Safety and Infection Control
A 24-year-old client with diabetes mellitus sustains a large laceration that requires suturing. Which of the following statements indicates that the client understands wound healing? a) "It's so hard to predict when this scar will disappear." b) "This procedure won't leave a scar." c) "If I don't get an infection, the scar may fade in 1 to 3 years." d) "My scar will fade within 4 months."
"It's so hard to predict when this scar will disappear."
Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed? a) "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." b) "Infusion set administration connections should be tight." c) "Cytotoxic parenteral infusion containers should be marked with special hazard labels." d) "Linen contaminated with blood or body fluids of a client receiving cytotoxic drugs should be placed in a leak-proof container and marked with a chemotherapy hazard label."
a) "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs."
A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When the nurse informs the client that the physician has ordered a wound care nurse to examine the wound, the client asks why should anyone other than the staff nurse care for the wound. The client states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." Which responses made by the nurse would be appropriate? Select all that apply. a) "You could possibly lose your foot without proper care." b) "This is a big deal, and you need to recognize how serious it is." c) "Do you want me to tell the physician you refused?" d) "We're very concerned about your foot and we want to provide the best possible care for you." e) "The wound nurse is specially trained to care for diabetic wounds."
a) "You could possibly lose your foot without proper care." d) "We're very concerned about your foot and we want to provide the best possible care for you." e) "The wound nurse is specially trained to care for diabetic wounds."
A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions? 1. Remove pump from toddler's room 2. Clean the pump 3. Take pump into infant's room 4. Use the pump
a) 1, 2, 3, 4
A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? a) Ask the physician for an order to obtain cultures of both of the neonate's eyes. b) Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. c) Obtain a nasal viral culture. d) Notify the physician immediately
a) Ask the physician for an order to obtain cultures of both of the neonate's eyes.
Which of the following instructions should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy? a) Change diapers as soon as they become soiled. b) Restrain the infant's hands. c) Keep the incision covered with a sterile dressing. d) Apply an abdominal binder.
a) Change diapers as soon as they become soiled
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a) Determine whether the client is allergic to iodine, contrast dyes, or shellfish. b) Immobilize the neck before the client is moved onto a stretcher. c) Administer a sedative as ordered. d) Place a cap over the client's head.
a) Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
A client who had a total hip placement at 9 a.m. (0900) is receiving an autologous blood transfusion that was started at 11 a.m.(1100) At the change of shift (3 p.m.) (1500), the day nurse reports that there is 50 ml of the unit of blood remaining to be infused. Which of the following is a action for the evening nurse? a) Discontinue the blood transfusion at the beginning of the shift. b) Maintain the current rate and discontinue the blood transfusion at 5 p.m.(1700) c) Keep the blood transfusing at the same rate. d) Increase the rate so it will infuse by 4 p.m. (1600)
a) Discontinue the blood transfusion at the beginning of the shift.
Which of the following types of restraints is best for the nurse to use for a child in the immediate postoperative period after cleft palate repair? a) Elbow restraints. b) Safety jacket. c) Body restraints. d) Wrist restraints.
a) Elbow restraints
The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child? a) Maintain a tidy environment around the child. b) Avoid startling the child by limiting excess noise. c) Use visual aids to facilitate communication. d) Request that the parents stay with the child.
a) Maintain a tidy environment around the child.
The nurse prepares to discharge a 5-year-old child from the 1-day surgery unit. The nurse leaves the room to get supplies and then, on returning, finds that the child is not breathing. The client is pulseless, and the nurse begins chest compressions. The nurse should apply pressure: a) On the lower sternum with the heel of one hand. b) On the upper sternum with the heels of both hands. c) Over the apex of the heart with the heel of one hand. d) Midway on the sternum with the tips of two fingers
a) On the lower sternum with the heel of one hand
Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)? a) Restrict staff and visitors with active infections. b) Place the child in strict isolation. c) Increase the child's oral fluid intake. d) Consult with the primary care provider to administer an antiemetic
a) Restrict staff and visitors with active infections
To examine an infant's thyroid gland, the nurse should place the infant in which position? a) Supine b) Standing c) Prone d) Sitting
a) Supine
A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The physician has ordered 2 units of packed red blood cells (RBCs). Prior to initiating the blood transfusion the nurse should determine if? Select all that apply. a) The client has an identification bracelet and red blood band b) The vital signs have been taken and documented in accordance with facility policy and procedure c) There is an I.V. access with the appropriate tubing and normal saline as the priming solution d) There is a signed informed consent for transfusion therapy e) There is the second unit of blood in the medication room f) Blood typing and cross-matching is documented in the medical record
a) The client has an identification bracelet and red blood band b) The vital signs have been taken and documented in accordance with facility policy and procedure c) There is an I.V. access with the appropriate tubing and normal saline as the priming solution d) There is a signed informed consent for transfusion therapy f) Blood typing and cross-matching is documented in the medical record
In which of the following situations can a client's confidentiality be breached legally? a) When a client near discharge is threatening to harm an ex-partner. b) In a student nurse's clinical paper about a client. c) When a client's employer requests the client's diagnosis to initiate medical claims. d) To answer a request from a client's spouse about the client's medication.
a) When a client near discharge is threatening to harm an ex-partner.
A physician writes a medication order for meperidine 500 mg. The nurse's appropriate action would be to: a) clarify the order with the physician. b) clarify the order with another nurse on the unit. c) give the medication as ordered. d) clarify the order with the pharmacy
a) clarify the order with the physician.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: a) cranial nerves IX and X. b) cranial nerves VI and VIII. c) cranial nerves I and II. d) cranial nerves III and V.
a) cranial nerves IX and X
A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him: a) onto the bedpan. b) to the bathroom. c) to the bedside commode. d) to a standing position so he can urinate.
a) onto the bedpan
X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? a) "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow." b) "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." c) "Place the crutches and injured leg on the first step, followed by the unaffected leg." d) "Place both crutches on the first step and swing both legs upward to this step."
b) "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."
A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? a) Start an I.V. infusion of normal saline solution. b) Arrange for typing and crossmatching of the client's blood. c) Compare the client's identification wristband with the tag on the unit of blood. d) Measure the client's vital signs.
b) Arrange for typing and crossmatching of the client's blood
The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. The nurse should: a) Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle. b) Explain to the client that the physician will write an order for the eye drops to be used at the hospital. c) Place the eye drops in the hospital medication drawer and administer as labeled on the bottle. d) Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital.
b) Explain to the client that the physician will write an order for the eye drops to be used at the hospital
A nurse is caring for a client with a central venous catheter and notices redness and tenderness at the catheter insertion site. Which assessment finding would indicate possible systemic infection? a) Blood pressure of 122/78 mm Hg b) Respiratory rate of 32 breaths/minute c) Temperature of 97.3 degrees Fahrenheit (36.3 degrees Celsius) d) Heart rate of 55 beats/minute
b) Respiratory rate of 32 breaths/minute
The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they're restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses: a) Touch the client, which increases their exposure to radiation. b) Work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. c) Work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged. d) Are at greater risk from the radiation because they are younger than the mother.
b) Work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.
A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? a) Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. b) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. c) Review and revise the way client education is conducted in the surgeons' office. d) Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center.
b) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.
A client admitted to the psychiatric unit for treatment of a panic attack comes to the nurses' station in obvious distress. After finding the client short of breath, dizzy, trembling, and nauseated, a nurse should first: a) ask the client why he is upset. b) escort the client to a quiet area and suggest that he use a relaxation exercise he's been taught. c) assure the client that his symptoms will disappear after he lies down and relaxes. d) administer an antianxiety medication, as ordered, and instruct the client to lie down in his room.
b) escort the client to a quiet area and suggest that he use a relaxation exercise he's been taught.
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: a) payment status will change if the client isn't sedated. b) nutritional protocol will be effective after the client sedation therapy is tapered. c) she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. d) to continue I.V. administration of other scheduled medications.
c) she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube
When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client's anxiety? a) "You look anxious, don't worry you will get used to this place." b) "You may have a seat right over here." c) "As a precaution, we wear gowns, goggles, and gloves to administer the medication." d) "We wear gowns and gloves to administer chemotherapy drugs because they're very dangerous."
c) "As a precaution, we wear gowns, goggles, and gloves to administer the medication."
Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which of the following statements indicates the primary reason for the nurse manager to perform an investigation to determine the causes of the two falls? a) "I would like to establish what needs to take place to prevent future falls." b) "I want to determine exactly what happened and why the two clients fell." c) "I would like to establish the causes and trends related to client falls." d) "I want to identify the environmental factors that contributed to the falls."
c) "I would like to establish the causes and trends related to client falls."
Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? a) Wear sterile gloves and a mask. b) Remove the drain before cleaning the skin. c) Clean from the center outward in a circular motion. d) Clean briskly around the site with alcohol.
c) Clean from the center outward in a circular motion.
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? a) Respiratory b) Strict c) Contact d) Enteric
c) Contact
While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? a) Sterile petroleum gauze b) Dry sterile dressing c) Moist sterile saline gauze d) Povidone-iodine-soaked gauze
c) Moist sterile saline gauze
Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which of the following measures should the nurse carry out before helping the client to dangle the feet a) Have the client do leg exercises for a few minutes. b) Encourage the client to take a short nap. c) Place the client in a high Fowler's position. d) Administer a prescribed analgesic.
c) Place the client in a high Fowler's position.
A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first? a) Place the client in a chair with a waist restraint. b) Ask the client to sit in a chair next to the nurses' station. c) Provide one-to-one supervision of the client until detoxification treatment can begin. d) Decrease stimuli by putting the client in bed with the room door closed.
c) Provide one-to-one supervision of the client until detoxification treatment can begin.
The nurse notices that a nurse colleague is wearing a lower lip ring. The nurse should do which of the following? a) Direct the nurse to go to the Office of Infection Control. b) Page the nurse supervisor to speak with the nurse. c) Request the nurse remove the ring. d) Report the nurse to the unit manager
c) Request the nurse remove the ring.
How should the nurse instruct the parent to position an infant to assess the thyroid gland? a) Prone over the mother's knees b) Sitting upright in the infant carrier c) Supine on the mother's lap d) Standing on the examination table
c) Supine on the mother's lap
To follow standard precautions, the nurse should carry out which measure? a) Wearing a gown when bathing a client b) Wearing gloves for all client contact c) Wearing gloves when administering I.M. medication d) Recapping needles after use
c) Wearing gloves when administering I.M.
A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that she: a) read a book in a quiet room. b) play a game with a few friends. c) reorganize a kitchen cabinet. d) go shopping with a friend.
c) reorganize a kitchen cabinet
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Increase the oxygen percentage. b) Check for an apical pulse. c) Ventilate the client with a handheld mechanical ventilator. d) Suction the client's artificial airway
d) Suction the client's artificial airway
A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? a) "I'll use an electric razor to shave." b) "I'll watch my gums for bleeding when I brush my teeth." c) "I'll report unexplained or severe bruising to my doctor right away." d) "I'll eat four servings of fresh, dark green vegetables every day."
d) "I'll eat four servings of fresh, dark green vegetables every day."
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when the client says: a) "I'm clear when my chest X-ray is negative after one month of medication." b) "My tuberculosis isn't contagious after I take the medication for 24 hours." c) "I'm contagious as long as I have night sweats." d) "I'll stop being contagious when I have a negative acid-fast bacilli test."
d) "I'll stop being contagious when I have a negative acid-fast bacilli test."
A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety? a) "When you move the walker, set the back legs down first. Then step forward." b) "Use a walker with wheels to help you move forward." c) "Maintain a firm grip on the front bar as you step into the walker." d) "Place the walker directly in front of you and step into it as you move it forward."
d) "Place the walker directly in front of you and step into it as you move it forward."
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first: a) Prepare for birth. b) Have naloxone hydrochloride available in the birthing room. c) Document the client's relief due to pain medication. d) Complete a vaginal examination to determine dilation, effacement, and station.
d) Complete a vaginal examination to determine dilation, effacement, and station
The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which of the following next to ensure the safest transition of the infant to the mother? a) Check the crib to determine if there are enough diapers and formula. b) Ask the mother if there is anything else she needs for the care of her baby. c) Assess whether the mother is able to ambulate to care for the infant. d) Complete the hospital identification procedure with mother and infant.
d) Complete the hospital identification procedure with mother and infant
A nurse is performing a sterile dressing change. Which action contaminates the sterile field? a) Leaving a 1″ (2.5-cm) edge around the sterile field b) Opening the outermost flap of a sterile package away from the body c) Holding sterile objects above the waist d) Pouring solution onto a sterile field cloth
d) Pouring solution onto a sterile field cloth
A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with the recommendation for: a) Providing sedation. b) Transferring the child to the pediatric intensive care unit (PICU). c) Ordering a chest computed tomography (CT) scan. d) Starting oxygen.
d) Starting oxygen.
A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best? a) Distract the neonate by talking to her in a calm voice. b) Stop the nurse and instruct her to administer the vitamin K using the Z-track method. c) Praise the nurse for accurately preparing to administer the injection. d) Stop the nurse and have her reevaluate her injection technique
d) Stop the nurse and have her reevaluate her injection techniques
The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children: a) have a low risk of developing rapid dehydration. b) have smaller body surface areas than adults. c) breathe at a slower rate than adults. d) have thinner skin than adults.
have thinner skin than adults
