NURSING NCLEX Module 6 Exam Questions and Answers,100% CORRECT

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NURSING NCLEX Module 6 Exam Questions and Answers Module 6 Exam Questions 1. 1.ID: 327496299 Which of the following events would require a nurse to complete and file an incident report? A. A cl... ient has a seizure. B. The nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct Rationale: An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test­Taking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 327496839 A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report Correct D. Telling the nursing supervisor that the physician did not want an incident report completed and filed Rationale: Incident reports are an important part of a healthcare agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the physician that the error warrants completion and follow­through with an incident report. Therefore, the other options are incorrect. Test­Taking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 327496835 Contact precautions are initiated for a client with methicillin­resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. Correct D. To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test­Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed­ ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 327496225 A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: Correct A. Removing the client from the room B. Pulling the nearest fire alarm C. Closing the door to the room D. Running to get the nearest fire extinguisher Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first step is to remove the client from the room, after which the nurse should activate the fire alarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to any type of fire emergency. Removing the client from the room is the first step. Pulling the nearest fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action. Test­Taking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind, sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 839, 840). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 2. 5.ID: 327495383 The mother of a 3­year­old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center Correct B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department D. Leave a message at the physician answering service about the incident Awarded 1.0 points out of 1.0 possible points. B. 6.ID: 327495361 A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan Correct B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm Awarded 1.0 points out of 1.0 possible points. C. 7.ID: 327496843 A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. “I need to follow the oxygen prescription exactly.” Correct B. “I can use my electric razor while I’m using oxygen.” C. “I have to keep the oxygen concentrator out of direct sunlight.” Correct D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Correct Awarded 1.0 points out of 1.0 possible points. D. 8.ID: 327495381 A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: A. Every 2 hours Correct B. Every 3 hours C. Every 4 hours D. Every 30 minutes Awarded 1.0 points out of 1.0 possible points. E. 9.ID: 327496271 A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity Correct Awarded 1.0 points out of 1.0 possible points. F. 10.ID: 327496807 The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client’s record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 am. Correct C. Twice the amount of the prescribed ramipril was administered at 9 am. D. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. Rationale: After an incident, the nurse would document a concise and objective description of what occurred and any follow­up actions taken in the client’s record. The nurse would not document in the client’s record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given. Test­Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the options that are comparable or alike in that they indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. References: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 704, 705). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. G. 11.ID: 327495339 A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? A. The client’s bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed. Correct Awarded 1.0 points out of 1.0 possible points. H. 12.ID: 327496281 A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. A. Skin Correct B. Lungs Correct C. Immune D. Urinary E. Lymphatic F. Gastrointestinal Correct Awarded 1.0 points out of 1.0 possible points. I. 13.ID: 327495341 A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin’s disease. Which of the following precautions should the nurse take while working with this intravenous (IV) infusion? A. Wearing gloves and a mask Incorrect B. Wearing gloves and a gown C. Wearing gloves, a mask, and eye protectionCorrect D. Wearing gloves, a mask, and a head covering Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological hood is not available. Wearing gloves and a mask or gloves and a gown will not provide adequate protection. A head covering is not necessary. Test­Taking Strategy: Knowledge regarding the precautions for handling chemotherapeutic agents is necessary to answer this question. Think about the effects and cytotoxic nature of chemotherapy to answer the question. Select the option that will provide the greatest degree of protection to the nurse handling chemotherapeutic agents. If you had difficulty with this question, review the precautions for preparing a chemotherapy infusion. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 423). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 0.0 points out of 1.0 possible points. J. 14.ID: 327495375 A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? A. Obtaining new IV tubing Correct B. Obtaining a new IV solution bag C. Scrubbing the tubing port with an alcohol swab D. Wiping the tubing port with povidone­iodine solution (Betadine) Rationale: If IV tubing becomes contaminated as a result of coming into contact with some nonsterile object, the nurse should obtain new IV tubing. Contaminated tubing could cause systemic infection in the client. The IV solution bag has not been contaminated and does not need replacement. Wiping the tubing port with Betadine or scrubbing it with alcohol is insufficient and would be contraindicated regardless, because the tubing will be attached directly to a catheter in the client’s vein. Test­Taking Strategy: Visualize the situation as you read the question. Use your knowledge of basic infection control measures and IV therapy to answer this question. Also, focus on the data in the question and note that the IV tubing has become contaminated. Review aseptic technique if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 179, 188). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. K. 15.ID: 327495385 A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? A. Staying secluded in the bedroom B. Wearing an oxygen mask at all times C. Keeping the house closed up to minimize the spread of disease D. Disposing of contaminated tissues in a container with a leak­proof bag Correct Rationale: The client under respiratory precautions at home does not need to remain secluded; the client would not be at home if he or she were infectious. However, proper respiratory precautions are necessary. The house should be properly ventilated, and the windows should be opened as much as possible. Wearing an oxygen mask at all times is not a respiratory precaution, and there is no information in the question to indicate that oxygen is necessary. Contaminated tissues should be discarded in container with a leak­proof bag and then placed in an outdoor trash bin. Tissues should not be left lying around. Test­Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and the subject, respiratory precautions at home. Recalling the mode of transmission and home care measures for TB will direct you to the correct option. Also note the words “secluded,” “all times,” and “closed up” in the incorrect options. If you had difficulty answering this question, review the precautions that should be taken by the client with TB who has been discharged home. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 670). St. Louis: Saunders. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. L. 16.ID: 327496221 A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. A. “I need to use night lights.” B. “I need to remove my wall­to­wall carpeting.”Correct C. “I need to get handrails put up in the bathroom.” D. “I need to use the staircase handrails when I go up the stairs.” E. “I should walk barefoot as much as possible so that I’ll know about any wet spots on the floor.”Correct Awarded 1.0 points out of 1.0 possible points. M. 17.ID: 327495353 A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? A. Planning to have the nuclear scan performed at the bedside B. Asking the technicians in the nuclear scan department to wear masks C. Placing a surgical mask on the client for transport and for contact with other individualsCorrect D. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued Awarded 1.0 points out of 1.0 possible points. N. 18.ID: 327496275 A nurse employed in a physician’s office hears a client in the waiting room call out, “Help! Fire!” The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately: A. Confines the fire B. Extinguishes the fire C. Activates the fire alarm D. Removes the clients from the waiting roomCorrect Awarded 1.0 points out of 1.0 possible points. O. 19.ID: 327496209 A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? A. Confining the fire B. Extinguishing the fire C. Activating the fire alarm Correct D. Running for the fire extinguisher Awarded 1.0 points out of 1.0 possible points. P. 20.ID: 327495325 The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first: A. Aiming at the base of the fire B. Pulling the pin on the fire extinguisher Correct C. Squeezing the handle of the extinguisher D. Sweeping from the top to the bottom of the fire with the extinguisher Awarded 1.0 points out of 1.0 possible points. Q. 21.ID: 327495387 A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? A. The assistant applies a tie knot in the restraint strap. B. The assistant attaches the restraint straps securely to the siderails. C. The assistant applies the restraint so that the strap does not tighten when force is applied against it. Correct D. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client’s skin. Awarded 1.0 points out of 1.0 possible points. R. 22.ID: 327496841 A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply. A. The assistant leans forward when turning a client in bed. B. The assistant positions a box that is to be lifted between his knees. Correct C. The assistant turns his back to change position while moving a client. D. The assistant keeps the object to be moved as close to his body as possible. Correct E. The assistant helps a client requiring total care into a chair without additional assistance. Awarded 1.0 points out of 1.0 possible points. S. 23.ID: 327496817 A home care nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? A. “A space heater should never be used in an apartment.” B. “A space heater can be used as long as it is kept at a low setting at all times.” C. “A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs.” D. “A space heater can be used as long as it’s placed at least 3 feet from anything that may ignite.”Correct Awarded 1.0 points out of 1.0 possible points. T. 24.ID: 327496241 A nurse is preparing to initiate a continuous tube feeding, using a tube­feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What should the nurse do? A. Plug in the pump cord into an available plug above the sink B. Ask the physician to change the prescription to intermittent feedings C. Determine the need for the appliances now plugged into the needed wall socket Correct D. Use a regular extension cord to allow the use of more than one electrical appliance Rationale: It is most appropriate for the nurse to assess the situation and determine the need for the appliances already plugged into the needed wall socket. The use of electrical appliances near a sink presents a hazard. It is not appropriate (and is premature) to ask the physician to change the prescription, because the prescription is based on the client’s needs. A regular extension cord should not be used, because it poses a risk of fire. Test­Taking Strategy: Use the process of elimination and the steps of the nursing process to answer the question. The only option that addresses assessment is the one that involves determining the need for the appliances currently plugged into the needed wall socket. Review electrical safety procedures if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 323). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. U. 25.ID: 327496243 View video. A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. A. Holding the pair of sterile forceps below waist level area B. Positioning the sterile field so that it remains in full view Correct C. Reaching across the sterile field to pick up a sterile gauze D. Leaving the room to obtain a bottle of sterile normal saline solution E. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Correct F. Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves Correct Rationale: View video. The principles of surgical asepsis must be followed in the preparation of a sterile field. Among these principles: A sterile object remains sterile only when touched by other sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of the range of vision or an object held below the nurse’s waist is to be considered contaminated; a sterile object or field becomes contaminated with prolonged exposure to air; when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by way of capillary action; fluid flows in the direction of gravity; a 1­inch edge of a sterile field or container is to be considered contaminated. Test­Taking Strategy: Focus on the subject, use of the principles of aseptic technique. Reading each option carefully and recalling the principles of aseptic technique will direct you to the correct options. Review aseptic technique and the procedure for preparing a sterile field if you had difficulty with this question. References: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 670­672). St. Louis: Mosby. Video/animation: Preparing a sterile field: L001_preparing_a_sterile_field.flv Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. V. 26.ID: 327495397 A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately: A. Asks the LPN to complete and file an incident report Correct B. Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided C. Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route D. Instructs the LPN to write “pr” (per rectum) on the medication record next to the time at which the medication was administered Rationale: If a medication is prescribed to be administered by way of the oral route, the nurse may not use an alternate route to administer the medication unless the change is prescribed by the physician. The nurse would ask the LPN to complete and file an incident report because the LPN, legally speaking, made a medication error. Telling the LPN that she made a sound judgment in administering the medication by way of the rectal route is incorrect. Although the client must be reassessed and the LPN would document administration of the medication by way of the rectal route in the client’s record, the most appropriate option given is having the LPN complete and file an incident report. Test­Taking Strategy: Use the process of elimination and note the strategic words “most appropriately.” Focusing on the data indicates that the LPN made a medication error. This will direct you to the correct option. Review the appropriate actions in the event of a medication error if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 403, 704, 705). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. W. 27.ID: 327495335 A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client’s plan of care? A. Wearing gloves when emptying the client’s bedpan Correct B. Allowing the client to ambulate in the hall only once a day C. Placing the client in a semiprivate room at the end of a hallway D. Placing used linen in double bags and sending a bag to the laundry room every evening Rationale: A primary goal of care for the client with an internal radiation implant is to prevent exposure of others to radiation. Therefore, a client with an internal radiation implant is required to remain in a private room to prevent accidental exposure of other clients, staff, and visitors to radiation. For this reason, a private room with a private bath is essential. All client linens should be kept in the client’s room until the implant is removed. Wearing gloves when emptying the client’s bedpan is the only appropriate intervention, of those provided, for a client with an internal radiation implant. Test­Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed­ ended word “only.” Also eliminate the option involving the use of a semiprivate room. To select from the remaining options, use your knowledge of standard precautions and precautions for a client with an internal radiation implant. This will direct you to the correct option. Review radiation safety principles if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 420). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. X. 28.ID: 327496223 A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which of the following observations by the instructor indicates a need for further teaching? A. The nursing student changes gloves between tasks and procedures. B. The nursing student washes hands before making contact with the client. C. The nursing student wears a gown to change the bed of an incontinent client. D. The nursing student washes her hands before glove removal after emptying a Foley bag. Correct Rationale: Standard precautions require that gloves be removed promptly after use and before the wearer touches noncontaminated surfaces or other clients. Gloves are not washed before removal, because splashing of contaminated material may result. Changing gloves between tasks and procedures, washing the hands before making contact with the client, and wearing a gown to change the bed of an incontinent client reflect correct understanding of the principles of standard precautions. Test­Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect action. Use the process of elimination, visualizing each of the procedures described in the options. Thinking about the principles of standard precautions will direct you to the correct option. Review the principles associated with standard precautions if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 178, 179). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. Y. 29.ID: 327495337 A physician writes a prescription for the application of a heating pad to a client’s back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply. A. Placing the heating pad under the client B. Adjusting the heating pad to the high setting C. Frequently assessing the client’s skin for signs of burns Correct D. Assessing the client’s medical history and risk factors for burns Correct E. Assessing the heating pad periodically for proper electrical function Correct Rationale: The nurse should first assess the client’s medical history, including risk factors for burns. The heating pad should never be placed under a client; instead, it should be placed lightly against or on top of the involved area. Burns may result when a client lies on a heating pad. The heating pad is adjusted to the low setting; the high setting can cause burns. Assessing the client for altered skin integrity and checking for proper electrical function are appropriate measures for the use of a heating pad. Test­Taking Strategy: Focus on the subject, the correct use of a heating pad for a client. Thinking about the hazards or risks to the client will assist you in selecting the correct options. Placing the heating pad under the client or adjusting the heating pad to the high setting could result in a burn. If you had difficulty with this question, review the principles of safe use of a heating pad. References: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 1047, 1048). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. Z. 30.ID: 327495373 A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to: A. Place the ice pack directly on the eye B. Avoid the use of commercially prepared ice bags C. Keep the ice pack on the eye continuously for 24 hours D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye Correct Awarded 1.0 points out of 1.0 possible points. AA. 31.ID: 327496213 A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line–related sepsis is diagnosed. The nurse interprets this finding as meaning that this infection is: A. An iatrogenic infection B. A result of bacterial colonization C. A community­acquired infection D. A healthcare­associated infection Correct Awarded 1.0 points out of 1.0 possible points. AB. 32.ID: 327496253 A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. A. The use of latex gloves B. The use of shielded needles Correct C. The use of recessed needles Correct D. The use of needleless devices Correct E. Disposal of needles in special puncture­resistant containers Correct Awarded 1.0 points out of 1.0 possible points. AC.33.ID: 327496259 A nurse is preparing to clean up a blood spill on the client’s bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. A. Using tongs to collect any broken glassCorrect B. Wearing gloves for the cleanup procedureCorrect C. Placing the pieces of broken glass in a plastic bag D. Blotting up the spill with a face cloth or cloth towel E. Disinfecting the area of the blood spill with a dilute bleach solution Correct Awarded 1.0 points out of 1.0 possible points. AD.34.ID: 327495389 The unit supervisor of an emergency department (ED) is called at home and told by an emergency department nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the unit supervisor be? A. “Has the disaster plan been activated?”Correct B. “Call as many nursing staff as you can to come in to work.” C. “Make sure all of the rooms are well stocked with supplies.” D. “Be sure that the nursing staff finds as many stretchers as they can.” Awarded 1.0 points out of 1.0 possible points. AE. 35.ID: 327496803 A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to: A. Induce vomiting B. Call an ambulance C. Call the poison control center Correct D. Bring the child to the emergency department (ED) Awarded 1.0 points out of 1.0 possible points. AF. 36.ID: 327496247 A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low­bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. A. Fresh apple B. Raw celery C. Italian bread Correct D. Tossed salad E. Baked chicken Correct F. Well­cooked cheeseburger Correct Awarded 1.0 points out of 1.0 possible points. AG. 37.ID: 327496833 Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. A. Saving vomitus for laboratory analysis Correct B. Placing the client in the supine position C. Determining the type and amount of substance ingested Correct D. Removing any visible materials from the nose and mouth Correct E. Inducing vomiting if a household cleaner has been ingested F. Assessing the client’s airway patency, breathing, and circulation Correct Rationale: In the event of accidental poisoning, the poison center is called before any attempt at interventions is made. Additional interventions in an accidental poisoning include assessing the client’s airway patency, breathing, and circulation; removing any visible materials from the nose and mouth to terminate exposure; determining the type and amount of substance ingested, if possible, to identify an antidote; saving vomitus for laboratory analysis, which may aid further treatment; and positioning the victim with the head to the side to prevent aspiration of vomitus and help keep the airway open. Because of the risk of aspiration, vomiting is never induced in an unconscious client or in a client who is experiencing seizures. Additionally, vomiting is not induced if lye, a household cleaner, a hair care product, grease, a petroleum product, or furniture polish has been ingested, because of the risk of internal burns. Test­Taking Strategy: Focus on the subject, interventions in the event of accidental poisoning. Visualize each of the interventions and how they might be helpful in treating the poisoning. Use of the ABCs (airway, breathing, and circulation) will also help you determine the correct interventions. Remember, too, that caustic substances may cause further injury to the client if vomiting is induced. If you had difficulty with this question, review the interventions for a victim of accidental poisoning. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 840­842). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Awarded 1.0 points out of 1.0 possible points. AH.38.ID: 327496267 A nurse is assigned to care for a client with an infection caused by methicillin­ resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client’s room, which necessary protective items does the nurse obtain? Select all that apply. A. Mask Incorrect B. Gown Correct C. Gloves Correct D. Face shield Correct E. Shoe protectors Rationale: Infection caused by MRSA necessitates contact precautions. The care of this client requires the use of gown, gloves, and a face shield. The face shield is worn to protect the face and the mucous membranes of the mouth, nose, and eyes during interventions that could produce splashes of blood, body fluids, secretions, and excretions (e.g., wound irrigation and suctioning). Contact precautions also require the use of gloves and a gown if direct client contact is anticipated. A mask does not provide adequate protection. Shoe protectors are not necessary. Test­Taking Strategy: Focus on the data in the question and think about the events that might occur during a wound irrigation and suctioning. This will help you determine the necessary items for the care of this client. If you had difficulty with this question, review standard and contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 0.0 points out of 1.0 possible points. AI. 39.ID: 327495365 A nurse is assisting with disaster relief after a tornado. The nurse’s goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? A. Initial B. Primary C. Tertiary Correct D. Secondary Awarded 1.0 points out of 1.0 possible points. AJ. 40.ID: 327495327 A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? A. Airway patency Correct B. Active bowel sounds C. Adequate urine output D. Orientation to surroundings Awarded 1.0 points out of 1.0 possible points. AK. 41.ID: 327496823 A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client’s physician does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is appropriate? A. Asking a family member to sit with the client B. Asking a nursing assistant to monitor the client C. Staying with the client and consulting with the nurse manager about the situation Correct D. Telling the family that the application of wrist restraints is critical in preventing injury to the client Awarded 1.0 points out of 1.0 possible points. AL. 42.ID: 327495379 A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10­car wreck on the interstate will be brought to the ED. The nurse manager initially manages this situation by: A. Telling EMS to take the victims to another hospital B. Closing the emergency department temporarily to incoming clients C. Calling the nursing supervisor to discuss activation of the disaster plan Correct D. Demanding that the nurses from the night shift stay until all of the victims have been treated Awarded 1.0 points out of 1.0 possible points. AM. 43.ID: 327496265 A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first? A. A victim who has died of multiple serious injuries B. A hysterical victim who has sustained a head injury C. An alert victim who has numerous bruises on the arms and legs D. A victim with a partial amputation of a leg who is bleeding profusely Correct Awarded 1.0 points out of 1.0 possible points. AN.44.ID: 327496827 A nurse giving a client a bed bath drops the towel on the floor. The nurse should: A. Use a bath blanket as a towel B. Borrow a towel from the client’s roommate C. Wash her hands, pick up the towel, and shake the towel out D. Wash her hands and go to the linen room to obtain another towel Correct Rationale: To avoid spreading the client’s germs, the nurse must wash her hands before leaving the client’s room. Therefore the nurse should cover the client and ensure that the client is safe, wash her hands, and go to the linen room to obtain another towel. It is not appropriate to use a bath blanket as a towel. It is never appropriate to borrow other clients’ supplies, because this is inconsistent with the principles of infection control. The nurse would never use linen that had been dropped on the floor. Also, shaking linen spreads germs. Test­Taking Strategy: Focus on the data in the question and note that the nurse has dropped the towel on the floor. Read each option carefully and use your knowledge of infection control and the principles of bathing a client to direct you to the correct option. Review the principles of infection control if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 874­877). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. AO. 45.ID: 327496809 A nurse is attending an inservice program on disaster preparedness. Which of the following events is described as an example of a natural disaster? A. Drought Correct B. Bus accident C. Terrorist attack D. Toxic waste spill Awarded 1.0 points out of 1.0 possible points. AP. 46.ID: 327495391 A nurse manager tells the nursing staff that the agency’s disaster preparedness plan will be distributed to all employees for review. The nurse manager states that the plan is an important component of disaster readiness because it primarily: A. Identifies the location of healthcare supplies B. Identifies the types of disasters that may occur C. Aids determination of how victims will be triaged D. Describes a formal plan of action for the coordination of a response Correct Awarded 1.0 points out of 1.0 possible points. AQ. 47.ID: 327496279 A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? A. Declaring a disaster B. Providing disaster relief Correct C. Activating disaster medical assistant teams D. Developing a federal disaster response plan Awarded 1.0 points out of 1.0 possible points. AR.48.ID: 327496255 A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. A. Anthrax is never fatal. B. No vaccine to prevent anthrax is available. C. Anthrax can be transmitted from person to person. D. A blood test is available for the detection of anthrax. Correct E. One way that anthrax can be contracted is through the skin. Correct Awarded 1.0 points out of 1.0 possible points. AS. 49.ID: 327496205 Acccording to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, in which phase are the available resources for the care of infants, older clients, the disabled, and people with chronic health problems addressed? A. Response B. Recovery C. Mitigation Correct D. Preparedness Rationale: The mitigation phase consists of actions or measures that can either prevent the occurrence of a disaster or reduce a disaster’s damaging effects. The task of determining the resources available for the care of infants, older clients, the disabled, and people with chronic health problems is addressed in this phase. The preparedness phase involves actions that plan for rescue, evacuation, and care of disaster victims. The response phase involves putting disaster­planning services into action and enumerating the actions needed to save lives and prevent further damage. The recovery phase includes actions taken to return to normal after the disaster. Test­Taking Strategy: Focus on the subject, available resources. Think about the definition of each item in the options. This will help you determine the correct phase. Review the phases of disaster management if you had difficulty with this question. Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for families and populations (4th ed., pp. 566, 567). Philadelphia: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Biological/Chemical Warfare Awarded 1.0 points out of 1.0 possible points. AT. 50.ID: 327496801 An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. A. Keep visitors to a minimum B. Acknowledge the client’s feelings Correct C. Provide information about hospital routinesCorrect D. Put the client in a room far from the nurses’ station E. Keep the door open and the room lights on at all times F. Allow the client to have as many choices regarding his care as possible Correct Rationale: Several general interventions can be used to minimize stress in the hospitalized client. These include acknowledging the client’s feelings, providing information, providing social support, and giving the client control, when possible, over choices related to care. Admitting the client to a room far from the nurses’ station and limiting visitors would both serve to increase the client’s anxiety. Keeping the door open and the room lights on at all times could cause further disruption in the client’s sleep pattern in addition to the disruption created by the hospitalization. Test­Taking Strategy: The strategic words are “safe” and “minimize the stress.” This tells you that the correct option(s) allay(s) the client’s fears and anxiety after sudden placement in a foreign environment. Use your knowledge of the principles of safety and stress reduction to answer the question and review these principles if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., pp. 17, 18). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. AU.51.ID: 327495349 A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. A. Have a first aid kit available. Correct B. Have a firearm or other weapon available. C. Plan a meeting place for family members.Correct D. Obtain a 1­day supply of water (1 gallon per person). E. Have an adequate supply of prescription medications. Correct F. Have a battery­operated radio and a flashlight and batteries available. Correct Awarded 1.0 points out of 1.0 possible points. AV. 52.ID: 327496215 A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. A. A victim with respiratory distress Correct B. A victim with a fractured humerus C. A victim with partial amputation of the footCorrect D. A victim with a forehead laceration that is not bleeding E. A victim with multiple nonbleeding bruises of the arms and legs Rationale: One rating system commonly used in the ED consists of three tiers — emergent, urgent, and nonurgent — with the categories sometimes identified with color coding or numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life­threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a. yellow or priority 2) classification is given to clients whose injuries and complications are not life threatening (here, the client with the fractured humerus), provided that they are treated within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients with the forehead laceration and bruises of the arms and legs) who do not have immediate complications and can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Test­Taking Strategy: Use the ABCs — airway, breathing, and circulation — which will easily direct you to the correct options. Respiratory distress involves the airway, and the victim with amputation is at risk for bleeding (i.e., circulation). Review the triage system and priorities of care if you had difficulty with this question. References: Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for families and populations (4th ed., p. 567). Philadelphia: Saunders. McEwen, M., & Pullis, B. (2009). Community­based nursing: An introduction (3rd ed., p. 157). Philadelphia: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Awarded 1.0 points out of 1.0 possible points. AW. 53.ID: 327495371 A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply. A. Untacked rugs on the stairs Correct B. Small rugs in the living room Correct C. Carpet on stairs secured with tacks D. Clothes hamper at the end of the hallway E. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator Correct Rationale: Area rugs and runners should not be used on or near stairs. Injuries in the home are frequently the result of loose objects, including small rugs on the stairs or floor, wet spots on the floor, or clutter on bedside tables, closet shelves, the top of the refrigerator, and bookshelves. Care should also be taken to ensure that end tables are secure and have stable straight legs. Nonessential items should be placed in drawers to eliminate clutter. If the stairs must be carpeted, carpeting should be secured with the use of tacks. Test­Taking Strategy: Note the strategic words “requires instruction.” These words indicate a negative event query and the need to identify safety hazards in the environment. Reading each option carefully will assist you in answering correctly. Review safety hazards in the home if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 1062). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. AX. 54.ID: 327496273 A home health nurse is performing an assessment of a client’s skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client? A. Putting on a pair of gloves B. Donning a mask and gloves C. Putting on a gown and gloves Correct D. Avoiding sitting on the client’s furniture Awarded 1.0 points out of 1.0 possible points. AY. 55.ID: 327496825 An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? A. An open ulcer B. An itchy bump Correct C. A weeping blister D. A black skin area of skin Awarded 1.0 points out of 1.0 possible points. AZ. 56.ID: 327496829 A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of inhalation anthrax is: A. Hemorrhage B. Signs of shock C. Flulike symptoms Correct D. Respiratory distress Rationale: Inhalation anthrax is caused by the inhalation of spores from Bacillus anthracis, which multiply in the alveoli. This form of anthrax begins with the same symptoms as the flu, including fever, muscle aches, and fatigue. Symptoms suddenly become more severe with the development of breathing problems and shock. Toxins from the anthrax spores cause hemorrhage and destruction of lung tissue. Test­Taking Strategy: Focus on the data in the question and note the strategic word “inhalation.” This will assist you in eliminating the options that indicate hemorrhage and signs of shock. To select from the remaining options, note the word “early,” which will direct you to the correct option. Review the signs of inhalation anthrax if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., pp. 672, 673). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/Chemical Warfare Awarded 1.0 points out of 1.0 possible points. BA. 57.ID: 327495345 A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse? A. “You really need to ask your doctor about that.” B. “That’s hard to say. We won’t know for a week or two.” C. “Antibiotic therapy is usually prescribed and will cure the infection.” Correct D. “It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly.” Rationale: Skin anthrax starts with an itchy bump (papule) that looks like a mosquito bite. It progresses to a small fluid­filled sac that becomes a painless ulcer with an area of dead black tissue in the middle. (Toxins from the anthrax spores destroy surrounding tissue.) Antibiotic treatment cures this infection, but untreated skin anthrax can result in overwhelming septicemia and death. Replying, “You really need to ask your physician about that” or “That’s hard to say. We won’t know for a week or two” is nontherapeutic and places the client’s question on hold. Stating, “It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly” is incorrect. Test­Taking Strategy: Use your knowledge of therapeutic communication techniques to eliminate the options that place the client’s question on hold. To select from the remaining options, note that the correct option is the only one that directly addresses the client’s question. Review skin anthrax and therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient–centered collaborative care (6th ed., pp. 166, 167). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Biological/chemical warfare Awarded 1.0 points out of 1.0 possible points. BB. 58.ID: 327496207 The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? A. Enteric B. Inhalation Correct C. Gastrointestinal D. Through open wounds Rationale: Smallpox, transmitted in air droplets and in the handling of contaminated materials, is highly contagious. Symptoms include fever, back pain, vomiting, malaise, and headache, followed 2 days later by the appearance of papules that progress to pustular vesicles, which are initially abundant on the face and extremities. Enteric, gastrointestinal, and open wounds are not routes of smallpox transmission. Test­Taking Strategy: Specific knowledge regarding the route of transmission of smallpox is necessary to answer this question. Remember that smallpox is transmitted in air droplets and through the handling of contaminated materials. Review the characteristics of smallpox if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., p. 338). St. Louis: Saunders. McEwen, M., & Pullis, B. (2009). Community­based nursing: An introduction (3rd ed., pp. 411, 412). Philadelphia: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. BC.59.ID: 327495343 A client with paraplegia has spasticity of the leg muscles. Which interventions should be included in the plan of care for this client? Select all that apply. A. The use of restraints to immobilize the limbs B. Range­of­motion exercises of the affected limbsCorrect C. An as­needed prescription for a muscle relaxantCorrect D. Removal of potentially harmful objects near the client Correct E. The use of padding against the client’s legs when the client is sitting in a wheelchair Correct Awarded 1.0 points out of 1.0 possible points. BD.60.ID: 327495369 A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet? A. Soak the scab that forms with warm water every day. B. Keep the vaccination site open to air as much as possible. C. Apply an antihistamine ointment to the scab to prevent itching. D. Avoid sharing towels or other items that have come in contact with the vaccination site. Correct Awarded 1.0 points out of 1.0 possible points. BE. 61.ID: 327496217 An older client in a long­term care facility is at risk for injury because of confusion. Which of the following devices would be the best choice to help prevent injury while the client is in bed? A. B. C. D. Correct restraint is used to immobilize an extremity as a means of protecting the client from injury resulting from a fall or the accidental removal of a therapeutic device such as a Foley catheter. The mitten restraint is a thumbless mitten device that is used to restrain the client’s hand. It prevents the client from dislodging invasive equipment, removing dressings, or scratching him­ or herself. Test­Taking Strategy: Use the process of elimination and knowledge of the various restraint methods and the ethical and legal ramifications of using a restraint. The use of the words “best choice” will guide you to the correct option. Also recall that the least invasive method of restraint should be used; this will help you answer correctly. Review the guidelines for the use of restraints if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 834, 835, 837­839). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BF. 62.ID: 327496235 A nurse in a long­term care facility recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. The appropriate nursing action would be to: A. Contact the physician Correct B. Apply the restraints anyway C. Medicate the client with a sedative, then apply the restraints D. Compromise with the client and use only one wrist restraint instead of two Awarded 1.0 points out of 1.0 possible points. BG. 63.ID: 327495355 After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. A. The restraints are applied tightly. B. The restraints are being released every 2 hours.Correct C. A safety knot has been used to secure the restraints. Correct D. The restraints have been tied to the siderails of the bed. E. The call light has been placed within reach of the client. Correct Awarded 1.0 points out of 1.0 possible points. BH.64.ID: 327495395 A nurse caring for a 9­month­old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother’s request? A. Remove both restraints B. Remove a restraint from one extremityCorrect C. Tell the mother that the restraints may not be removed D. Loosen the restraints after telling the mother that they may not be removed Rationale: Elbow restraints are used after cleft palate repair to prevent the child from touching the repair site, which could cause rupture or tearing of the sutures. The restraints may be removed one at a time only with a parent or nurse in constant attendance. Removing both restraints, telling the mother that the restraints may not be removed, and loosening the restraints are all incorrect nursing actions. Test­Taking Strategy: Eliminate the options that are comparable or alike in that they indicate that the restraints may not be removed. To select from the remaining options, recall the purpose of the restraints after this surgical procedure. This will direct you to the correct option, the safe nursing action. Also note the word “both” in the incorrect option. Review nursing interventions after cleft palate repair if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal­child nursing (3rd ed., p. 1095). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BI. 65.ID: 327496211 A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster management phase identified by the Federal Emergency Management Agency (FEMA)? A. Response B. Recovery C. Mitigation D. Preparedness Correct Rationale: The preparedness phase has many functions, including planning for rescue, evacuation, and caring for disaster victims; the training of disaster personnel and gathering of resources, equipment, and other materials needed in dealing with a disaster; identifying specific responsibilities for various disaster response personnel; establishing a community disaster plan and an effective public communication system; setting up an emergency medical system and a plan for its activation; checking for proper function of emergency equipment; making anticipatory provisions and setting up a location for food, water, clothing, medication, shelter, and other supplies; checking supplies on a regular basis and replenishing outdated materials; and practicing community disaster plans (mock­ disaster drills). The mitigation phase refers to actions or measures to either prevent the occurrence of a disaster or reduce the damaging effects of a disaster. The response phase includes putting disaster planning services into action and the actions taken to save lives and prevent further damage. The recovery phase includes actions taken to return to a normal situation after the disaster. Test­Taking Strategy: Use the process of elimination. Note the relationship between the subject, developing a community disaster plan, and the correct option, preparedness. Review the four disaster management phases if you had difficulty with this question. Reference: McEwen, M., & Pullis, B. (2009). Community­based nursing: An introduction (3rd ed., p. 159). Philadelphia: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Disasters Awarded 1.0 points out of 1.0 possible points. BJ. 66.ID: 327496237 A nurse is admitting a postoperative client from the postanesthesia care unit to the surgical nursing unit. Which of the following measures should the nurse take for the safety of the client? A. Asking the client to slide from the stretcher to the bed B. Quickly moving the client from the stretcher to the bed C. Putting the siderails up after moving the client from the stretcher Correct D. Uncovering the client before making the transfer from the stretcher to the bed Rationale: Because the client may be experiencing residual effects of anesthesia, the nurse should raise the siderails after transferring the client from the stretcher to the bed. Agency policy for the use of siderails is always followed; some agencies’ policies set forth the number of siderails that may be used. Because of the effects of anesthesia and postoperative pain, it is not realistic to ask the client to slide from the stretcher to the bed. Hurried movements and rapid changes in position should be avoided because they may trigger orthostatic hypotension. The nurse should avoid exposing the postoperative client during transfer because of the potential for heat loss, respiratory infection, and shock. Test­Taking Strategy: Use the process of elimination. First eliminate the options that are not standard nursing interventions. Choose from the remaining options knowing that the subject of the question is client safety. Noting the words “asking the client to slide,” “quickly,” and “uncover” will help you eliminate these options. Review care of the postsurgical client if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., p. 218). St. Louis: Saunders. Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 456). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BK. 67.ID: 327496233 A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply. A. “Change positions slowly.” Correct B. “Remove clutter from your home.” Correct C. “Use public transportation as much as possible.” D. “Drive your car only if you’re not feeling dizzy.” E. “Turn your head slowly when someone speaks to you.” Rationale: Any sudden movement could precipitate a vertigo attack, so, to help prevent vertigo attacks, the client should avoid such movements. The client with chronic vertigo should avoid driving; the use of public transportation should also be avoided because of the sudden movements that occur with this mode of transport. The client should also change position slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of stable furniture. The client should maintain the home in a state free of clutter and remove throw rugs, because the effort of trying to regain balance after slipping could trigger the onset of vertigo. Test­Taking Strategy: Focus on the subject, safety measures for a client with chronic vertigo. Read each option carefully. Thinking about general safety principles and those that are important for a client with chronic vertigo will help you answer correctly. Review safety measures for the client with chronic vertigo if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 1127). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BL. 68.ID: 327496837 An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply. A. A victim with a limb amputation Correct B. A victim who is alert but complaining of loss of vision Correct C. A victim who is bleeding profusely from a head laceration Correct D. A victim who is dazed and staggering around the other victims E. A victim who has sustained minor bruising of an arm and the lower legs Rationale: The emergent designation (a.k.a. red or priority 1), the highest priority, is assigned to the victim who has sustained life­threatening injuries and requires immediate attention and continuous evaluation yet has a high probability of survival once his or her condition has been stabilized. In this scenario, emergent status should be assigned to the victim with a limb amputation, the victim with vision loss, and the victim who is bleeding profusely. The urgent designation (a.k.a. yellow or priority 2) is given to the victim who requires treatment but whose injuries and their complications are not life threatening, provided that they are treated within 1 to 2 hours. The victim who is dazed and staggering around the other victims may be assigned to this category because it is possible that the client has sustained a head injury. The nonurgent (a.k.a. green or priority 3) designation is given to the victim with local injuries who does not exhibit immediate complications and who will be able to wait several hours for medical treatment; such victims require evaluation every 1 to 2 hours thereafter. In this scenario, the victim who has sustained minor bruises of the arm and lower legs would be assigned to this category. Test­Taking Strategy: Focus on the subject, the victims that would be assigned to the emergent category. Use the ABCs — airway, breathing, and circulation — to identify the victim with a limb amputation and the victim bleeding profusely from a head laceration as belonging in the emergent category. Noting that another victim has lost vision will help you determine that this victim requires emergency care. Review the triage classification system used in the ED if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., p. 2194). St. Louis: Saunders. Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for families and populations (4th ed., p. 567). Philadelphia: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. BM. 69.ID: 327496263 A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precaution does the nurse understand is most appropriate to help ensure the safety of this client? A. Doubling the dose of anticoagulant B. Applying a pressure bandage to the site after each IM injection C. Applying prolonged pressure to the sites of the IM and SC sites Correct D. Decreasing the sizes of the needles used for the IM and SC injections Rationale: The use of anticoagulants puts the client at risk for bleeding. Prolonged pressure over the site of an IM injection will help prevent bleeding into the tissues surrounding the injection site. Doubling the dose of anticoagulants is incorrect. Decreasing the needle sizes may be helpful but is not necessary. A pressure bandage is not an appropriate measure and is also unnecessary. Test­Taking Strategy: Use the process of elimination and note the strategic words “most appropriate.” Eliminate the option that involves doubling the dose. Next recall the principles of medication administration, then eliminate the option involving a decrease in needle size. To select from the remaining options, visualize each. It is inappropriate and unnecessary to apply a pressure bandage after each injection. Review safety measures for the client receiving injections and taking an anticoagulant if you had difficulty with this question. References: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing:Patient­centered collaborative care (6th ed., p. 683). St. Louis: Saunders. Lehne, R. (2010). Pharmacology for nursing care(7th ed., p. 616). St. Louis: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BN.70.ID: 327496257 A nurse, assessing a client’s readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply. A. “I live in a single­story house.” B. “I don’t have any nightlights in the house.”Correct C. “I’ve removed the scatter rugs from the house.” D. “I keep my personal items within reach when I sit in my easy chair.” E. “I haven’t changed the batteries in the smoke detectors in my home for quite a few years now.”Correct Rationale: If the client tells the nurse that there are no nightlights in the home, the nurse should further investigate the situation. Nightlights help prevent falls by the client who may need to get up during the night. The batteries in smoke detectors should be changed at least once a year, so the nurse must investigate further if the client indicates that this has not been done for “quite a few years.” The other statements by the client do not reflect environmental hazards in the home. Test­Taking Strategy: Note the strategic words “investigate further.” These words indicate a negative event query and the need to select the statements by the client that indicate the presence of environmental hazards. Reading each option carefully will direct you to the correct options. Review environmental hazards in the home if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 1062). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BO. 71.ID: 327495367 A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3. Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply. A. Providing a soft toothbrush for oral care B. Monitoring the client’s oral temperatureCorrect C. Maintaining sterile occlusion of intravenous (IV) catheters Correct D. Requiring the client to use an electric shaver rather than a razor E. Performing meticulous skin decontamination before venipuncture Correct F. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure Rationale: When the neutrophil count falls below 500 cells/mm3, the client is at risk for infection. Monitoring of the oral temperature, maintaining sterile occlusion of IV and central venous catheters, and meticulous skin decontamination before venipuncture are critical nursing interventions for the client at risk for infection. The remaining options are interventions that are necessary for the client who has a low platelet count and is at risk for bleeding. Test­Taking Strategy: Focus on the information in the question and note that the client’s neutrophil count is low. Recalling the relationship between a low neutrophil count and the risk for infection will direct you to the correct options. If you had difficulty with this question, review the nursing plan of care for a client with leukemia who has a low neutrophil count. Reference: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., pp. 2121. 2122). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. BP. 72.ID: 327495359 A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is especially important? A. The religious affiliation or church of preference B. The names of close friends and family membersCorrect C. What medications have been prescribed and what the client knows about their side effects D. The name of the person from whom the client contracted TB, so that the person may be reported for follow­up care Awarded 1.0 points out of 1.0 possible points. BQ. 73.ID: 327495377 A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls? A. “I took the bathmat out of my tub.” Correct B. “I use a shower chair when I bathe.” C. “I’ve placed nightlights in my hallway.” D. “The railings on my stairs are sturdy and secure.” Awarded 1.0 points out of 1.0 possible points. BR.74.ID: 327495399 An adolescent client asks the nurse questions about the transmission of the Epstein­Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted? A. Fecal­oral B. Airborne particles C. Respiratory droplets D. Close intimate contact Correct Rationale: Epstein­Barr virus is transmitted by way of contact with infectious saliva, close intimate contact with an infectious individual, or contact with infected blood. The infectious period is unknown, but the virus is commonly shed from before clinical onset of disease until 6 months or longer after recovery. It is not transmitted by way of the fecal­oral route, in airborne particles, or in respiratory droplets. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (i.e., airborne particles and respiratory droplets). To select from the remaining options, it is necessary to know the route of transmission of infectious mononucleosis. If you are unfamiliar with transmission of the Epstein­Barr virus, review this content. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal­child nursing (3rd ed., p. 1025). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. BS. 75.ID: 327495351 A teenage client returns to the gynecological (GYN) clinic for a follow­up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching? A. “I finished all the antibiotic, just like you said.” B. “I know you won’t tell my parents that I’m sick.” C. “I always make sure my boyfriend uses a condom.” D. “My boyfriend doesn’t have to come in for treatment.” Correct Rationale: In the treatment of STIs, all sexual contacts must be alerted and treated with medication. Any treatment at a GYN clinic for teenagers is confidential, and parents will not be contacted even if the client is under 18 years. The client should always finish the medication prescribed by the healthcare provider. Every client who is being treated for an STI or is at risk for an STI should use a condom for any sexual contact Test­Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect client statement. Read each option carefully. Using knowledge of safe sex practices and the treatment of STIs will help you answer this question. Review content related to the transmission of STIs if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal­child nursing (3rd ed., p. 1034). St. Louis: Elsevier. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. BT. 76.ID: 327495347 A nurse has provided instructions to a mother regarding the use of safety seats in car travel for her newborn infant. Which statement by the mother indicates understanding of the instructions? A. “I’ll put the baby’s car seat in the front seat, facing forward and reclined a little.” B. “I’ll put the baby’s car seat in the front seat, facing backward and reclined a little.” C. “I’ll put the baby’s car seat in the middle back seat, facing forward and reclined a little.” D. “I’ll put the baby’s car seat in the middle back seat, facing backward and reclined a little.”Correct Rationale: The infant should be restrained in a car seat in a semireclined, rear­facing position to allow the seat and infant’s spine to bear the forces of impact should a collision occur. The infant should never face forward or ride in the front seat. Test­Taking Strategy: Use the process of elimination. Visualize each of the descriptions in the options with safety in mind. Recalling that an infant should not be placed in the front seat or in a forward­facing position will direct you to the correct option. If you had difficulty with this question, review car safety measures for the infant. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal­child nursing (3rd ed., p. 119). St. Louis: Elsevier. http://www.healthychildren.org/English/safety­prevention/on­the­go/pages/Car­Safety­Seats­ Information­for­Families­2010.aspx Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. BU.77.ID: 327496269 During a laboratory training session, the nurse is watching as a nursing assistant repositions a client. Which observation tells the nurse that further training is necessary? A. The nursing assistant positions himself close to the client. B. The nursing assistant keeps his neck, back, pelvis, and feet aligned. C. The nursing assistant encourages the client to assist as much as possible. D. The nursing assistant keeps his knees straight and his feet close together. Correct Awarded 1.0 points out of 1.0 possible points. BV. 78.ID: 327495357 A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take? A. Discarding the package Correct B. Using the gauze pads, because the tear was small C. Examining the gauze pads and using them as long as they appear untouched D. Discarding the gauze pad closest to the outside of the package and using the others Awarded 1.0 points out of 1.0 possible points. BW. 79.ID: 327496286 A nurse preparing a sterile field is placing sterile items on the field. The nurse understands that the border of the sterile drape is considered contaminated. How many inch(es) is the contaminated border? Type your answer in the box provided. inch(es) Correct 1 Correct Responses: "1" <i>Rationale: </i>Because the edge of a sterile drape touches a nonsterile surface such as a table, 1­inch (2.5­cm) border around the drape is considered contaminated. Objects placed on the sterile field must be within this border.<i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i></ i><sup></SUP><i></i><i></i><i></i><i></i><br><i></i><i>Test­Taking Strategy: </i>Specific knowledge of the principles of aseptic technique is needed to answer this question. It is important to remember that a 1­inch border around a drape is to be considered contaminated. If you had difficulty with this question, review the principles of aseptic technique.<i></i><i></i><sup></SUP><i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i></i>< sup></SUP><i></i><i></i><i></i><i></i><br><i></i><i></i><i>Reference: </i>Potter, P., & Perry, A. (2009). <i>Fundamentals of nursing</i> (7th<sup> </SUP>ed., p. 669). St. Louis: Mosby.<i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i></ i><i></i><br><i></i><i></i><i></i><i></i><sup></SUP><i>Cognitive Ability: </i>Understanding<i></i><i></i><i></i><br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i> <i></i><i></i><br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i>Client Needs: </i>Safe and Effective Care Environment<i></i><i></i><br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i></i> <br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i>Integrated Process: </i>Nursing Process/Implementation<i></i><br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i ></i><br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i>Content Area:</i> Infection Control Awarded 1.0 out of 1.0 possible points. BX. 80.ID: 327496811 A nurse who is preparing to leave the room of a client who is under airborne precautions needs to remove the following protective items: gloves, gown, mask, and goggles. Place in order of priority the items that need to be removed. Correct A. Gloves B. Goggles C. Gown D. Mask Rationale: The gloves are removed first, because they are considered the dirtiest item. The goggles are then removed to help prevent contamination of the eyes by other dirty items. Next the nurse removes the gown by untying it and turning it inside out as it is removed. Because protective garb is removed before the staff member leaves the room of a client under airborne precautions, the mask is removed last to help prevent exposure to airborne particles. Hand hygiene is performed after the protective garb is removed. Test­Taking Strategy: Focus on the data in the question and note that the client is under airborne precautions. This will help you determine that the mask is the last item to be removed. Recalling that the gloves are the dirtiest item will help you determine that they need to be removed first. To select the order of the remaining items, recall that the goggles should be removed from the face with clean hands. If you had difficulty with this question, review the procedure for removing protective garb. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 670). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. 2. 81.ID: 327496251 A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide (Lasix) through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? A. Verifying the physician’s prescription Correct B. Sitting and talking to the client to alleviate his concern C. Explaining to the client that the oral route will not permit the medication to exert an adequate effect D. Letting the client know that most medications are administered by way of the IV route when a client is hospitalized Rationale: If the client questions a physician's prescription, the nurse must verify the prescription. This is the most appropriate action. Although it is appropriate to talk to the client and alleviate concerns, this is not the most appropriate action of those provided. Although in some client situations the IV route of administration of certain medications is more effective than the oral route, providing the client with this information is not the most appropriate action of the options provided. Critical care units in the hospital may administer most medications by way the IV route, but this is not necessarily the situation in a medical care unit. Test­Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting that the client is questioning the route of administration of the medication will direct you to the correct option. Remember to always verify a prescription if the client questions it. If you had difficulty with this question, review nursing responsibilities related to the administration of medications. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 336). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. B. 82.ID: 327495331 At the beginning of the 7 am–3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL, notifies the physician, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply. INCIDENT REPORT Events that Occurred A. The physician was contacted. Correct B. The blood glucose level at 7:15 am was 149 mg/dL. Correct C. An IV solution of 5% dextrose in water was infusing at 7 am. Correct D. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. Incorrect E. A 5% dextrose in water solution is not usually prescribed for clients with diabetes, and the solution was changed immediately on its discovery. Rationale: The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the incident, any injuries sustained by those involved, and the outcome of the situation. The nurse should avoid the use of subjective data, instead documenting objective data. The nurse also avoids any implication that an accident occurred or an error was made. The statement that a 5% dextrose in water solution was infusing instead of the prescribed 0.9% normal saline solution implies that an accident occurred or an error was made. Likewise, the statement that 5% dextrose in water is not usually prescribed for clients with diabetes and that the solution was changed immediately on its discovery makes an implication. The remaining statements identify factual and observable data without making implications. Test­Taking Strategy: Read each statement carefully. Recalling the guidelines for completing an incident report form and remembering that factual, observable information without implications is the goal will direct you to the correct options. Remember to focus on factual information when documenting, and avoid including interpretations. Review the principles of documentation for incident reports if you had difficulty with this question. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 171. 172). St. Louis: Mosby. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. C. 83.ID: 327495329 A nurse performs an evaluation to determine whether a client’s home is electrically safe. Which finding indicates the need for further investigation and intervention? A. Wiring for the television runs under the carpet.Correct B. Electrical cords are free of frayed and damaged wires. C. Electrical kitchen appliances are located away from the sink. D. A safety­type extension cord is secured to the floor with electrical tape. Rationale: Electrical safety guidelines must be followed to help prevent fires and injuries. These guidelines include the maintaining of electrical equipment in good working order with proper grounding; periodically checking electrical cords and outlets for exposed, frayed, or damage wires and loose or missing parts; avoiding overload of electrical circuits; reading warning labels on all equipment; never operating unfamiliar equipment; using safety­style extension cords and using such cords only when absolutely necessary, securing them to the floor with electrical tape; never running electrical wiring under a carpet; never pulling a plug by the cord; never using electrical appliances near sinks, bathtubs, or other water sources; and disconnecting a plug from the outlet before cleaning the equipment or appliance to which it is attached. Test­Taking Strategy: Note the strategic words “need for further investigation and intervention.” These words indicate a negative event query and the need to select the unsafe finding. Note the words “runs under the carpet” in the correct option. If you had difficulty with this question, review electrical safety guidelines. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 842). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. D. 84.ID: 327496219 Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. A. Wear a lead shield when in the client’s room.Correct B. Limit visits from family to 60 minutes per day. C. Wear a dosimeter film badge when in the client’s room. Correct D. Allow children to visit the client as long as they are at least 12 years old. E. Keep all bed linens and dressings in the client’s room until the implant is removed. Correct Rationale: Nursing responsibilities in the care of a client with an internal radiation implant, which involve preventing exposure to the radiation, include placing the client in a private room with a private bath; rotating nursing assignments and organizing nursing tasks to minimize exposure to the radiation source; limiting time to 30 minutes per care provider per shift; wearing a dosimeter film badge to measure radiation exposure; wearing a lead shield to reduce the transmission of radiation; not allowing pregnant women or children younger than 16 years to visit the client; limiting visitors to 30 minutes per day (visitors should stay at least 6 feet from the source); keeping all bed linens and dressings in the client’s room until the implant is removed; keeping a lead container in the client’s room for housing the implant if it should be dislodged; and avoiding touching a dislodged radiation source (long­handled forceps are used to place the source in the lead container). Test­Taking Strategy: Focus on the subject, safety guidelines for the client with an internal radiation implant. Recalling that the goal of care is to prevent exposure to the radiation will direct you to the correct options. If you had difficulty with this question, review radiation safety guidelines. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 420). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. E. 85.ID: 327496231 A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client’s safety? A. Belt Correct B. Wrist C. Elbow D. Mitten Awarded 1.0 points out of 1.0 possible points. F. 86.ID: 327496819 A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive? A. Belt B. Wrist C. Elbow D. Ambularm Correct Awarded 1.0 points out of 1.0 possible points. G. 87.ID: 327496245 Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. A. The client’s temperature B. The client’s 24­hour urine output C. Skin integrity of the restrained body partCorrect D. The procedure used in applying the restraintCorrect E. The date and time of application of the restraintCorrect F. Circulatory and neurovascular status of the restrained extremities Correct Awarded 1.0 points out of 1.0 possible points. H. 88.ID: 327496805 Which of the following actions are in keeping with the principles of standard precautions? Select all that apply. A. Handwashing between client contacts Correct B. Cleaning of blood spills with soap and warm water C. Discarding needles in puncture­resistant containers Correct D. Handwashing before removal of a pair of soiled gloves E. Wearing a face shield as a part of the protective garb during a wound irrigation Correct F. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg Correct Awarded 1.0 points out of 1.0 possible points. I. 89.ID: 327496277 A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply. A. The client’s range of motion is limited. Correct B. Transmission of hot impulses is delayed.Correct C. The client’s peripheral vision is decreased.Correct D. The client complaints of frequent nocturia.Correct E. High­frequency hearing tones are perceptible. F. Voluntary and autonomic reflexes are slowed.Correct Awarded 1.0 points out of 1.0 possible points. J. 90.ID: 327496201 The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply. A. Scabies B. Hepatitis A C. Tuberculosis Incorrect D. Pharyngeal diphtheria Correct E. Streptococcal pharyngitis Correct F. Meningococcal pneumonia Correct Awarded 0.0 points out of 1.0 possible points. K. 91.ID: 327496831 Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which of the following findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. A. The client is agitated. Correct B. The skin under the restraint is red. Correct C. The client’s left hand is pale and cold. Correct D. The client verbalizes the reason for the restraints. E. The client is unable to reach the gastrostomy tube with his hands. F. The client slips his hand from its restraint and pulls at his gastrostomy tube. Correct Awarded 1.0 points out of 1.0 possible points. L. 92.ID: 327495363 A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. Which items in the home increase the client’s risk for injury? Select all that apply. A. A nightlight in the bathroom B. Elevated toilet seat with armrests C. Cooking equipment such as a stove Correct D. Smoke and carbon monoxide detectors E. Common household objects such as doormatsCorrect F. A water heater thermostat adjusted to a low setting Awarded 1.0 points out of 1.0 possible points. M. 93.ID: 327496239 In which of the following situations would the nurse use this type of restraint (see figure)? Select all that apply. A. To secure the shoulders and the waist B. To immobilize a client’s arm and shoulders C. To prevent the client from getting out of bed D. To prevent dislodgment of an intravenous lineCorrect E. To prevent the client from turning from side to side F. To prevent the use of the hands while allowing free arm movement Correct Rationale: A mitten restraint is a thumbless device used to restrain the hands. It prevents the use of the hands while allowing free arm movement. Mitten restraints are useful for the client who must be prevented from dislodging an intravenous line, indwelling urinary catheter, nasogastric tube, other types of tubes, or wound dressings. A belt restraint prevents the client from falling out of a bed, a chair, or a stretcher. A mitten restraint does not secure the shoulders and the waist and is not used to prevent the client from turning side to side. Test­Taking Strategy: Focus on the figure and note that the device covers the client’s hand. Visualizing this device will help you determine its uses. Review the uses of a mitten restraint if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. N. 94.ID: 327496249 A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client’s safety risk? Select all that apply. A. Assessing the client’s visual acuity Correct B. Observing the client’s gait and postureCorrect C. Evaluating the client’s muscle strengthCorrect D. Looking for any hazards in the home environment Correct E. Asking a family member to move in with the client until her recovery is complete F. Requesting that the client transfer to an assisted living environment for at least 1 month Awarded 1.0 points out of 1.0 possible points. O. 95.ID: 327496821 Which of the following statements reflect the principles of sterile technique? Select all that apply. A. The edge of a sterile field and a border 1 inch inward is unsterile. Correct B. If a package is not labeled as sterile, it should be considered unsterile. Correct C. Sterile objects that come in contact with unsterile objects are to be considered contaminated. Correct D. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. E. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. F. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.Correct Awarded 1.0 points out of 1.0 possible points. P. 96.ID: 327496203 Which of the following actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms? Select all that apply. A. Practicing hand hygiene Correct B. Reapplying a sterile dressing C. Sterilizing contaminated items D. Applying a sterile gown and gloves E. Routinely cleaning the hospital environmentCorrect F. Wearing clean gloves to prevent direct contact with blood or body fluids Correct Awarded 1.0 points out of 1.0 possible points. Q. 97.ID: 327495333 Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. A. Keeping bedside table surfaces clean and dryCorrect B. Placing tissues and soiled dressings in paper bags C. Changing dressings that become wet or soiledCorrect D. Placing capped needles and syringes in puncture­resistant containers E. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client’s skin Correct F. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician Correct Awarded 1.0 points out of 1.0 possible points. R. 98.ID: 327496291 Place in order of priority the actions that the nurse should take to perform hand­washing procedure. Correct A. Wet the hands and wrists, keeping the hands lower than the elbows. B. Obtain 3 to 5 mL of soap from the dispenser. C. Wash all surfaces for 15 to 30 seconds. D. Rinse the hands and wrists. E. Dry the hands. F. Turn off the water faucet. Awarded 1.0 points out of 1.0 possible points. 2. 99.ID: 327495393 A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client’s room and tells the nurse that a physician has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse? A. Asking the nursing assistant to take a message B. Covering the client and answering the telephone call C. Finishing the wound irrigation while the physician waits on the telephone D. Asking the nursing assistant to obtain a telephone number from the physician so that the nurse may return the call after the wound irrigation is complete Correct Rationale: Because wound irrigation is a sterile procedure and a risk for infection exists with any open wound, the nurse should ask the nursing assistant to obtain a telephone number from the physician so that the call may be returned after the wound irrigation is complete. It is not appropriate to ask a physician to wait while a procedure is being completed. It is best to return the call. It is not the responsibility of the nursing assistant to take a message. Test­Taking Strategy: Note the strategic word “appropriate” and use your knowledge of the priorities of care. Recalling that a wound irrigation is a sterile procedure and that a risk for infection exists with any open wound will direct you to the correct option. Remember that the client is the priority and must be protected from the risk of infection. With that in mind, you must select the option of returning the call to the physician once the irrigation is complete. Review the principles of priorities of care if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 5, 822, 823). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. B. 100.ID: 327496261 A registered nurse (RN) is watching as a new licensed practical nurse (LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely? A. Gloves and mask B. Gloves and gown C. Gloves, gown, and face shield. Correct D. Gown and protective eyewear Rationale: The RN is responsible for supervising procedures performed by a new LPN to ensure that safety is maintained and that policies and procedural guidelines are followed. Standard precautions include use of gloves whenever there will be actual contact with blood or body fluids or the potential for contact exists. Therefore the LPN must wear gloves. The LPN also needs to protect the eyes, nose, and mouth from contact with the client’s respiratory secretions; a face shield will provide this protection. A mask or protective eyewear does not provide adequate protection. Gowns are worn in those instances when it is anticipated that there will be contact with body fluid or blood. Test­Taking Strategy: Note that the question addresses suctioning, so remember that airborne secretions and possibly airborne particles of blood are a possibility with this procedure. Basic knowledge of standard precautions should guide you to look for an option that includes adequate protection during this procedure. This will direct you to the option that includes a face shield as one of the necessary protective items. If you had difficulty with this question, review standard precautions and the procedure for suctioning. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6thed., pp. 368, 369, 446). St. Louis: Saunders. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. [Show More]

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