Quizzes - Safety and infection control
Which factor puts the nurse at highest risk for developing acute stress disorder after working during a mass casualty event? Took breaks Talked to clergy Contacted family Worked for 24 hours Correct answer
To decrease the risk of acute stress disorder during a mass casualty event, nurses would not work more than 12 hours per day. The nurse that has worked 24 hours is at highest risk for acute stress disorder. Using available counseling, taking regular breaks, and keeping in contact with family and friends decrease the risk of acute stress disorder.
Which action will the nurse include in the plan for care for a client after a bronchoscopy examination?Check for the gag reflex.Correct answerSend the client for a chest x-ray examination.Assess breathing every 30 minutes.Your answer is incorrectHave the client avoid the Valsalva maneuver.
After bronchoscopy, the nurse will assess for return of the gag reflex before providing anything by mouth. A chest x-ray examination is not needed after bronchoscopy but would be prescribed after diagnostic procedures such as thoracentesis. Breathing should be assessed at least every 15 minutes for 2 hours after bronchoscopy. The Valsalva maneuver is safe to perform after bronchoscopy.
Based on their conditions, which client would be triaged first according to the 3-tiered triage system? Client A Correct answer Client B Client C Client D Your answer is incorrect
Client A reporting chest pain is considered to have a life-threatening condition and is triaged as emergent. Clients B and C having displaced or multiple fractures and renal colic need quick treatment but are not considered to have immediately life-threatening conditions, particularly when compared with client A's condition. They are triaged in the urgent tier level. Client D with strains and sprains is triaged as nonurgent because this client has strains and sprains and can wait for treatment.
The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach? To prevent a confused client from pulling out an intravenous (IV) line To prevent an adult client from getting up at night when there is insufficient staffing on the unit Correct answer To maintain immobilization of a client's leg to prevent dislodging a skin graft To keep an older adult client from falling out of bed after a surgical procedure
Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.
The nurse teaches a client who is concerned about hepatitis transmission routes. Which type of hepatitis spreads more frequently through food? A Correct answer B C D
An RNA virus transmits hepatitis A, also known as an infectious hepatitis, via the fecal-oral route, most frequently though food. Hepatitis B transmission occurs parenterally, sexually, and by direct contact with infected body secretions. An RNA virus causes hepatitis C and is transmitted parenterally. Hepatitis D is a complication of hepatitis B.
Punctal occlusion is performed after the administration of eyedrops to prevent which from occurring? Tearing Infection Allergic reaction Systemic absorption Correct answer
Punctal occlusion prevents systemic absorption of the medication. For example, systemic absorption of beta-blockade used to treat glaucoma can affect heart rate and blood pressure. Punctal occlusion does not prevent tearing, infection, or allergic reaction.
Which training will help nurses identify signs of biological terrorism? Mass casualty incident (MCI) Hazardous materials (HAZMAT) Correct answer Federal Emergency Management (FEMA) Community Emergency Response Team (CERT)
Staff in the emergency department will be trained for HAZMAT, which they will use to manage the handling and identification of hazardous materials. An MCI is the actual disaster where there are many casualties. FEMA is a federal agency that oversees emergency responses across the country. The CERT responds to disasters for search and rescue, but not managing hazardous materials.
Which priority action would the nurse perform when caring for a client with suspected anaphylaxis? Obtain full set of vital signs. Assess airway and oxygenation. Correct answer Determine level of consciousness. Notify the client's health care provider.
The first action the nurse will perform when caring for a client with suspected anaphylaxis is to assess respiratory status including airway and oxygenation. Next the nurse will notify the Rapid Response Team. After the airway and oxygenation have been assessed, the nurse will obtain vital signs, assess level of consciousness, and notify the health care provider.
The nurse finds that her or his surgical mask has become moist before going to a surgery. Which would the nurse do? Dispose of the mask and put on a new one. Correct answer Wait until the mask gets dry and then enter the operating room. Do not cough or sneeze while wearing the mask. Talk less after wearing the mask to minimize respiratory airflow.
The nurse would dispose of a mask if it gets moist or wet because the mask might have been contaminated. The nurse would not wait until the mask gets dry; instead, the mask should be changed. Coughing or sneezing should be avoided when the nurse is in a sterile area. The nurse would talk less after wearing a dry or sterile mask to minimize respiratory airflow.
A client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem. Which response by the nurse is best? 'This is an unfortunate situation, but there was such a limited supply available.' 'There are many others who were unable to obtain a flu vaccine this month.' 'The limited supply doesn't really matter because the vaccine is for one particular strain.' 'There are other things you and your family can do to prevent the flu, such as hand washing.' Correct answer
The statement 'There are other things you can do to prevent the flu, such as hand washing' is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response 'It's unfortunate, but there was such a limited supply available' is empathic, but it does not address the client's concern of vulnerability. The response 'There are many others who also were unable to get a flu vaccine' belittles the client for being concerned. The response 'It doesn't matter because the vaccine is for just one particular strain' may be true, but it belittles the client's concern.
Which diagnostic test result indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)? Level of immunoglobulin M (IgM) in the client's blood The number of CD4+ T cells available Correct answer Presence of antigen-antibody complexes Speed with which the virus invades the ribonucleic acid (RNA)
Whether HIV becomes AIDS depends on the number of CD4+ T cells. IgM and the presence of antigen-antibody complexes have no effect on HIV. The speed with which HIV invades the RNA has no effect on the future development of AIDS.
When interviewing and assessing a 17-year-old client, which findings alert the nurse to explore substance abuse with the adolescent? Select all that apply. One, some, or all responses may be correct. Failing grades Correct answer Blood spots on clothing Correct answer Absenteeism from school Correct answer Long-sleeved shirts in warm weather Correct answer Separating emotionally from the family Your answer is incorrect
Adolescents are developing independence and should be assessed for risk-taking behaviors such as drug abuse. Signs of drug abuse include failing grades and absenteeism because school performance is impacted, as well as blood spots on clothing and long sleeves in warm weather, which is related to intravenous (IV) drug use. Separating emotionally from family is a normal development finding in adolescents.
Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station? Red Black Green Correct answer Yellow
An emergency triage system uses colored tags to designate both the seriousness of the injury and the likelihood of survival. Green would be used for minor injuries such as the victim who is able to ambulate independently. Red indicates life-threatening injuries requiring immediate attention. Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening injuries.
Which action is required before several disaster medical assistance team (DMAT) nurses from Pennsylvania can provide health care to hurricane victims in South Carolina? Applying for licensure in South Carolina Showing Pennsylvania state nursing license None because the nurses are acting as federal employees Correct answer Calling the National Council for the State Boards of Nursing and request licensure Your answer is incorrect
Because licensed health care providers such as nurses act as federal employees when they are deployed, their professional licenses are recognized and valid in all states. There is no need for the nurses to apply for licensure in South Carolina, show Pennsylvania license, or call the National Council for the State Board of Nursing to request licensure.
Which condition is triaged as urgent among these client conditions? A Correct answer B C D
Client A with displaced or multiple fractures does not have an immediately life-threatening condition, but needs immediate treatment when compared with other clients, so is considered urgent and triaged under urgent. Client B with a skin rash, client C with strains and sprains, and client D with a simple fracture could wait several hours and are triaged as nonurgent.
The nurse is managing the care of several clients today. Which client poses the highest risk for harming others? A 16-year-old female with depression who cuts A 20-year-old male who has been incarcerated Correct answer A 25-year-old female with binge-eating disorder A 30-year-old male with autism spectrum disorder Your answer is incorrect
Demographic risk factors for possible anger and aggression issues include males between the ages of 14 to 24 years of age who have no support systems and have served time in prison. Therefore the 20-year-old male who has been incarcerated has the highest risk for harming others. Both the client with depression who cuts and the client with binge-eating disorder are at risk for self-harm but not at an increased risk for harming others. Because the autism spectrum is so large, more information would be needed to determine the risk of this client harming others.
The nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery would the nurse report to the primary health care provider immediately? Small amount of yellowish-green oozing Correct answer Moderate area of serosanguineous oozing Epithelialization under the nonadherent dressing Separation of the edges of the nonadherent dressing
Any amount of yellowish-green oozing indicates infection and should be reported immediately. Serosanguineous oozing is expected. Epithelialization under the nonadherent dressing indicates healing and is desirable. Separation of the edges of the nonadherent dressing is not a problem.
Which nursing action helps reduce the development of health care associated methicillin-resistant Staphylococcus aureus (HA-MRSA)? Applying triple antibiotic ointment to puncture sites Bathing clients every other day with soap and tepid water Bathing clients with chlorhexidine gluconate (CHG) solution Correct answer Performing hand hygiene with soap and water after removing gloves Your answer is incorrect
Current evidence shows that bathing hospitalized clients with premoistened cloths or warm water containing CHG solution can significantly reduce HA-MRSA infection by 23% to 32%. Topical antibiotic ointment, every other day bathing, and washing hands with soap and water after removing gloves are not identified as reducing HA-MRSA.
The nurse educator is presenting to a group of nurses about the use of de-escalatory techniques. Which actions would the nurse include in the presentation? Select all that apply. One, some, or all responses may be correct. Identify client needs. Correct answer Stand close to the client. Use a loud and commanding voice. Determine stressors and triggers. Correct answer Refrain from arguing with the client. Correct answer
De-escalatory techniques that should be included in the presentation include identifying client needs, determining stressors and triggers, and refraining from arguing with the client. These techniques can help prevent the situation from becoming worse. The nurse would keep a safe distance from the client, because getting too close to the client can increases anxiety. The nurse would use a calm, clear tone of voice when talking with the client.
Which factor increases an adolescent's risk for injury in the community? Employment Eating disorders Sleep deprivation Distracted driving Correct answer
Studies show 60% of teens report texting and emailing while driving. Employment, eating disorders, and sleep deprivation are not factors that increase the risk of injury in the community setting.
Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? Pica Correct answer Caffeine intake Alcohol abuse Artificial sweetener use
The practice of pica, especially the ingestion of heavy metals, must be considered when pregnant women are found to be anemic. Caffeine, alcohol, and artificial sweeteners are not directly linked to anemia in pregnant women.
A child is admitted with a fever of 103°F (39.4°C), stiffness of the neck, and general malaise. Which is the priority nursing intervention for this child? Increasing fluids Administering oxygen Giving a tepid sponge bath Instituting droplet precautions Correct answer
Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort.
Which method of delivering client care works well in disaster situations? Team nursing Your answer is incorrect Primary nursing Functional nursing Correct answer Total client care nursing
The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Team nursing, primary nursing, and total client care nursing are not the ideal models for delivering client care during disaster situations.
Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. Switch positions every 4 hours. Use a heating pad for the first 24 hours. Apply for 30-minute time intervals. Correct answer Place the ice pack directly to injury site. Take ibuprofen every 4 hours PRN.
To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.
Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. Monitoring vital signs Correct answer Cutting off the clothing Correct answer Inserting a urinary catheter Correct answer Removing the client's jewelry Correct answer Establishing an intravenous line Correct answer
According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client's clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids.
Which finding would the nurse be most concerned about in the client receiving a bolus of magnesium sulfate intravenously for the treatment of preeclampsia? Flushing Diaphoresis Blurred vision Correct answer Burning at the intravenous (IV) site
Blurred vision is a symptom of magnesium toxicity. Flushing, diaphoresis, and burning at the IV site are common side effects of the magnesium sulfate.
When planning nursing care for a child with acute poststreptococcal glomerulonephritis, which would the nurse emphasize that the child and family must maintain? A bland diet high in protein Bed rest lasting at least 4 weeks Isolation from children with infections Correct answer A daily intramuscular dose of penicillin
During the acute stage, anorexia and general malaise lower the child's resistance to infection, so the child should be isolated from others with infections. A bland diet is not necessary, but high-protein and high-sodium foods should be avoided. Bed rest is not a necessary restriction. It is encouraged when the child is easily fatigued. Antibiotics are not necessary for all children with acute glomerulonephritis, only those with persistent streptococcal infections. The intramuscular route is not used.
Which information would the nurse provide to a toddler's parent who asks how to prevent burns at home? Select all that apply. One, some, or all responses may be correct. Place cords out of reach. Correct answer Turn pot handles to the side. Your answer is incorrect Use protective guards on outlets. Correct answer Keep hot curling irons out of reach. Correct answer Turn burner knobs to the 'off' position. Your answer is incorrect
Home safety practices to prevent burns include the following: placing cords out of reach, inserting protective outlet guards, and keeping curling irons out of reach. Pot handles should be turned toward the back of the stove to prevent the child from reaching up and pulling the hot contents onto themselves. Burner knobs should be removed entirely so toddlers cannot accidentally turn the burners on.
Which assessment question will help the nurse determine the source of the lead when admitting a toddler with symptoms of lead poisoning? 'What year was your home built?' Correct answer 'Do you have plants in your home?' 'Does your child consume fish?' 'Where do you store your cleaning solutions?'
Homes built before 1978 may contain lead-based paint, which increases the risk for lead poisoning; therefore this is an appropriate question for the nurse to ask the parents of this child. Plants, fish, and cleaning solutions are not associated with lead poisoning.
Which diseases require implementation of droplet precautions? Select all that apply. One, some, or all responses may be correct. Scabies Shingles Measles Your answer is incorrect Pertussis Correct answer Diphtheria Correct answer
Pertussis and diphtheria are infectious diseases known to be transmitted by droplets. Shingles and measles are infectious diseases known to be transmitted by air. Scabies is an infectious disease transmitted by direct contact.
The nurse teaches a couple about how to care for their newborn who has just been circumcised. Which statement made by the infant's father would lead the nurse to conclude that the teaching has been effective? 'We shouldn't expect fussy behavior.' 'We should leave the baby undiapered.' 'We should apply petrolatum gauze to the penis.' Correct answer 'We should notify the clinic if we see a yellow discharge.' Your answer is incorrect
Petrolatum gauze helps control bleeding and prevents adherence to the diaper. Fussy behavior is expected for a few hours after the procedure. Leaving the baby undiapered is not practical with a male infant. Observing yellow exudate covering the glans penis for 2 to 3 days after a circumcision is normal and should not be removed during that time because it is a sign of healing and not an infectious process.
After the nurse provides education about all-terrain vehicle (ATV) safety for a parent of a 11-year-old child, which statement made by the parent indicates an understanding of the information? 'I will have my child ride with an adult.' 'I will make sure my child wears a helmet.' Your answer is incorrect 'I will make sure my child does not get on an ATV.' Correct answer 'I will make sure my child has had safety training before he or she rides.'
The American Academy of Pediatrics recommends that children under 16 years of age not ride in or operate an ATV. The child should not ride with another adult. When the child is 16 years of age and begins riding an ATV, safety gear such as a helmet should be worn and proper safety training should be implemented.
Which information would the nurse provide a client with a new colostomy about managing the appliance? Use stoma powder for fungal rashes. Wash peristomal area with soap first. Your answer is incorrect Measure stoma once a month for size. Cut opening 1/8- to 1/16-inch larger than stoma. Correct answer
The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore it is important to measure the stoma once a week and cut the opening 1/8- to 1/16-inch larger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powder is used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.
Which action would the nurse take when preparing to discharge a 3-day-old newborn whose birth weight was 3800 grams and who currently weighs 3344 grams? Continue the discharge plan. Notify the health care provider. Correct answer Instruct the mother to supplement feedings with formula. Instruct the mother to alternate feedings with breast milk and formula. Your answer is incorrect
The health care provider should be notified of the newborn's 12% weight loss. An acceptable weight loss is 10% or less in the first 3 to 5 days of life. Discharging the newborn, encouraging the mother to supplement feedings with formula, or instructing the mother to alternate feedings with breast milk and formula would be inappropriate actions.
Which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis? Select all that apply. One, some, or all responses may be correct. Wear a mask during the procedure. Correct answer Clean the catheter exit site every day. Correct answer Maintain meticulous aseptic technique. Correct answer Wash your hands before the exchange. Correct answer Store supplies in a clean and dry location. Correct answer
The location of the peritoneal dialysis catheter makes it a direct portal to the peritoneum, which increases the client's risk for peritonitis. The nurse would ensure that the client understands the importance of preventing peritonitis when providing instructions on performing peritoneal dialysis. The client would be instructed to wear a mask during the procedure, especially when changing connector sets. The nurse would show the client how to properly clean the area around the catheter exit site and instruct that this be done every day to remove secretions. The client must be aware that meticulous aseptic technique throughout all phases of the exchange is essential. Proper hand-washing technique would be demonstrated and the client instructed on the importance of hand washing before the exchange. Supplies would be stored in a clean and dry place.
The nurse is developing a plan of care for a client who underwent extensive oral surgery for head and neck cancer. Which interventions would the nurse include in the plan to prevent infection? Select all that apply. One, some, or all responses may be correct. Protect incision site. Correct answer Elevate head of the bed. Remove thick secretions. Correct answer Offer small frequent feedings. Your answer is incorrect Provide oral care at least every 4 hours. Correct answer
The nurse must take care to protect the incision site, remove thick secretions, and provide oral care at least every 4 hours to prevent infection. Elevating the head of the bed prevents aspiration. When the client can initiate oral intake, small, frequent feedings prevent aspiration.
When preparing to administer medications to a client, which action made by the new nurse requires an intervention? Obtaining vital signs Scanning medications Using one client identifier Correct answer Assessing level of orientation
The nurse should always use two client identifiers to verify the client before administering any medication. Therefore the nurse only using one client identifier requires intervention. The nurse should obtain vital signs before administering certain medications. All medications should be scanned before giving them to the client. Level of orientation will assist the nurse in identifying the client's ability to take the medications.
After teaching a client measures to decrease the risk for antibiotic-resistant infections, which statements made by the client indicate understanding of content? Select all that apply. One, some, or all responses may be correct. 'I should wash my hands frequently.' Correct answer 'I should skip doses when I am completely well.' 'I should avoid taking antibiotics to treat the common cold.' Correct answer 'I should save unfinished antibiotics for later emergency use.' 'I should avoid taking antibiotics without asking the primary health care provider.' Correct answer
Hand washing is necessary to prevent infections. Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. Clients should take antibiotics only after asking the primary health care provider. Clients should not stop taking antibiotics even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. Clients should not save antibiotic doses for later use because old antibiotics can lose their effectiveness, and in some cases can even be fatal if taken.
Which nursing behavior is essential when working with leadership personnel during the activation of the emergency preparedness plan? Triage Assessment Collaboration Correct answer Resource management
During an actual disaster, the nurse works in collaboration with leadership personnel to organize nursing and ancillary services to meet client needs. Although essential nursing skills, triage, assessment, and resource management are not identified as being essential when working with leadership personnel during a disaster.
Which statement indicates a client understands transmission of the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. 'I can contract HIV by participating in oral sex.' Correct answer 'I can contract HIV by eating from used utensils.' 'HIV is contracted by using contaminated needles.' Correct answer 'I can contract HIV by using the bathroom of a person who is HIV positive.' 'Babies can contract HIV because of contact with maternal blood during birth.' Correct answer
HIV is transmitted sexually through oral sex. HIV is transmitted through the use of contaminated needles. HIV is transmitted by contact with maternal blood during the birthing process. HIV cannot be transmitted by sharing eating utensils or using the bathroom of a person who is HIV positive.
Which product would the nurse instruct intravenous drug users (IDUs) to use for cleaning of needles and syringes between uses?BleachCorrect answerHot waterAmmoniaRubbing alcoholYour answer is incorrect
IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.
A full-term infant who is large for gestational age (LGA) should be monitored for which risk? Hypotension Hypothermia Hypocalcemia Hypoglycemia Correct answer
Infants that are LGA are considered at risk for hypoglycemia, and their glucose should be monitored following a protocol. LGA infants are not at an increased risk for hypotension, hypothermia, or hypocalcemia.
Which would be monitored in a client in labor who takes iron with levothyroxine every morning at breakfast? Anemia Infection Preeclampsia Correct answer Thyroid storm
Levothyroxine is prescribed for hypothyroidism. Ferrous sulfate should be taken at least 4 hours apart from levothyroxine. When taken together, the ferrous sulfate decreases the absorption of T 4, increasing the client's risk for inadequately treated hypothyroidism. Pregnant women with untreated or inadequately treated hypothyroidism are at risk for preeclampsia. The risks for anemia and infection are not increased. A thyroid storm is associated with hyperthyroidism.
Which topics will the nurse include when educating the parents of an adolescent on home safety? Nutrition needs Monitoring of schoolwork Limiting video game time Keeping firearms locked away Correct answer
Parents will be instructed to keep firearms locked and put away to promote safety in the home. Nutrition, grades and schoolwork, and limiting video game time are factors related to maintaining adolescent health but are unrelated to safety.
An infant is being admitted to a pediatric unit with bacterial meningitis. Which is the priority nursing action? Assessing the infant's neurological status Your answer is incorrect Beginning intravenous fluids and antibiotics Implementing respiratory isolation precautions Correct answer Teaching the parents the importance of maintaining a quiet environment
The infant's illness, bacterial meningitis, is contagious, and the nurse, as well as other clients, must first be protected with the implementation of respiratory isolation precautions. Assessment of neurological status would be performed after implementing isolation. Parental teaching and implementation of prescribed fluids and antibiotics may be done after assessment. Also, antibiotics are usually not administered until after all cultures have been obtained.
The nurse is educating a client on the use of heat and cold for osteoarthritis (OA) pain. Which action by the client indicates the need for additional teaching?Places ice pack on skinCorrect answerUses ice pack for 20 minutesApplies lightweight heating padTests water before getting into shower
When using hot and cold packs, clients will be instructed to avoid placing ice packs directly on the skin because it can cause damage. To prevent skin injury, clients will be instructed to use ice packs for 20-minute intervals, apply a lightweight heating pad, and test the water temperature before getting into the shower.
Surgical asepsis means that the defined area will contain no microorganisms. The purpose of personal protective equipment is to protect self from microorganisms in the wound. Confining the microorganisms to the surgical incision site and keeping the number of opportunistic microorganisms to a minimum apply to medical, not surgical, asepsis.
Which action would the nurse take when preparing to change a client's dressing using surgical asepsis? Keep the area free of microorganisms. Correct answer Protect self from microorganisms in the wound. Confine the microorganisms to the surgical incision site. Limit the number of opportunistic microorganisms to a minimum.
To which disaster triage class would the nurse infer a client with a green triage tag belongs? Class I Class II Class III Correct answer Class IV
The green disaster triage tag is issued to nonurgent or 'walking-wounded' clients who belong to class III. A red disaster triage tag is issued to clients who require immediate treatment and belong to class I. Clients with yellow and black tags belong to class II and IV respectively.
The nurse is caring for a client with dysphagia. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. Recline after meals. Rinse mouth with water. Your answer is incorrect Keep suction equipment nearby. Correct answer Provide thickened liquids. Correct answer Sit in high Fowler position. Correct answer
The nurse would keep suction equipment close to the client and provide thickened liquids to a client on aspiration precautions. The client should sit in a high Fowler position during and after meals to prevent aspiration. The client should not recline after meals. Using unthickened water to rinse out the mouth could lead to aspiration.
Which are the priority emergency assessments the nurse will perform for a client with bomb blast injuries? Select all that apply. One, some, or all responses may be correct. Airway Correct answer Breathing Correct answer Circulation Correct answer Giving comfort measures Facilitating family presence Exposure or environmental control Correct answer
The primary survey focuses on airway-breathing-circulation (ABC) and environmental control. These are surveyed during emergency assessments in a primary survey to identify life-threatening conditions and to analyze the appropriate interventions. Giving comfort measures and facilitating family presence are performed in a secondary survey of emergency assessment followed by a primary survey.
Which clinical findings would the nurse recognize as indicative of possible neglect of a 5-year-old child? Select all that apply. One, some, or all responses may be correct. Enuresis Your answer is incorrect Lacerations Your answer is incorrect Malnutrition Correct answer Poor hygiene Correct answer Sleep disturbances
Malnutrition and poor hygiene are signs of physical neglect. Enuresis and sleep disorders are signs of emotional neglect. Lacerations may indicate physical abuse.
Which intervention is the nurse's priority when caring for a child with human immunodeficiency virus (HIV)? Maintaining optimal hydration Protecting the child from infection Correct answer Promoting growth and development Ensuring adequate and balanced nutrition
Children with HIV have a dysfunction of the immune system (depressed or ineffective T cells, B cells, and immunoglobulins) and are susceptible to opportunistic infections; infection can result in death. Although optimal hydration is important, insufficient hydration is not as potentially life threatening as an infection. Although children with HIV are most likely small for their age, and it is important to promote growth and development, inability to do so is not as potentially life threatening as an infection. Although adequate and balanced nutritional intake is important, it is not the priority because it is not as potentially life threatening as an infection.
According to triage based on tier levels, which client conditions would receive higher priority? Select all that apply. One, some, or all responses may be correct. Stroke Correct answer Skin rash Active hemorrhage Correct answer Respiratory distress Correct answer Chest pain with diaphoresis Correct answer Displaced or multiple fractures Your answer is incorrect
Clients presenting with signs of a stroke, active hemorrhage, respiratory distress, or chest pain with diaphoresis should be triaged under the emergent tier level because the conditions are life threatening. Clients with a skin rash are categorized as nonurgent because treatment can be delayed. Displaced or multiple fractures are triaged as urgent, which needs quick treatment but is not immediately life threatening.
The nurse is discussing suicide risk with the parents of a group of adolescents. Which types of suicide would the nurse discuss when talking about soft methods? Select all that apply. One, some, or all responses may be correct. Guns Hanging Ingesting pills Correct answer Carbon monoxide Your answer is incorrect Cutting one's wrists Correct answer
Ingesting pills and cutting one's wrists are lower-risk methods and are soft methods. Higher-risk methods include using guns, hanging, or carbon monoxide.
Which suicide method would indicate a low threat of lethality? Hanging Ingesting pills Correct answer Jumping from a tall bridge Poisoning with carbon monoxide
Ingesting pills is considered the least lethal of these suicide methods, because it is considered slower. Hanging, jumping, and carbon monoxide poisoning are all quicker and therefore more lethal methods.
A 2-year-old boy living on a farm is found to have a roundworm (Ascaris lumbricoides) infestation. The nurse teaches the mother about the transmission of these parasites. Which statement indicates that the mother needs further teaching? 'The rest of the family won't need the medicine.' Your answer is incorrect 'My little boy won't be able to play in the fields until he gets older.' 'We're going to have to wash everyone's bedding in soapy water every day.' Correct answer 'We're going to have to make sure vegetables are well cooked before we eat them.'
It is not necessary to wash bedding daily because roundworm is not transmitted by fomites. Because the organism is not transmitted from person to person, the family does not have to be medicated. It is advisable to keep small children from playing in areas where there is dirt because young children explore their environment by putting their hands and objects in their mouths. Cooking vegetables should destroy the organism if it is present, so it is advisable.
Which parental statement would the nurse recognize as placing the children at risk for injury? 'I take my children to the hill at the park to sled.' 'I watch my children sled in the backyard of our home.' 'My children like to pull each other down the street on the sled.' Correct answer 'The children both sit together and slide down the hill on the sled.'
Sledding accidents are more likely to occur when children ride sleds without adult supervision and in streets, as opposed to parks. Riding a sled down the hill at the park, sledding supervised in the backyard, or sledding together down a hill does not necessarily place children at risk for injury.
The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. Administer intravenous (IV) levothyroxine. Correct answer Avoid use of corticosteroids. Give IV normal saline. Correct answer Wait for laboratory results before treating. Your answer is incorrect Monitor blood pressure every 4 hours. Your answer is incorrect
Myxedema coma is a major complication of poorly treated hypothyroidism. Interventions include administering IV levothyroxine. This promotes the return to normal thyroid hormone levels. IV normal saline corrects dehydration. Corticosteroids are administered as part of the treatment. Levothyroxine is initiated before obtaining laboratory results because waiting can cause death. The blood pressure should be monitored hourly.
A client prescribed omeprazole for gastroesophageal reflux disease reports a new occurrence of significant diarrhea. Which response by the nurse is most appropriate? 'Stop taking your omeprazole.' 'This is a normal side effect of omeprazole.' 'We are going to collect a stool sample for testing.' Correct answer 'Antidiarrheal medication can be used to decrease this.'
Omeprazole has been linked to an increased risk of diarrhea because of Clostridium difficile, so the stool should be tested. The nurse would not instruct the client to stop any medications without consulting the prescribing health care provider. Significant diarrhea in the setting of omeprazole is not a normal finding and should be investigated for Clostridium difficile. Antidiarrheal medication should not be recommended until Clostridium difficile infection is investigated and ruled out.
Which nursing resource must be available to effectively meet potential needs during a disaster? Select all that apply. One, some, or all responses may be correct. Staff Correct answer Medication Correct answer Hospital beds Correct answer Mechanical ventilators Correct answer Personal protective equipment Correct answer
Preparation for disasters includes ensuring resources are available to meet potential needs. The nurse leader must ensure there is adequate staff, medication, hospital beds, medical devices such as mechanical ventilators, and personal protective equipment available to address potential needs during a disaster.
The nurse is providing care to a toddler admitted to the hospital with symptoms of mercury poisoning. Which assessment question would help the nurse determine the source of the mercury? 'What year was your home built?' 'Do you have plants in your home?' 'Does your child consume fish?' Correct answer 'Where do you store your cleaning solutions?'
There are several types of fish (king mackerel, shark, swordfish, tilefish) that are high in mercury, and the nurse would question the toddler's parents regarding consumption of these fish. Asking the parents the year their home was built is an assessment question that is pertinent for lead, not mercury, poisoning. Plants and cleaning solutions are not known to be a source of mercury.
Which assessment findings indicate an older client is at risk for developing an infection? Select all that apply. One, some, or all responses may be correct. Thin skin Correct answer Weak cough Correct answer Sluggish bowel sounds Correct answer Male-pattern baldness Indwelling urinary catheter Correct answer Decreased or absent leg hair
Thin skin indicates a loss of protection by the integumentary system. A weak cough indicates a loss of protection by the respiratory system. Sluggish bowel sounds indicate a loss of protection by the gastrointestinal system. An indwelling urinary catheter is an invasive device that can introduce microorganisms into the client's system. Male-pattern baldness does not indicate a loss of protection by a body system. Decreased or absent leg hair indicates decreased perfusion of the extremity and potential arterial involvement.
Which nursing interventions are applicable to a client receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. One, some, or all responses may be correct. Restricting visitors Correct answer Limiting fluid intake Preparing for a precipitate birth Your answer is incorrect Maintaining a quiet environment Correct answer Keeping magnesium gluconate at the bedside Your answer is incorrect
Visitors should be limited to significant others to reduce excessive stimuli that could precipitate a seizure. A quiet room helps reduce stimuli and the risk of seizures. Fluid intake should not be restricted. A precipitous birth is not a usual side effect of magnesium sulfate therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be readily available if signs of toxicity appear.
Which certification course may be an elective for the nurse qualified to care for clients in a disaster-related emergency situation? Basic Life Support (BLS) Certified Emergency Nurse (CEN) Correct answer Advanced Cardiac Life Support (ACLS) Pediatric Advanced Life Support (PALS)
A CEN course is optional and it validates the knowledge of the nurse for core emergency nursing. BLS is mandatory and training is given for noninvasive assessment and management skills. This includes skills such as airway maintenance and cardiopulmonary resuscitation. In ACLS, invasive airway management skills such as pharmacology and special resuscitation are taught. PALS is also mandatory and provides neonatal and pediatric resuscitation procedure training to nurses.
By which age should an infant have had his or her first dental examination? 3 months 9 months 12 months Correct answer 18 months Your answer is incorrect
A child will have completed an initial dental visit by the age of 12 months. The initial examination should be completed by age 6 months or within 6 months of the first tooth erupting, which averages at around the age of 12 months.
Which are barriers the registered nurse's (RN's) effective delegation? Select all that apply.One, some, or all responses may be correct. The nurse believes delegation is too time-consuming. Correct answer The nurse lacks confidence in the delegatee's abilities. Correct answer The nurse overburdens the delegatee with too many tasks. Correct answer The nurse understands the delegatee's level of competence. The nurse determines delegation is appropriate for the situation.
Barriers to effective delegation by the RN include the belief that delegation is too time-consuming, or the nurse lacks confidence in the delegatee's abilities and overburdens the delegatee with too many tasks. Understanding the delegatee's level of competence is a desired skill of delegation and is not a barrier. Determining that delegation is appropriate to the situation is not a barrier to delegation.
Which information would the nurse's teaching plan include for a client scheduled for an elective vacuum aspiration abortion in the first trimester of pregnancy? It is a lengthy procedure; however, it will cause little to no pain. Both the client and the father must sign the consent form. A temperature of 100.4°F (38°C) or higher should be reported immediately. Correct answer The client will experience a heavy menstrual flow for 1 to 2 weeks after the procedure
Increased temperature may be indicative of an infection; if infection is present, immediate treatment would be indicated. The procedure is a short one, but there is some pain or discomfort. The father is not required to sign the consent form. A light menstrual flow is expected for several days after the procedure.
Which would the nurse conclude about isolation for the child admitted to the pediatric unit with a diagnosis of meningococcal meningitis? It is unnecessary during the incubation period. It is required for 7 to 10 days until the fever subsides. Your answer is incorrect It will be unnecessary after the diagnosis is confirmed. It will be necessary for 24 to 72 hours after the initiation of antibiotic therapy. Correct answer
The meningococcal organism is rendered inactive after 24 to 72 hours of antibiotic therapy; isolation is not required after this time. Meningitis is not evident during the incubation period. The presence of a fever is not the influencing factor indicating the need for isolation. After the diagnosis of meningitis is confirmed, isolation is required for 24 to 72 hours after the institution of antibiotic therapy.
The nurse places a client in restraints due to violent combative behavior. Which intervention would the nurse perform next?Offer food and drink.Document the behavior.Your answer is incorrectObtain a written or verbal prescription.Correct answerProvide a 1:1 attendant in the room.
The nurse can use restraint or seclusion when client behavior is violent, and it is an emergency. However, the next nursing intervention should be to obtain a verbal or written prescription for their use. Food and drink should be offered every 15 to 30 minutes. After the situation is resolved, the nurse documents the behavior. It is not necessary to have a 1:1 attendant in the room when restraints are being used because these provide the safety.
Which interventions regarding preventing future infections are taught to a sexually active female client with a urinary tract infection? Select all that apply. One, some, or all responses may be correct. Increase fluid intake. Correct answer Wear snug nylon underwear. Use douche and scented lubricants. Clean the perineum wiping front to back. Correct answer Empty the bladder before and after sexual intercourse. Correct answer
Increasing fluid intake increases urine volume to flush out invading bacteria. Cleaning the perineum front to back avoids introducing bacteria from the rectum forward. Emptying the bladder before and after intercourse flushes the urethra of bacteria. Underwear should be loose fitting and cotton to allow air flow. Douche and scented lubricants should be avoided because they disrupt the normal flora and may contain irritants.
Which leukocyte is responsible for the allergic response? Basophils Correct answer Monocytes Eosinophils Macrophages
Basophils stimulate the inflammation of allergy and hypersensitivity reactions. Monocytes are responsible for the destruction of bacteria and cellular debris before maturing into macrophages. Eosinophils act against parasitic infestations and limit inflammatory reactions. The main function of the macrophages is phagocytosis.
Which education would the nurse provide the parents of an exclusively breast-fed infant about vitamin D supplementation? Select all that apply. One, some, or all responses may be correct. 'Do not administer more than 400 IU per day.' Correct answer 'Add the vitamin D into supplemental formula.' 'Read the syringe before administering the vitamin D.' Correct answer 'Supplement your breast-feeding with formula fortified with vitamin D.' Your answer is incorrect 'Do not administer vitamin D supplementation if your baby is solely taking in formula.' Your answer is incorrect
To avoid vitamin D toxicity, the infant should receive no more than 400 IU of vitamin D daily. It is important for the parents to read the markings on the syringe to administer the proper dosage. Vitamin D should not be added into supplemental formula. There is no need to give the infant supplemental formula with vitamin D because the infant is already prescribed liquid vitamin D. Vitamin D supplementation is recommended if the infant is consuming less than 1 liter per day of vitamin D-supplemented formula.
The nurse is applying capsaicin to a client with diabetic neuropathy. Which action should the nurse perform immediately after applying the medication? Monitor for skin irritation. Perform a painful procedure. Notify the health care provider. Remove gloves and wash hands. Correct answer
Topical applications of local anesthetics such as capsaicin are used to interrupt transmission of pain signals to the brain in a client with diabetic neuropathy. The nurse has to use gloves or wash the hands with soap and water after application of capsaicin to prevent nerve blockage in the nurse. The client should be monitored for skin irritation at the site of application. Painful procedures are performed only when the client loses pain perception at the site. The health care provider is notified if the client has severe side effects.
Which information would the nurse provide to a client taking dulaglutide? Give with insulin. Administer medication orally. Your answer is incorrect Works without exercise. Perform self-injection weekly. Correct answer
Dulaglutide is an injection that, unlike insulin, is only administered subcutaneously once a week. It is not administered with insulin, it is not an oral medication, and it works with modified diet and exercise.
Which guidance would the nurse provide to the parent of an 8-year-old child? Expect an increase in minor injuries. Correct answer The child may need more rest during this period. Strong food preferences and frequent food refusals are common. Your answer is incorrect Support the child's desire to 'grow up,' but allow regressive behavior when needed.
Guidance for an 8-year-old child includes the expectation for an increase in minor injuries. Children ages 11 to 12 years of age require more rest and have a strong desire to 'grow up.' However, the parent should be encouraged to allow regressive behavior when needed. Children 6 years of age have strong food preferences and frequent food refusals are common.
How do toddlers learn self-protection? Through trial-and-error strategies Correct answer By imitating playmates and siblings By obeying orders from mother and father By playing with age-appropriate toys and puzzles
The toddler is developing autonomy, is curious, and learns self-protection from experience. Toddlerhood play is parallel, not interactive. The struggle for autonomy at this age limits learning from siblings, even though the toddler attempts to copy their behavior. The toddler is still learning from experiences, not from others. The toddler is still attempting to distinguish the self as separate from the parents; the struggle for autonomy limits learning from parents. Toddlers learn gross and fine motor skills as they play with their toys, not self-protection.
The nurse is caring for an adolescent who is pregnant and reports a past history of gonorrhea. Which intervention will the nurse perform before delivery to decrease perinatal exposure? Select all that apply. One, some, or all responses may be correct. Screen at 36 weeks' gestation Correct answer Plan to use standard precautions Administer intramuscular ceftriaxone Correct answer Recommend bottle feeding after birth Report any greenish-yellow purulent discharge Your answer is incorrect
To decrease risk of perinatal exposure, the nurse will screen clients for gonorrhea at 36 weeks' gestation to determine the presence of infection. The nurse also will administer intramuscular ceftriaxone to treat the infection. Standard precautions protect the nurse, not the newborn. The infection is passed vaginally; clients with gonorrhea do not need to avoid breast-feeding. Female clients frequently do not display symptoms, but the presence of purulent discharge indicates infection, which could be transmissible.
After the home health nurse has taught a client with asthma how to use a peak flow meter, which statement by the client needs correction? 'I will record the highest reading of 3.' Your answer is incorrect 'I will use the peak flow meter while standing.' 'I will take a deep breath before blowing into the peak flow meter.' 'I will repeat the test in 15 minutes if the reading is in the red zone.' Correct answer
A red zone reading is a serious situation; the client should be instructed to use airway reliever medications and seek immediate medical care. Clients need to conduct a peak flow test 3 times and record the highest reading. Clients should use the peak flow meter while standing independently without leaning. Correct use of the peak flow meter begins with the client taking a deep breath before blowing into the meter.
Which criteria would the nurse consider when determining if an infection is a health care-associated infection? Originated primarily from an exogenous source Is associated with a medication-resistant microorganism Occurred in conjunction with treatment for an illness Correct answer Still has the infection despite completing the prescribed therapy
Health care-associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care-associated infection. The source of health care-associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care-associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus. Association with a medication-resistant microorganism is not a criterion for identifying a health care-associated infection. A health care-associated infection may or may not be caused by a medication-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care-associated infection.
Which long-term care facility staff member statements indicate correct understanding of a disaster response plan for staff and residents? Select all that apply. One, some, or all responses may be correct. 'We have to implement annual drills.' Correct answer 'The plan must include an evacuation plan.' Correct answer 'Nursing homes are not required to have a plan.' 'Our facility is held to the same standards as hospital facilities.' Your answer is incorrect 'This is an important component to receive insurance payments for care.'
Hospitals are not the only health care agencies that are required to practice disaster drills. Long-term care (LTC) facilities are also mandated to have annual drills to prepare for mass casualty events. Part of the response plan must include a method for evacuation of residents from the facility in a timely and safe manner. Nursing homes are also required to have a disaster response plan. LTC facilities are not held to the same standards as hospital facilities. Insurance payment for medical care is not contingent on the implementation of a disaster response plan.
Which response would the nurse make when obtaining a health history from a client who is known to be verbally abusive and says, 'You're ugly, and you're probably stupid, too. Why am I stuck with you'? 'It doesn't matter what you think, because I know I'm a capable nurse.' 'Tell me more about why my caring for you today is so upsetting to you.' 'If you like, I will arrange to switch assignments so you can have another nurse.' 'You are talking inappropriately, so I'm going to leave and will come back when you stop being verbally abusive.' Correct answer
The nurse would respond, 'You are talking inappropriately, so I'm going to leave and will come back when you stop being verbally abusive.' This response provides specific realistic feedback without rejecting the client. The reply, 'It doesn't matter what you think, because I know I'm a capable nurse,' is defensive and insulting to the client. The reply, 'Tell me more about why my caring for you today is so upsetting to you,' will most likely encourage more inappropriate communication because it keeps the focus on the nurse and uses 'why' which is nontherapeutic. The client's behavior is the issue and switching assignments does not address this. The client may view a change of nurse as rejection or that the client 'won.'
Offspring of men of advanced paternal age are at an increased risk for which condition? Schizophrenia Correct answer Cystic fibrosis Your answer is incorrect Sickle cell anemia Tay-Sachs disease
Advanced paternal age increases the risks of some autosomal dominant disorders, autism spectrum disorder, and schizophrenia. Cystic fibrosis, sickle cell anemia, and Tay-Sachs disease are recessive diseases, and the risk of these diseases does not increase because of advanced paternal age.
Which personal protective equipment would the nurse use when giving a bath to a client with acquired immunodeficiency syndrome (AIDS), pneumonia, and AIDS wasting syndrome with fecal incontinence? Select all that apply. One, some, or all responses may be correct. Goggles Correct answer Surgical mask Correct answer Shoe covers Gown Correct answer Gloves Correct answer N95 hepa mask
Evidence-based guidelines indicate the need to use standard and contact precautions (consisting of a gown and gloves) in clients who have fecal incontinence to avoid possible transmission of gastrointestinal infection. Standard precautions are used for clients with AIDS, but the client's pneumonia diagnosis indicates the need for droplet precautions with eye protection and a surgical mask, because the client may be coughing during the bath. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside. An N95 hepa mask would be necessary if the client had tuberculosis, but not for pneumonia.
Which actions transmit the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. Multiple mosquito bites Sharing syringe needles Correct answer Breast-feeding a newborn Correct answer Dry kissing an infected individual Anal intercourse Correct answer Sharing drinking glasses
Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites, sharing of drinking glasses, or dry kissing. Deep kissing involving a large amount of salvia does transmit HIV.
When preparing to administer medications safely, it is important for the nurse to remember at which age an infant's gastric emptying time reaches adult values? 6 to 8 months Correct answer 10 to 12 months 14 to 16 months 18 to 24 months Your answer is incorrect
Gastric emptying is prolonged and irregular in early infancy. It gradually reaches adult values by 6 to 8 months of age. By the ages of 10 to 24 months, gastric emptying time will have already reached adult values.
Which factor can be used to determine the source of infection in a client who tests positive for Giardia lamblia? Select all that apply. One, some, or all responses may be correct. Sexual orientation Past antibiotic use Recent camping trips Correct answer Raw egg consumption Canned vegetable intake
Giardia is found in freshwater lakes and rivers. Clients who test positive for the bacteria should be asked about recent travel and activity history including outings like camping or hiking. Giardiasis is associated with anal intercourse regardless of sexual orientation. Antibiotic use can cause Clostridium difficile infection. Raw eggs can carry Salmonella. Botulism is associate with improperly canned foods.
Which type of assessment is performed when the nurse uses the mnemonic AMPLE to determine the client's condition after a natural disaster during a secondary emergency assessment survey? Give comfort measures Inspect posterior surfaces Facilitate family presence History and head-to-toe assessment Correct answer
History and head-to-toe assessment involves use of the mnemonic AMPLE that includes Allergies, Medication history, Past health history, Last meal, and Events preceding illness or injury to determine the history of the client. Giving comfort measures is an emergency assessment that is used to assess, treat, and reassess for pain and anxiety. Posterior surfaces are inspected to determine bleeding, bruises, and lacerations. Facilitating family presence includes determining the caregiver's desire to be present during invasive procedures.
Which instructions would the nurse teach a client about preventive measures for Lyme disease? Select all that apply. One, some, or all responses may be correct. 'Wear dark-colored dresses.' 'Tuck your shirt into your pants.' Correct answer 'Obtain a Lyme disease vaccination annually.'
Lyme disease is a vector-borne disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick, also known as the blacklegged tick. Light-colored, rather than dark-colored clothing is preferred to spot the ticks easily, thereby preventing an insect bite and infection. Wearing closed shoes and boots and tucking the shirt in the pants prevent the entry and the bite of the blacklegged tick. Bathing should be done immediately after being in an infested area to prevent any possible infection. Currently, there is not a vaccination available for the prevention of Lyme disease.
A sexually active female client is upset with her diagnosis of gonorrhea and asks the nurse, 'What can I do to prevent getting another infection like this?' Which practical response would the nurse provide? 'Douche after every sexual intercourse.' 'Avoid engaging in sexual behaviors.' 'Insist that your partner uses a condom.' Correct answer 'Use a spermicidal cream with sexual intercourse.
Once people become sexually active, they usually remain sexually active; a condom, although not 100% effective, is the best protection against gonorrhea in a sexually active person. The response, 'Douche after every intercourse,' has no proven protective effect against sexually transmitted infections; excessive douching can alter the vaginal environment and may promote an ascending infection. The response, 'Avoid engaging in sexual behavior,' is not a realistic response to a sexually active person. Spermicidal cream has no protective effect against sexually transmitted infections.
The nurse understands which interventions are needed to prevent accidental poisoning of children? Select all that apply. One, some, or all responses may be correct. Medicines should be referred to as candy. Potent poisons should be kept out of reach of children. Correct answer Containers of the poisonous substances should be tightly closed. Correct answer Old, unused, and unnecessary medications should be safely disposed. Correct answer Medications should be transferred from their original containers to alternative ones.
Poisonous substances should be kept out of the reach of children and out of their sight. Containers of poisonous substances should be stored, secured properly, and tightly closed. Old or unused medications should be disposed of properly. Because candy is desirable, medications should never be referred to as such to prevent children from trying to consume them without adult supervision. Additionally, medications should not be transferred from their original containers because this can cause confusion and subsequent misuse.
Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? Apical pulse rate 96 beats/minute Bilateral foot and ankle pitting edema Crackles heard at the base of both lungs Potassium level of 2.3 mEq/L (2.3 mmol/L) Correct answer
Symptoms of digoxin toxicity, including life-threatening dysrhythmias, can occur when digoxin is administered to a client with hypokalemia. The nurse would hold the digoxin and notify the health care provider, anticipating that potassium supplements would be prescribed before administration of digoxin. An apical pulse of 96 beats per minute is at the upper end of normal and would not be a reason to hold digoxin. Lower extremity edema is a sign of heart failure, which would be improved with administration of digoxin. Crackles at the lung bases are common in clients with heart failure and not a reason to hold digoxin.
Which statement indicates misunderstanding of the precautions required for clients infected by the Ebola virus? 'I will isolate the infected client in a private room.''I will use standard, contact, and droplet precautions.'Your answer is incorrect'I will not touch the prepared food for the infected client.'Correct answer'I will avoid direct contact with body fluids of the infected client at all times.'
The Ebola virus is not spread via air, water, or food. Avoiding the touching of prepared food for the infected client may not help in preventing Ebola. The nurse should correct this misconception. Clients with Ebola should be isolated in a single room to prevent the spread of infection. While caring for a client with Ebola, the nurse should use standard, contact, and droplet precautions to prevent Ebola infection spread. The nurse should avoid direct contact with body fluids of the infected client to prevent the spread of Ebola infection.
Which intervention would the nurse use for a client taking quetiapine for acute psychosis who develops lead-pipe rigidity, trismus, and tachycardia? Select all that apply. One, some, or all responses may be correct. Perianal care Correct answer Fall precautions Correct answer Use of a cooling blanket Correct answer Monitoring of intake and output Correct answer Discontinuation of the medication Correct answer Administration of bromocriptine as prescribed Correct answer
The client is demonstrating symptoms of neuroleptic malignant syndrome (NMS). Perianal care would be needed for incontinence. Fall precautions would be instituted for alterations in consciousness. Cooling blankets would be used for pyrexia. Intake and output would be monitored to assess for dehydration caused by diaphoresis, fever, and reduced oral intake because of a change in consciousness. The medication would be discontinued as NMS is a potentially fatal adverse effect of antipsychotic therapy. Symptoms usually last for 5 to 10 days after discontinuation of oral medications and 13 to 30 days with depot antipsychotic medicine. Bromocriptine is a dopamine agonist used to treat NMS.
Which is the facility-level organizational model for disaster management? Medical Reserve Corps (MRC) Disaster Medical Assistance Team (DMAT) Hospital Incident Command System (HICS) Correct answer National Incident Management System (NIMS)
The facility-level organizational model for disaster management is the HICS. The MRC is made up of a group of volunteer medical and public health care professionals who offer services to health care facilities or to the community during a disaster or pandemic disease outbreak. The DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. The NIMS was implemented by the Department of Homeland Security and the Federal Emergency Management Agency (FEMA) to standardize disaster operations.
Which statement by the parents of a toddler indicates the need for further education? 'I should follow the manufacturer instructions regarding use.' 'I should allow my child to ride unrestrained for short car trips.' Correct answer 'I should allow my child to have a toy for quiet play while in the car.' 'I should encourage my child to help fasten seatbelt buckles.'
Toddlers never should be allowed to ride in a motor vehicle unrestrained, even for short trips. This statement indicates the need for further education. The parental statements regarding following manufacturer instructions, allowing the child to have a toy for quiet play, and encouraging the toddler to assist with buckles all indicate correct understanding.
After the nurse has instructed a client with active tuberculosis (TB) on self-care at home, which client statement indicates understanding of the teaching? 'I will plan to stop drinking alcohol during treatment.' Correct answer 'Once the cough and fever go away, I can stop the medication.' 'While taking this medication I will stop all my other medications. 'I will make sure no visitors enter my home until I have finished treatment.' Your answer is incorrect
The medications used for treatment of TB can be toxic to the liver, and other substances that are hepatotoxic (such as alcohol) should be avoided during TB treatment to decrease the risk for liver damage. The medications must be taken for 6 months or longer to complete therapy; treatment should not be discontinued when symptoms subside. A client's health care provider will review current medications and let the client know if any should be stopped while being treated for TB, although most medications are safe to take with the medications used to treat TB. Most clients who are taking medications are not contagious after several weeks of treatment. A client who has started TB treatment and has had negative sputum cultures is not contagious and may return to usual activities such as having visitors, although the client will need to continue treatment for at least 6 months.
The nurse is caring for a child admitted with suspicious injuries. Which question would the nurse ask to obtain further information about possible child abuse? 'What behaviors cause you to get into trouble?' 'What problems do you have when at school?' 'What is it about your parents that upsets you the most?' 'What happens when you do something wrong?' Correct answer
The nurse would ask the child what happens when the child does something wrong. This provides information about punishment and physical and/or verbal abuse that may be taking place. Asking the child what behaviors cause the child to get into trouble allows the child to understand what actions are inappropriate to perform. Problems the child may have at school may reflect poor coping skills or bullying, but not child abuse. Asking the child what upsets him or her the most about their parents may elicit responses about strict rules but not necessarily evidence of child abuse.
Which statement from a pregnant client with premature rupture of membranes (PROM) demonstrates an understanding of the infection risk? Select all that apply. One, some, or all responses may be correct. 'I will report a fever to my doctor.' Correct answer 'I will wipe from front to back when using the bathroom.' Correct answer 'If I have contractions, medications will be administered.' Correct answer 'If I develop chorioamnionitis, my doctor will induce labor.' Correct answer 'I will let my doctor know if I experience foul-smelling vaginal discharge.' Correct answer
The nurse would provide thorough education on signs of infection, infection prevention, and possible outcomes of infection for pregnant clients with PROM. The client would be instructed on how to keep the genital area clean and advised that nothing is to be introduced into the vagina. The client would be made aware of the importance of being vigilant for signs of infection, such as fever and foul-smelling vaginal discharge, and that these signs would be reported immediately. Clients would be made aware that labor will need to be induced if chorioamnionitis develops. If preterm labor occurs, tocolytic medications can be administered to 'buy time' enough for transporting the client to a hospital capable of providing preterm infant care. The additional time also allows antenatal corticosteroids or antibiotics to reach effective levels.
Based on the information in the chart of this client who came to the emergency department reporting pink-tinged urine, which nursing action is a priority? Monitor the intake and output. Take apical pulse for a full minute. Institute measures to prevent physical injury. Correct answer Obtain stool specimen to test for occult blood. Your answer is incorrect
The therapeutic International Normalized Ratio (INR) level usually is between 2 and 3; the expected range for platelets is 150,000 to 450,000/mm 3 (150 × 10 9/L to 400 × 10 9/L). The platelet count is significantly decreased, and the INR level of 4.5 is high. The client is at risk for bleeding and must be protected from injury. Monitoring the intake and output is useful for clients with blood-tinged urine but not essential because there is no indication of fluid imbalance. An apical pulse for a full minute is indicated when a client has an irregular heart rhythm, but this client has been previously cardioverted and has a regular rhythm now. Obtaining a stool specimen to check for possible gastrointestinal bleeding is important, but the highest priority is to ensure client safety.
Which action would the nurse take to avoid red man syndrome when preparing to administer a vancomycin infusion? Infuse slowly. Correct answer Change the intravenous (IV) site. Reduce the dosage. Administer vitamin K.
Vancomycin should be infused slowly to avoid the occurrence of the reaction known as 'red man syndrome.' Changing the IV site reduces the incidence of thrombophlebitis. Reducing the dosage is done in the setting of renal dysfunction. Administration of vitamin K is done to correct an elevated prothrombin time.
