Safety and Infection Control
Which medication is safe to take during pregnancy?
Acetaminophen - safe during all stages of pregnancy Metronidazole should not be used during the first trimester. Salicylates like aspirin, codeine, and antihistamines like diphenhydramine HCL should be avoided throughout pregnancy.
The nurse is reviewing the procedure for intervention if a fire occurs. Which interventions would the nurse include in the procedure if a fire occurs that relate to the acronym RACE?
Activate the alarm Remove all clients from the area Confine the fire by closing doors and windows R: remove all clients from immediate danger A: Activate the alarm C: Confine the fire by closing doors and windows E: Extinguish the fire with an appropriate fire extinguisher
Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster?
Acylovir Silvadine (can be applied to open vesicles) Gabapentin (to treat nerve pain associated with herpes zoster) Wet compresses (to relieve discomfort) Contact isolation (HZ is highly contagious)
Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal?
Administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures and autonomic hyperactivity
Which statement by parents indicates that teaching has been effective regarding their child's pinworm infestation?
"Ill have to reinforce her hand-washing habits before she handles food" Pinworms are transferred by anal-oral route pinworms are found in the rectum or colon and travel to the perianal area only when the person sleeps
Which cause may produce abnormal uterine bleeding?
-Hypothyroidism (endocrine disorders) -Failure to ovulate or respond appropriately to ovulation hormones -Bleeding disorders -Pregnancy complications such as an unidentified pregnancy that is ending in spontaneous abortion -Breakthrough bleeding, which may occur in the women taking oral contraceptives -Lesions of the vagina, cervix, or uterus (benign or malignant)
At which interval are humidified oxygen systems replaced to prevent infection?
1 Day Oxygen delivery W/O humidification will need to be changed out every 7 days
At which height is it no longer safe for a toddler to sleep in a crib?
36 inches a toddler who has reached the height of 35 inches should be transitioned from a crib to a bed At that height: children likely can pull themselves up and over the crib rail, putting them at risk for injury.
Which school-age children require close supervision when using a skateboard?
6,7,8,9 years old the 5 year old should NOT be allowed to ride a skateboard due to high risk for injury
Which manifestation indicated tertiary syphilis?
A: Gummas (chronic, destructive lesions affecting the skin, bone, liver, and mm) Chancre: during primary syphilis Alopecia and condylomata occur during secondary syphilis
The nurse is preparing to insert an NG tube for a client to allow continuous suctioning. Which tube would the nurse select?
A: Salem sump (has a cent that prevents the suction from pulling at the GI mucosa and should be used for clients requiring continuous suction) Levin: does NOT have a vent and should be used strictly for intermittent suction Dobhoff: NG tube used for feeding, not suction Gastrostomy tube: surgically placed for feeding
Which STIs are caused by bacteria?
A: Syphilis: Treponema pallidum A: Gonorrhea: Neisseria gonorrhoeae Other: Herpes and Hepatitis A (virus) Trichomonoiasis (protozoan)
Which reaction is an example of a type 1 hypersensitivity reaction?
Anaphylaxis -Serum sickness is type 3 immune complex reaction. -Contact dermatitis is type 4 delayed hypersensitivity reaction -Blood transfusion is type 2 cytotoxic reaction
Which clinical condition is associated with lead poisoning?
Anemia Lead can interfere with the blinding of iron onto the heme molecule
Which side effect would the nurse monitor for when administering a selective serotonin reuptake inhibitor?
Anxiety Nausea Sedation Restlessness Suicidal Ideation Increased energy level
Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain?
Apply for 30 minute intervals
Which intervention would the nurse encourage the parents of a child with plumbism (lead poisoning) to do?
Assess the family's home environment for lead sources and have them removed
Which birth factors place the neonate at risk for sudden infant death syndrome?
Birth order Multiple births low apgar scores
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?
Bowel Obstruction Causes: Bowel obstruction, appendicitis, external penetrating wound, peritoneal dialysis
The nurse is teaching participants in a prenatal class regarding breast-feeding versus formula feeding. A client asks, "what is the primary advantage of breast-feeding?" Which response is most appropriate?
Breast-fed infants have fewer infections
For which client illness would airborne precautions be implemented?
Chickenpox Droplet: influenza and pneumonia Direct contact: RSV
Which STI is most commonly reported?
Chlamydia
Which would the nurse use to perform hand hygiene when caring for an immunocompromised client?
Chlorhexidine decreases the risk of spreading infection
To which disaster triage class would the nurse infer a client with a green triage tag belongs?
Class 3 Red: class 1 Yellow: Class 2 Black: Class 4
Which is prevented by providing warm, humidified oxygen to a preterm infant?
Cold stress
A child becomes cyanotic during a generalized tonic-clonic seizure. Which is the most appropriate action by the nurse?
Continuing to observe the seizure - the child's status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time.
Which information would the nurse provide a client with a new colostomy about managing the appliance?
Cut opening 1/8 to 1/16 inch larger than stoma 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 larger than the stoma so the wafer does not cut into the stoma
The school nurse is planning to teach the importance of hand washing to the children in first grade. Which is the MOST effective approach for this age group?
Demonstrating hand washing and asking for return demonstrations 6 year olds are still in the perceptual phase of cognitive development. They base judgments on what they see rather than on what they reason; reasoning begins around age 7. These children are at the developmental stage where they want to show off their accomplishments; just watching without feedback is not sufficient at this stage.
Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection?
Discharge from the penis Soreness, rust-colored semen, and light rectal bleeding are expected after transrectal prostate biopsy
Which safety precaution would the nurse employ when assisting with the removal of a client's vaginal radium seeds?
Ensure long forceps are available for removing the radium
The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle?
Every 7 days to decrease the risk of infection
Which symptom indicated pelvic inflammatory disease?
Fever Elevated Erythrocyte sedimentation rate chronic pelvic pain irregular vaginal bleeding abnormal vaginal discharge bilateral adnexal tenderness
Which method of delivering client care works well in disaster situations?
Functional nursing (each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently)
Which initial nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom?
Giving the client one simple direction at a time in a firm, low-pitched voice patients with delirium typically respond to simple directions stated one at a time
Which STI causes condylomata acuminate?
HPV they are genital warts that are caused by HPV.
Which lab value would the nurse assess when preparing a client for a renal biopsy?
Hematocrit Hemoglobin To determine Blood loss before and after Platelet Count PT with INR PTT To determine if the client is at risk for hemorrhage
A full-term infant who is large for gestational age should be monitored for which risk?
Hypoglycemia glucose should be monitored following a protocol
Which statement shows that the newly diagnosed asthma patient understands how to use a peak expiratory flow meter?
I have to blow out as fast and hard into the machine as I can the PEFM is used to measure the amount of air being exhaled. The client should use the PEFM while in a standing position to permit better lung expansion the highest of 3 readings is recorded
Which antibody forms FIRST, after exposure to an antigen?
IgM first antibody formed by a newly sensitized B-lymphocyte plasma cell IgA: very low circulating levels and is reponsible for preventing infection in the upper and lower respiratory tracts, and the GI/GU tracts IgE: variable concentrations in the blood and is associated with antibody-mediated hypersensitivity reactions. IgG: heavily expressed on second and subsequent exposures to antigen to provide sustained, long-term immunity against invading microorganisms.
Which condition is commonly seen following infestation with pediculosis capitis (lead lice)?
Impetigo (may develop as a secondary bacterial infection because of breaks in the skin caused by scratching) Eczema is an allergic response and not related to episodes of pediculosis. Cellulitis is an extended inflammation that is not commonly found in children with pediculosis Folliculitis: pimple or an infection of the hair follicle
The nurse is preparing a child who has undergone a myringotomy for discharge. Which would the parents be taught about their child's care at home?
Insert earplugs whenever a bath is given water in the ears about myringotomy supports the growth of pathogens and should be avoided the ears should be kept open to air and allowed to drain naturally.
The nurse is planning to teach the four-point alternate crutch gait to a 9-year old child with Cerebral Palsy. How would the nurse explain this choice to the parents?
It provides for equal but partial weight bearing on each limb four-point alternate crutch gait is a simply, slow, stable gait because there are always 3 points of support on the floor with equal but partial weight bearing on each limb
Which method of swaddling could cause risk for injury?
Legs extended The correct way is with hips in slight flexion and abducted and allowing for freedom of movement of the knees
Which disease process places a client at increased risk for infection?
Leukemia Lymphoma Emphysema
Which plant, if ingested by a toddler, would necessitate further action by the nurse?
Lily the plant is poisonous and to proceed to the ED for further care.
Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?
Mild soap and water sterile saline, a humidifier, or pans of water can be used to humidify the air entering the stoma
Which medication for treatment of GERD would be contraindicated in the pregnant client?
Misoprostol (can cause uterine contractions, expelling the developing fetus.
Which nursing action would be included in the plan of care for a child with acute post-streptococcal glomerulonephritis?
Monitoring for seizures Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures (Measure abdominal girth for children with nephrotic syndrome, in which hypoalbuminemia that causes fluid to child from plasma to the abdominal cavity)
Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm?
Monitoring vital signs Cutting off the clothing Inserting urinary catheter Removing the clients jewelry Establishing an IV line Rule of Nine's: The client has full thickness burns. The nurse would monitor vital signs (including O2 sat), remove the clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert and IV line to administer fluids).
Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)?
Move the client to a private room CONTACT precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room
Which information would the nurse provide to a client taking dulaglutide?
Perform self-injection weekly unlike insulin, is only administered subcu once a week it is not administered with insulin, it is not an oral medication, and it works with modified diet and exercise
A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?
Personal protective equipment will be worn by staff - essential for prevention of infection in clients
The nurse changed a dressing on a client's wound with VRE. Which step would the nurse take to ensure proper disposal of the soiled dressing?
Place the dressing in a red bag/ hazardous materials bag
Which features would the ED nurse use from an automated tracking system for triage during mass casualty incidents?
Priority upon arrival Interaction with caregivers Priority per process of care Priority according to location Automated tracking systems using infrared and radiofrequency technology are available in some EDs to track a clients triage priority upon arrival, location, and process of care
Which team member acts as a liaison between the healthcare facility and the media?
Public information officer Triage officer: applies disaster triage tags after evaluating the client's condition. The medical command physician decides the number, acuity, and resource needs to clients. The hospital incident commander assumes overall leadership for implementing the emergency plan.
To ensure accuracy when assessing a client's blood pressure, how would the nurse prevent parallax error?
Read the manometer at eye level Parallax error is the apparent displacement of an observed object, such as the indicators on the manometer, because of the position of the observer.
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis?
Rebound tenderness Diminished bowel sounds Rigid, board-like abdomen Constipation and tachycardia
Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections?
Removing the catheter
Which condition would the nurse monitor for in the client on amino-glycoside therapy and skeletal muscle relaxants?
Respiratory Arrest Aminoglycosides can intensify the effect of skeletal muscle relaxants, placing the client at risk for respiratory arrest.
Which agent of terrorism can cause death within a few minutes?
Sarin Gas it paralyzes respiratory muscles
An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. Which would the nurse tell the girl that may help her wear the bracelet consistently?
Select a bracelet that is similar to one worn by peers
A child with meningitis suddenly assumes an opisthotonic position. In which position would the nurse position the child?
Side lying Maximal safety and comfort are ensured with the side-lying position because the child's neck and back are hyperextended Trendelenburg position increases ICP and is contraindicated in meningitis
Which stage of the HIV would a client with a CD4+ T Cell count of 325 cells/ mm3 be classified?
Stage 2 Stage 1: greater than 500 Stage 2: 200-499 Stage 3: less than 200 Stage 4: client with confirmed infection by no information regarding CD4 T cell counts available
Which is the nurse's priority intervention after discovering an infant is apneic?
Stimulate the trunk Next action would be to call loudly for help, place the infant in a prone position and flick the heels. If there is still no response, the nurse will immediately begin CPR and after 2 minutes of CPR activate the emergency system
Which object would the nurse teach the client with a newly implanted pacemaker to avoid?
Strong magnet (can change setting and function of the pm) Microwave is not a concern remote control devices are not contraindicated Mobile phones should be used in the ear opposite the pacemaker.
Why is an infection caused by Neisseria gonorrhoeae particularly troublesome for a female client?
Symptoms are often overlooked Many females who contract gonorrhea are asymptomatic or overlook the minor symptoms, making possible for the bacteria to remain a source of infection
Punctal occlusion is performed after the administration of eyedrops to prevent which from occuring?
Systemic absorption Systemic absorption of beta-blockage used to treat glaucoma can affect the HR and BP.
When is administration of activated charcoal indicated after a poisoning?
The charcoal has to be administered within 1 hour after the poisoning Charcoal is NOT administered after a gastric lavage, in any poisoning situation, or up to 24 hours after a poisoning has occurred
A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container?
The local hazardous waste collection site
How do toddlers learn self-protection?
Through trial and error strategies 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.
Which of these age groups has the highest incidence of lead poisoning?
Toddler highest in late infancy and toddlerhood. increased level of oral activity, put objects into their mouths Adults: increased risk of cardiovascular and pulmonary disease Adolescents: drowning and motor vehicle accidents School age: bike accidents
A client with TB asks the nurse about the communicability of the disease. Which response would the nurse use?
Untreated active tuberculosis is communicable treatment is necessary to stop communicability
How would the nurse position a client to practice supraglottic swallowing after tracheostomy?
Upright out of bed, if possible
Which behavior is an early sign of an abusive personality?
Verbal abuse Jealous, controlling Enforces rigid sex roles Hypersensitive, easily insulted Isolated partner from family and friends Makes others responsible for their feelings
The nurse is preparing to administer methyphenidate to an older adult with apathy and depression. Which would the nurse include in the assessment to monitor for complications?
Vision (glaucoma) Weight Heart Rate
Which statement would the nurse include in the teaching plan of a client anticipating discharge with acquired immunodeficiency syndrome (AIDS)?
Wash used dishes in hot, soapy water
Which information would the nurse provide a client with diabetes mellitus regarding alcohol consumption?
With or shortly after meals (to prevent alcohol-induced delayed hypoglycemia)
Which group has the highest rate of meningococcal infection?
Young adults (16-21 years old)
The nurse is preparing to administer an IM injection to a newborn. To administer the injection safely, the nurse would be cognizant of which cause of slow absorption in newborns?
blood flow low blood flow through muscle during the first days of postnatal life
Which substance can cause life-threatening dysrhtymias when inhaled?
glue gasoline paint thinner
Which cardiac disease has the lowest risk for maternal mortality?
patent ductus arteriosis
The nurse explains to the parents of a 6 year old child with a pinworm infestations how pinworms are transmitted. Which statement indicates that the teaching has been understood?
she needs to wash her hands before eating anything
Which client/ parent education would the nurse include about a potential complication of mumps?
sterility mumps can cause orchitis (inflammation of the testes) in males and oophoritis (inflammation of the ovaries) in females. they can render the postpubescent child sterile
