saunders safety exam 2
The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication? 1.Dry mouth 2.Diaphoresis 3.Excessive urination 4.Pupillary constriction
1.Dry mouth
The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply. 1.Eat a nutritious diet with adequate protein. 2.Use a pressure relief pad while in a wheelchair. 3.Shift weight every 4 hours while in a wheelchair. 4.Check the bottom sheet for wetness and wrinkles. 5.Use a mirror weekly to inspect for redness and breakdown
1.Eat a nutritious diet with adequate protein. 2.Use a pressure relief pad while in a wheelchair. 4.Check the bottom sheet for wetness and wrinkles
The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action? 1.Insert the suppository 1 to 2 cm into the rectum. 2.Position the child on the right side with the left leg flexed. 3.Ask the child to expel the suppository after it has been inserted. 4.Ask the child to hold the breath during insertion of the suppository.
1.Insert the suppository 1 to 2 cm into the rectum.
A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic? 1."What is it you don't remember?" 2."You can't always depend on your family to help." 3."It's not really necessary for you to remember this." 4."Let me go over your prescribed medications with you again."
4."Let me go over your prescribed medications with you again."
The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately? 1.It ensures that the client does not have any medication allergies. 2.It educates the client on the reason that medications are being given. 3.It notifies the client's pharmacy about the medications the client is taking in the hospital. 4.It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.
4.It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks? 1.Gloves 2.Gown and gloves 3.Gloves and mask 4.Gown, gloves, and a mask:
2.Gown and gloves
A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity? 1.Giving the client nectar-thickened coffee 2.Placing food on the affected side of the mouth 3.Allowing ample time for chewing and swallowing 4.Giving foods and fluids with the consistency of oatmeal
2.Placing food on the affected side of the mouth
The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately? 1.It helps to avoid medication errors. 2.It educates the client about any adverse or side effects of the medications being given. 3.It makes sure that the client's medical insurance will pay the cost of the medications. 4.It notifies the client's pharmacy about the medications the client is taking in the hospital and screens for allergies.
1.It helps to avoid medication errors.
The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? 1.Aim at the base of the fire. 2.Squeeze the handle on the extinguisher. 3.Sweep the fire from side to side with the extinguisher. 4.Sweep the fire from top to bottom with the extinguisher.
1.Aim at the base of the fire
The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply. 1.Time the start and stop of the seizure. 2.Apply oxygen at 2L with nasal cannula. 3.Turn the client to the side and do not restrain. 4.Note the distinguishing characteristics of the seizure. 5.Use a padded tongue blade to avoid tongue injury. 6.Turn on the suction machine with oral catheter.
1.Time the start and stop of the seizure. 2.Apply oxygen at 2L with nasal cannula. 3.Turn the client to the side and do not restrain. 4.Note the distinguishing characteristics of the seizure. 6.Turn on the suction machine with oral catheter.
The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply 1.Reinforce the dressing. 2.Place the client flat in bed. 3.Notify the registered nurse of the drainage. 4.Check the Jackson-Pratt drain for patency. 5.Check the strength and sensation in all four extremities.
2.Place the client flat in bed. 3.Notify the registered nurse of the drainage.
The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply. 1."I need to make sure to keep medications in childproof bottles." 2."I need to refer to medication as 'candy' only when really necessary." 3."I need to keep the poison control center telephone number available." 4."I need to place all toxic substances in a locked area after labeling them." 5."I can place several medications in the same bottle if I am going for an overnight trip.
2."I need to refer to medication as 'candy' only when really necessary." 5."I can place several medications in the same bottle if I am going for an overnight trip.
A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action? 1.Setting the heating pad on a low setting 2.Placing the heating pad under the client 3.Assessing the skin integrity frequently for signs of burns 4.Assessing the heating pad periodically for proper electrical function
2.Placing the heating pad under the client
A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply. 1.Keeping a padded tongue blade at the bedside 2.Removing any toy with bright blinking lights 3.Keeping the sides rails of the child's bed padded 4.Turning the infant on the side during any seizure 5.Restricting the amount of sugar the child ingests 6.Having oxygen and suction available at the bedside
2.Removing any toy with bright blinking lights 3.Keeping the sides rails of the child's bed padded 4.Turning the infant on the side during any seizure 6.Having oxygen and suction available at the bedside
The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply. 1.Neutropenic precautions 2.Testing stools and urine for blood 3.Using a soft toothbrush for mouth care 4.Monitoring closely for signs of infection 5.Monitoring the temperature every 4 hours
2.Testing stools and urine for blood 3.Using a soft toothbrush for mouth care
The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1.A clotting time of 10 minutes 2.A hemoglobin of 11 g/dL (110 mmol/L) 3.A platelet count of 40,000 mm3 (40 × 109/L) 4.A white blood cell (WBC) count of 3,000 mm3 (3 × 109/L)
3.A platelet count of 40,000 mm3 (40 × 109/L)
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1.Call for help. 2.Extinguish the fire. 3.Activate the fire alarm. 4.Confine the fire by closing the room door
3.Activate the fire alarm
The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief? 1.Pillow 2.Air ring 3.Alternating air pad 4.Plastic-lined absorbent pad
3.Alternating air pad
The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement? 1.Follow the oxygen prescription exactly. 2.Use a straight razor to shave while wearing the oxygen. 3.Keep the oxygen concentrator as close to the room wall as possible. 4.Forbid smoking or open flames within 10 feet of the oxygen source.
3.Keep the oxygen concentrator as close to the room wall as possible.
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? 1.An obturator 2.A Kelly clamp 3.An irrigation set 4.A pair of scissors
4.A pair of scissors
The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse? 1.Confine the fire. 2.Extinguish the fire. 3.Activate the fire alarm. 4.Remove the clients from the waiting room.
4.Remove the clients from the waiting room.
During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed? 1.Aiming at the top flames of the fire 2.Sweeping across from side to side 3.Pulling the pin on the fire extinguisher 4.Squeezing the handle on the extinguisher
1.Aiming at the top flames of the fire
The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? 1."We will be sure not to leave hot liquids unattended." 2."I guess my child needs to understand what the word 'hot' means." 3."We will be sure that our child stays in his room when we work in the kitchen." 4."We will install a safety gate as soon as we get home so that our child can't get into the kitchen."
1."We will be sure not to leave hot liquids unattended."
The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply 1.Clean towel 2.Sterile gloves 3.Water-soluble lubricant 4.Sterile 5- or 6-mL syringe 5.Sterile 10- or 12-mL syringe
1.Clean towel 5.Sterile 10- or 12-mL syringe
The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. 1.Wearing gloves when emptying the client's bedpan 2.Keeping all linens in the room until the implant is removed 3.Wearing a film (dosimeter) badge when in the client's room 4.Wearing a lead apron when providing direct care to the client 5.Placing the client in a semiprivate room at the end of the hallway
1.Wearing gloves when emptying the client's bedpan 2.Keeping all linens in the room until the implant is removed 3.Wearing a film (dosimeter) badge when in the client's room 4.Wearing a lead apron when providing direct care to the client
A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable? 1.The client shuts off the device immediately. 2.The client increases the device settings slightly. 3.The client adjusts the setting downward slightly. 4.The client adjusts the setting downward by half.
3.The client adjusts the setting downward slightly.
A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1.Uncaps the distal end of the tubing 2.Uncaps the spike portion of the tubing 3.Opens the roller clamp on the IV tubing 4.Closes the roller clamp on the IV tubing
4.Closes the roller clamp on the IV tubing
The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? 1.Every hour 2.Every 2 hours 3.Every 3 hours 4.Every 4 hours
1.Every hour
The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint? 1.A safety knot is made in the restraint strap. 2.The restraint straps are safely secured to the side rails. 3.The restraint strap does not tighten when force is applied against it. 4.The restraint is secure, and the client is able to turn from back to side.
2.The restraint straps are safely secured to the side rails.
The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now? 1.The nurse should bend at the waist to assist the client to the floor. 2.The nurse should stand with legs close together for added support. 3.The nurse should extend one leg to use to slide the client's body down to the floor. 4.The nurse should hold the client under the arms and hold the upper body off the floor.
3.The nurse should extend one leg to use to slide the client's body down to the floor.
The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason? 1.There is a decreased risk for infection through a central line IV. 2.Antibiotics can be infused with the TPN through a central line IV. 3.There is less risk for hyperglycemia with TPN infused through a central line IV. 4.There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.
4.There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.
A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply. 1.Aspirin 2.Dilantin 3.Penicillin 4.Furosemide 5.Gentamycin 6.Docusate sodium
1.Aspirin 4.Furosemide 5.Gentamycin
The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply. 1.Wear gloves while administering the injected medication. 2.Wear gown, gloves, and goggles to administer the medication. 3.Dispose of the needle and syringe in a puncture-resistant container. 4.Ask the client to dispose of the needle on the syringe in the sharps. 5.Contact the pharmacy to determine if an enteral form of the medication is available.
1.Wear gloves while administering the injected medication. 3.Dispose of the needle and syringe in a puncture-resistant container.
The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client? 1.Wrap a light roll of gauze to cover the IV site. 2.Move the client to a room close to the nurse's station. 3.Reinforce instructions to the client about not pulling the IV out. 4.Contact the primary health care provider for a prescription for wrist restraints
1.Wrap a light roll of gauze to cover the IV site.
The nurse is instructing a group of unlicensed assistive personnel (UAP) in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the UAP doing which action? 1.Leaning forward when turning a client in bed 2.Positioning a box that is to be lifted between the knees 3.Turning the back to change position while moving a client 4.Helping a client requiring total care into a chair without additional assistance
2.Positioning a box that is to be lifted between the knees
The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply. 1.Allowing the client sufficient time to eat 2.Providing oral hygiene after each meal 3.Maintaining a suction machine at the bedside 4.Providing a full liquid diet to aid in swallowing 5.Placing the client on the side in a supine position when feeding
1.Allowing the client sufficient time to eat 2.Providing oral hygiene after each meal 3.Maintaining a suction machine at the bedside
The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints? 1.Removing the restraints periodically 2.Applying lotion to the skin under the restraints 3.Providing range-of-motion exercises to the wrists 4.Checking color, sensation, and pulses distal to the restraints
4.Checking color, sensation, and pulses distal to the restraints
The nurse is reinforcing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with security devices (hand restraints). How often should the nurse instruct the UAP to check the client's skin and circulation under the security devices? 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 30 minutes
4.Every 30 minutes
The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater? 1.A space heater should not be used in an apartment. 2.The space heater should always be kept at a low setting. 3.The space heater should be placed in the hallway at nighttime. 4.The space heater needs to be placed at least 3 feet from anything that can burn.
4.The space heater needs to be placed at least 3 feet from anything that can burn.
The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply. 1.Securing the oxygen tubing to the client's bottom sheet 2.Observing the client's nares frequently for skin breakdown 3.Examining the top of the client's ears for redness and irritation 4.Checking the oxygen flow rate and primary health care provider's prescriptions every shift 5.Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible
1.Securing the oxygen tubing to the client's bottom sheet 5.Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible
The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose? 1.Promoting venous return to the heart 2.Preventing edema in the lower extremities 3.Improving oxygenation to the lower extremities 4.Decreasing the size of any thrombus that formed during surgery
1.Promoting venous return to the heart
The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply. 1.Provide adequate lighting. 2.Apply a restraint to keep her in bed at night. 3.Ensure that frequently used items are easily accessible. 4.Have the bedside stand and overbed tray table within reach. 5.Leave the side rails down to reach books stacked on the floor by the bed.
1.Provide adequate lighting. 3.Ensure that frequently used items are easily accessible. 4.Have the bedside stand and overbed tray table within reach
The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client? 1.Upright in a chair 2.On the left side in bed 3.On the right side in bed 4.In a low-Fowler's position, with the legs elevated
1.Upright in a chair
The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the UAP is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval? 1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 6 hours
1.Every 2 hours
The nurse is preparing to apply a mitten restraint to the client's hand. The nurse does which to ensure that the restraint is applied correctly? 1.Applies the restraint loosely 2.Makes sure that two fingers can be inserted under the restraint 3.Secures the restraint straps to the side rail using a quick-release tie 4.Makes sure that the sheepskin is on the outside rather than against the client's skin
2.Makes sure that two fingers can be inserted under the restraint
The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply. 1."I need to apply the cold pack for at least 60 minutes." 2."I will remove the ice pack if I start to feel numbness." 3."I should check my pulse before using the ice on my joints." 4."I can lie on the ice by placing it between the bed and my body." 5."I should wrap the frozen ice pack in a towel to help adjust to the cold."
2."I will remove the ice pack if I start to feel numbness." 5."I should wrap the frozen ice pack in a towel to help adjust to the cold."
A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)? 1.Toys 2.A bottle of alcohol 3.Lightweight pajamas 4.Washcloths and towels
2.A bottle of alcohol
The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply. 1.The client speaks in a quiet tone. 2.The client answers questions incorrectly. 3.The client states she quit attending social events. 4.The client holds on to the furniture when walking in the room. 5.The client asks appropriate questions to clarify information given. 6.The client does not respond to a person unless facing the speaker.
2.The client answers questions incorrectly. 3.The client states she quit attending social events. 6.The client does not respond to a person unless facing the speaker.
A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother? 1."You should tell your children never to cook." 2."You should tell your children to play in neighborhood homes after school." 3."You should seek community after-school programs or activities for your children." 4."You should tell your children to call you at work when they get home and every hour thereafter."
3."You should seek community after-school programs or activities for your children."
Which client is the safest one for a licensed practical nurse (LPN) to care for? 1.A client who is receiving a blood transfusion 2.A client with a history of von Willebrand disease 3.A client recovering from a scheduled cesarean delivery 4.A client with a previous history of postpartum hemorrhage
3.A client recovering from a scheduled cesarean delivery
The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? 1.Performs mouth care 2.Starts feeding the client 3.Adds thickener to the food 4.Places the client in an upright position
4.Places the client in an upright position
The nurse enters the room to find that the client's trash can is in flames. The client is in bed and the edge of the gown is smoking. The nurse should take which action first? 1.Get the nearest fire extinguisher. 2.Pull the nearest fire alarm switch. 3.Pour water into the flaming trash can. 4.Remove the gown from the client and remove the client from the room.
4.Remove the gown from the client and remove the client from the room.
The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take? 1.Apply the new neck ties securely before removing the old neck ties. 2.Insert the obturator in the tracheostomy tube while the neck ties are changed. 3.Ask the client to hold the tracheostomy tube in place while the nurse changes the neck ties. 4.Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.
4.Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.
The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action? 1.Leave the leg padding in the device. 2.Use the "stop-go" button found on the machine. 3.Keep the knee aligned with the hinged joint on the machine. 4.Reset the degrees of flexion or extension according to comfort.
4.Reset the degrees of flexion or extension according to comfort.
The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. 1.Explain the procedure to the client. 2.Irrigate the NG tube with saline. 3.Aspirate all stomach contents and discard. 4.Elevate the head of the bed to 45 degrees. 5.Have a pair of scissors for emergency use at the bedside. 6.Ensure that the end of the NG tube is in the esophagus.
1.Explain the procedure to the client. 2.Irrigate the NG tube with saline 4.Elevate the head of the bed to 45 degrees.
The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply. 1.Pedal pulses 2.Capillary refill 3.Color of the extremity 4.Temperature of the skin 5.Condition of the toenails 6.Presence of numbness
1.Pedal pulses 2.Capillary refill 3.Color of the extremity 4.Temperature of the skin 6.Presence of numbness
The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which actions? Select all that apply. 1.Positioning the client supine 2.Using products with lemon or alcohol 3.Brushing the teeth with a small soft toothbrush 4.Cleansing the mucous membranes with tooth sponges 5.Having oral suction equipment at the bedside and turned on
1.Positioning the client supine 2.Using products with lemon or alcohol
The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply 1.Preoxygenating the client before suctioning 2.Applying suction for a period of no more than 15 seconds 3.Moistening the catheter tip in sterile saline solution before suctioning 4.Introducing the catheter into the tracheostomy tube using a sterile gloved hand 5.Placing suction on the catheter while introducing the catheter into the tracheostomy tube
1.Preoxygenating the client before suctioning 3.Moistening the catheter tip in sterile saline solution before suctioning 4.Introducing the catheter into the tracheostomy tube using a sterile gloved hand
A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply. 1.Restraints 2.Nasal cannula 3.Suction catheter 4.Padded side rails 5.Padded tongue blade
1.Restraints 5.Padded tongue blade
The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply. 1.The surgeon is the person that marks the area of the operative procedure. 2.Is is acceptable for the operating room nurse to mark the area of the operative procedure. 3.The site of the operative procedure is marked during the time-out period in the operating room suite. 4.The site marking is done before the client is brought to the surgical suite in the operating room. 5.The site of the operative procedure is marked at the completion of the procedure to assess measurement of any skin or incisional changes.
1.The surgeon is the person that marks the area of the operative procedure. 4.The site marking is done before the client is brought to the surgical suite in the operating room.
The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply. 1.Turn on the bed alarm. 2.Administer the prescribed PRN pain medication. 3.Ask the client about needing to void or move bowels. 4.Turn on the nightlight in the hospital room and bathroom. 5.Notify the primary health care provider and obtain a prescription for restraints.
1.Turn on the bed alarm. 3.Ask the client about needing to void or move bowels. 4.Turn on the nightlight in the hospital room and bathroom.
The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply. 1.Unsecured scatter rugs 2.Clear exit passageways 3.An operable smoke detector 4.A prefilled medication cassette 5.Cigarette pack and lighter on the bedside stand
1.Unsecured scatter rugs 5.Cigarette pack and lighter on the bedside stand
The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. 1.Use a friction-reducing slide sheet. 2.Use a mechanical lift to move the client. 3.Place the client in Trendelenburg's position. 4.Keep elbows close and work close to the body. 5.Administer oral pain medication 5 minutes before moving the client. 6.Obtain assistance of a second caregiver to assist with mechanical aids.
1.Use a friction-reducing slide sheet. 2.Use a mechanical lift to move the client. 4.Keep elbows close and work close to the body 6.Obtain assistance of a second caregiver to assist with mechanical aids
The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client? 1.Encourage the family to visit. 2.Admit the client to a private room. 3.Place the client on protective isolation. 4.Place the client in a room near the nurse's station
2.Admit the client to a private room.
The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? 1.Using a hospital gown with snaps at the sleeves 2.Disconnecting the IV tubing from the catheter in the vein 3.Checking the IV flow rate immediately after changing the hospital gown 4.Putting the bag and tubing through the sleeve, followed by the client's arm
2.Disconnecting the IV tubing from the catheter in the vein
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply. 1.Providing oral fluids three times per day 2.Monitoring the skin around the stoma site for skin irritation 3.Medicating the client with antidiarrheal medications every day 4.Using sterile technique when performing all procedures involving the apparatus 5.Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube
2.Monitoring the skin around the stoma site for skin irritation 5.Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube
The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method? 1.Asking the client to recap the needle 2.Placing the needle and syringe in a puncture-resistant container 3.Recapping the needle before placing it in a puncture-resistant container 4.Laying the needle and syringe on the bedside table and carefully recapping the needle
2.Placing the needle and syringe in a puncture-resistant container
The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct? 1.Restrain in a car seat in the back seat in a semi-reclined, face-forward position. 2.Restrain in a car seat in the back seat in a semi-reclined, rear-facing position. 3.Restrain in a car seat in the front seat in a semi-reclined, rear-facing position. 4.Restrain in a car seat in the front seat in a semi-reclined, face-forward position.
2.Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.
While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply. 1.Do you have a history of seizures? 2.Do you have a history of a clotting disorder? 3.How long and why have you been using ginkgo? 4.Have you been diagnosed with diabetes mellitus? 5.On what area of your body have you been applying ginkgo?
1.Do you have a history of seizures? 2.Do you have a history of a clotting disorder? 3.How long and why have you been using ginkgo? 4.Have you been diagnosed with diabetes mellitus?
The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply. 1.Listen to the client's bowel sounds. 2.Document and discard the residual. 3.Offer the client sips of water to drink. 4.Question the client regarding nausea. 5.Determine whether the client has abdominal distension. 6.Hold the feeding after flushing the tubing with 30 mL saline.
1.Listen to the client's bowel sounds. 4.Question the client regarding nausea. 5.Determine whether the client has abdominal distension. 6.Hold the feeding after flushing the tubing with 30 mL saline
The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply. 1.Check the client's temperature. 2.Check the placement of the tube. 3.Administer prescribed medications. 4.Warm the feeding to body temperature. 5.Aspirate the contents from the nasogastric tube. 6.Observe the characteristics and pH of the aspirate from the nasogastric tube.
2.Check the placement of the tube. 5.Aspirate the contents from the nasogastric tube. 6.Observe the characteristics and pH of the aspirate from the nasogastric tube.
The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions should the nurse place the client in to prepare for the procedure? Select all that apply. 1.Supine prone 2.Low-Fowler's position 3.High-Fowler's position 4.Slight flexion of the neck 5.Slight extension of the neck
3.High-Fowler's position 5.Slight extension of the neck
The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply. 1.Massage 2.Acupressure 3.Homeopathy 4.Herbal supplements 5.Mind-body therapy
3.Homeopathy 4.Herbal supplements
The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive? 1.Observe the skin in the wrist area for redness. 2.Check the temperature of the skin in the hands. 3.Place two fingers under the restraint to determine snugness. 4.Remove the restraint and exercise the extremity in 2 hours.
3.Place two fingers under the restraint to determine snugness.
The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply. 1.To maintain the client in a supine position 2.To change the NG tube with every other feeding 3.That aspiration as a complication is a primary concern 4.To increase the rate of the feeding if the infusion rate falls behind schedule 5.To determine correct placement by aspirating contents from the tube to observe characteristics and check pH
3.That aspiration as a complication is a primary concern 5.To determine correct placement by aspirating contents from the tube to observe characteristics and check pH
The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply. 1.Restrict fluid intake. 2.Obtain a Medic-Alert bracelet. 3.Keep the humidity in the home low. 4.Prevent debris from entering the stoma. 5.Avoid exposure to people with infections. 6.Avoid swimming and use care when showering
2.Obtain a Medic-Alert bracelet. 4.Prevent debris from entering the stoma. 5.Avoid exposure to people with infections. 6.Avoid swimming and use care when showering.
The nurse is reinforcing instructions to a client with chronic vertigo that is poorly controlled. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms? 1.Driving only when there is no dizziness 2.Removing throw rugs and clutter in the home 3.Turning the head from side to side if dizziness occurs 4.Going to a sofa or a bed and lying down when the vertigo starts
2.Removing throw rugs and clutter in the home
After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care? 1.Administer ciprofloxacin. 2.Institute contact precautions. 3.Check vital signs every 15 minutes. 4.Dispense the recommended vaccine.
2.Institute contact precautions
The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching? 1."I need to use the back burners for cooking." 2."I need to remain in the kitchen when I prepare meals." 3."I need to be sure to place my cup of coffee on the counter." 4."I need to turn pot handles inward and to the middle of the stove."
3."I need to be sure to place my cup of coffee on the counter."
The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply. 1.The reason the chest tube was inserted 2.The probable time the restraints will be discontinued 3.Adequacy of circulation in the body area that is restrained 4.Type of restraint and body area where the restraint was applied 5.Communication with client and family member about need for restraint 6.The alternative measures that were attempted before restraints were applied
3.Adequacy of circulation in the body area that is restrained 4.Type of restraint and body area where the restraint was applied 5.Communication with client and family member about need for restraint 6.The alternative measures that were attempted before restraints were applied
The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill? 1.Using tongs to collect any broken glass 2.Wearing gloves for the cleanup procedure 3.Blotting up the spill with a face cloth or cloth towel 4.Disinfecting the area of the blood spill with a dilute bleach solution
3.Blotting up the spill with a face cloth or cloth towel
The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply. 1.Crutches were fitted for a person who is the same height. 2.Handgrips are positioned so the axillae bear the weight of the client. 3.Handgrips are positioned so the elbows are bent approximately 30 degrees. 4.The space between the axilla and the top of the crutch pad is 1½ to 2 inches. 5.The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.
3.Handgrips are positioned so the elbows are bent approximately 30 degrees. 4.The space between the axilla and the top of the crutch pad is 1½ to 2 inches. 5.The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.
The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall? Select all that apply 1.Performing hourly rounding 2.Placing the bed in the lowest position 3.Keeping the bathroom light off at nighttime 4.Placing the call light within the client's reach 5.Keeping the upper side rails up while the client is in bed 6.Placing the client in the quiet area of the nursing unit in a room away from the nurse's station
3.Keeping the bathroom light off at nighttime 6.Placing the client in the quiet area of the nursing unit in a room away from the nurse's station
The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply. 1.Place a gait belt on the client. 2.If stretch bands are used, reinforce the correct use. 3.Stand on the same side of the bed as the unaffected leg. 4.Observe for any signs/symptoms of dizziness the first time the client gets out of bed. 5.Lift the client into the bedside chair if the client complains of pain when standing. 6.After the client sits on the side of the bed, remind the client to stand on the unaffected leg.
1.Place a gait belt on the client. 2.If stretch bands are used, reinforce the correct use. 4.Observe for any signs/symptoms of dizziness the first time the client gets out of bed. 6.After the client sits on the side of the bed, remind the client to stand on the unaffected leg.
An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury? 1.Have the police take the adolescent's gun away. 2.Explore the adolescent's knowledge of gun safety. 3.Refer the adolescent to a firearm safety class sponsored by the hospital. 4.Have the adolescent watch a video on the tragedies of improper firearm usage.
2.Explore the adolescent's knowledge of gun safety.
The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply. 1.Socialize with the restrained client. 2.Determine the type of restraint to be used. 3.Document the client's orientation and degree of confusion. 4.Remove the restraint and perform range of motion activity. 5.Reapply the restraint after assisting the client to the bathroom. 6.Plan the frequency that the position of the client should be changed.
1.Socialize with the restrained client. 4.Remove the restraint and perform range of motion activity. 5.Reapply the restraint after assisting the client to the bathroom.
A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide, penicillin, and ibuprofen. He has received ibuprofen twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure. 1. 6 total points (moderate risk) 2. 9 total points (moderate risk) 3. 13 total points (high risk) 4. 14 total points (high risk)
2. 9 total points (moderate risk
A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply. 1.Avoid walking for the next 2 weeks. 2.Avoid activities that involve pulling or pushing. 3.Do not lift objects weighing more than 5 pounds. 4.The client may drive home but should have someone present. 5.Do not climb stairs until after the follow-up appointment with the surgeon.
2.Avoid activities that involve pulling or pushing. 3.Do not lift objects weighing more than 5 pound 5.Do not climb stairs until after the follow-up appointment with the surgeon.
The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply. 1.Position the client supine to assist with medication absorption. 2.Clamp the NG tube for 30 minutes after medication administration. 3.Before medication administration, verify correct placement of tube. 4.Flush the NG tube with saline before and after medication administration. 5.Discontinue the suction from the tube during administration of medication.
2.Clamp the NG tube for 30 minutes after medication administration. 3.Before medication administration, verify correct placement of tube. 4.Flush the NG tube with saline before and after medication administration. 5.Discontinue the suction from the tube during administration of medication
The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply. 1.Arrange for a transfer board to be used. 2.Perform the transfer using a hydraulic lift only. 3.Question the client about feelings of dizziness. 4.Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 5.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
3.Question the client about feelings of dizziness. 4.Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 5.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
The nurse is preparing to initiate a tube feeding for a client and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action should the nurse implement? 1.Initiate the feeding without the use of a pump. 2.Contact the electrical maintenance department for assistance. 3.Use an extension cord from the nurse's lounge for the pump plug. 4.Plug the pump cord into the available outlet above the room sink.
2.Contact the electrical maintenance department for assistance.
