse should carefully observe the client's response. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine her injuries without first announcing her presence and assessing the dangers of the situation.
In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After her lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence her husband represents. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the nurse who witnesses this scene?
Calling a security guard and another staff member for assistance Explanation: The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, nurse should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective in his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.
In which areas of the United States and Canada is the incidence of tuberculosis highest?
inner-city areas Explanation: Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence.
When the nurse is preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain?
padding for the side rails Explanation: The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.
A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella?
"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children." Explanation: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.
A nurse is caring for a client diagnosed with a chlamydia infection. The nurse teaches the client about disease transmission and advises the client to inform his sexual partners of the infection. The client refuses, stating, "This is my business and I'm not telling anyone. Beside, chlamydia doesn't cause any harm like the other STDs." How should the nurse proceed?
Educate the client about why it's important to inform sexual contacts so they can receive treatment. Explanation: The nurse should educate the client about the disease and how it impacts a person's health. Further education allows the client to make an informed decision about notifying sexual contacts. The nurse must maintain client confidentiality unless law mandates reporting the illness; contacting sexual contacts breaches client confidentiality. Doing nothing for the client is judgmental; everyone is entitled to health care regardless of his health habits.
A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the medical record. Which action would be most appropriate for the nurse to implement?
washing hands before and after entering the room Explanation: Chemotherapy causes myelosuppression with a decrease in red blood cells (RBCs), WBCs, and platelets. This client's data demonstrate neutropenia, placing the client at risk for infection. An ANC of 500 to 1,000/mm3 (0.5 to 1 × 109/L) indicates a moderate risk of infection; less than 500/mm3 (0.5 × 109/L) indicates severe neutropenia and a high risk of infection. When the WBC count is low and immature WBCs are present, normal phagocytosis is impaired. Precautions to protect the client from life-threatening infections may be instituted when ANC is less than 1,000/mm3 (1 × 109/L). Hand washing is the best way to avoid the spread of infection. It is not necessary to wear a gown and mask to take care of this client. It is also not necessary to restrict visitors; however, visitors should be screened to avoid exposing the client to possible infections. Erythropoietin is used for stimulating RBCs, not WBCs. Granulocyte colony-stimulating factors or granulocyte macrophage colony-stimulating factors are useful for treating neutropenia.
