PrepU: Chapter 27 - Fundamentals
Correct response: Dilute with water or milk. Explanation: The decision tree for treating ingested poisons states that if petroleum is ingested, it should be diluted with water or milk, vomiting should be prevented, hydration should be given, and symptoms should be treated. Therefore, it is not appropriate to call 911, induce vomiting, or administer a laxative.
A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide? a. Call 911. b. Induce vomiting. c. Administer a laxative. d. Dilute with water or milk.
Correct response: Flush the eyes with water for 10 minutes. Explanation: If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.
A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care? 1. Wash the eyes with a hypertonic solution for at least 30 minutes. 2. Advise the client to avoid blinking until after the eyes are irrigated. 3. Flush the eyes with water for 10 minutes. 4. Flush the eyes with a cool saline solution for a 10-minute period.
Correct response: Conceal IV tubing with gauze wrap Explanation: Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Request a sedative from health care provider Conceal IV tubing with gauze wrap Ask visiting family member to stay Assure bed alarms are activated
Correct response: Avoid unattended baths for the toddler. Explanation: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety.
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? a. Instruct the toddler not to go near the pool. b. Avoid unattended baths for the toddler. c. Monitor the activities of the toddler. d. Allow the child to swim with friends.
Correct response: "How did the nurse's actions contribute to this error?" Explanation: Key to the establishment of a just culture is a recognition that not all errors are the same, and that nurses' contributions to errors vary greatly. Legal liability and communication with the client are valid considerations, but none directly promote the establishment of a just culture. It is of little value to learn how other organizations have responded to nurses during similar events once the research phase of establishing a just culture is completed.
A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error? a. "How did the nurse's actions contribute to this error?" b. "How have other organizations responded to nurses in events like this?" c. "Have the client and the family been informed about this?" d. "What is the organization's legal liability in this matter?"
Correct response: The nurse should question the client about the source of the bruises. Explanation: The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? a. The nurse should notify the primary care physician about the bruises. b. The nurse should contact the facility's social services department. c. The nurse should question the client about the source of the bruises. d. The nurse should request permission from the client to photograph the bruises.
Correct response: mass trauma terrorism. Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death.
During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: mass trauma terrorism. chemical terrorism. bioterrorism. nuclear terrorism.
Correct response: using pesticides for mosquitoes Explanation: Community problems such as water supply contaminated with sewage or tick infestations near residential areas also can result in infection. Influenza immunization is concentrated in the fall and winter. Antibiotic administration is not a prevention program but one geared to disease treatment. Fans may be delivered to older adults but this intervention will not reduce infection.
The health department is reviewing community health initiatives for the year. During the summer, the health department focuses infection control implementation activities on which program? a. administering influenza immunizations b. administering free antibiotics c. using pesticides for mosquitoes d. delivering fans to older adult residents
Correct response: Take a layperson's class to learn the Heimlich maneuver. Remove the soft pillow from the crib. Continue to supervise mealtimes for the children. Explanation: Recommendations the nurse would make to the new parents include taking a class on how to perform the Heimlich maneuver in case a child lodges an object in the throat. The nurse would recommend removing the pillow from the crib, as the infant could place his or her face in the pillow and suffocate. The nurse would tell the parents to continue supervising mealtimes to monitor for choking. The crib slats should be 2.375 inches (6 cm) or less apart. If a regular sized soda can fit through the slats of a crib, then the slats are too far apart. Larger spaces than 2.375 inches (6 cm) allow the infant to get his or her head stuck between the slats. Food should be cut into 1/2-inch pieces for the toddler aged 18 months old. The toddler could choke on bite size pieces of food. The nurse would not make this recommendation.
The nurse is assessing the home of new parents who adopted two siblings, one an infant and the other a toddler 18 months old. The nurse notes the following in the home. The parents have no experience with the Heimlich maneuver. The crib slats measure less than 2.375 in (6 cm) apart, and there is a soft pillow in the crib. The parents cut food into small pieces (approximately 1/2 inch in size) for the toddler and supervise mealtimes. What recommendations would the nurse make to the parents to provide for safety from asphyxiation or choking? Select all that apply. Take a layperson's class to learn the Heimlich maneuver. Replace the crib slats so the openings allow a regular sized soda can to fit through. Remove the soft pillow from the crib. Cut food into larger pieces, such as bite size, for the toddler. Continue to supervise mealtimes for the children.
Correct response: temporary application of devices that reduce the client's ability to move arms Explanation: If diversion behaviors and chemical (drug) restraints have failed, the nurse anticipates that the provider may order temporary application of devices to reduce the client's ability to move arms, which will prevent the behavior. The other actions are not appropriate, so the nurse would not anticipate them.
The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered? a. temporary application of devices that reduce the client's ability to move arms b. administration of an antipsychotic agent to alter the client's behavior c. delegating to the unlicensed assistive personnel (UAP) to sit with the client d. providing a sleep agent to help the client rest instead of pulling IV lines and the catheter
Correct response: 1 medium banana Explanation: The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will mark off a banana from the menu of a client with latex sensitivity
The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed? a. 1 medium banana b. handful of walnuts c. ½ cup of pineapple d. 3 ounces of chicken
Correct response: hot water heater thermostat set at 130 degrees F (54.4 degrees C) Explanation: The nurse will intervene if the hot water heater thermostat is set above 120 degrees F (48.8 degrees C). This could cause burning to an infant's skin. Other findings enhance safety within the home.
The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention? 1. hot water heater thermostat set at 130 degrees F (54.4 degrees C) 2. infant's sleepwear is made from flame-resistant fabrics 3. one fire extinguisher noted in the kitchen 4. electrical outlets with covers over them
Correct response: Refrain from using extension cords. Explanation: Extension cords should not be used so that overload is not placed on electric wires and circuits. For safest practices that decrease risk for electric shock, outlets and switches should be covered, machines that are used infrequently should be unplugged, and plugs should be removed from the wall by grasping the actual plug (not the cord).
The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock? a. Leave outlets and switches open so air circulates through them. b. All machines that are used infrequently are to remain plugged in. c. Remove the plug from the wall by pulling the electric cord. d. Refrain from using extension cords.
Correct response: the 2-year-old leaning against the screen of a window in a classroom Explanation: Windows pose a serious risk to toddlers. Screens can easily give way to the weight of a toddler. This is an unsafe behavior. Toddlers thrive in exploration. The parent must be fastidious in monitoring and helping the toddler accomplish tasks. The buddy system is a great safety tool for school-age children.
The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse? a. the 2-year-old leaning against the screen of a window in a classroom b. the 2-year-old and 6-year-old each holding the mother's hand c. the 2-year-old helping mom to open the front door of the school d. the 6-year-old riding a bike on the playground with his friend
Correct response: "Check breathing and heart rate." Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. After that, rescuers attempt to identify what was ingested, how much, and when. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach.
The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse? "Check breathing and heart rate." "What do you think that the child might have ingested?" "At what time did the child ingest the substance?" "Induce vomiting while you wait for emergency personnel to arrive."
More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep.
Which factor is related to the highest proportion of falls in long-term care settings? 1. Toileting 2. Agitation 3. Polypharmacy 4. Impaired sleep patterns
Correct response: "I have removed all throw rugs on the floor." Explanation: Nurses must evaluate the effectiveness of their interventions to promote safety and prevent injury. If the expected client outcomes have been met and evaluative criteria satisfied, the client should be able to correctly identify real and potential unsafe environmental situations and implement safety measures in the environment. Keeping the outside lights on would help to deter outside intruders. Placing a phone by the bed does not prevent injury. While taking courses in cardiopulmonary resuscitation (CPR) and first aid is a great way to be prepared for injury, it is not a method of preventing injury.
Which statement by a client would indicate that a nurse had successfully implemented an educational strategy to prevent injury in the home? a. "I turn off the outside lights and lock the doors every night." b. "I place my phone next to my bed during the night for emergencies." c. "I have removed all throw rugs on the floor." d. "I have taken a CPR and first aid class."
