- The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction?
- The student nurses places the sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her.
- The student nurses’ hands, once in the sterile gloves, do not go above her head or below her waist.
- The student nurse drops the sterile gloves into the sterile field before disposing of the outer packaging.
- The student nurse places an unwrapped sterile 4×4 on the sterile drape.
The student nurse cannot turn her back on the sterile field or it is no longer considered sterile.
- The nurse at the daycare center observes children playing on the playground. The nurse is MOST concerned if which of the following is observed?
- Two children are fighting over a ball.
- One child tries to pull another off the swing.
- A 2-year-old is crying, tugging at his ear, and hugging a stuffed animal.
- A 3-year-old is leaning forward with mouth open, tongue protruding, and drooling.
Children fighting over balls or pulling others off of swings are normal safety issues of child development and play. The child crying while tugging at his ear depicts classic signs of an earache or ear infection. The child leaning forward with mouth open, tongue protruding, and drooling is the most immediate threat to safety because it describes signs of epiglottitis where the child is in danger of losing his or her airway.
- A day shift nurse notices that the charting by the previous night shift nurse is not fully complete and ends mid-sentence. What is the CORRECT method to fix this issue?
- Forgive the night nurse because she was probably tired and just forgot.
- Cross out the entire entry in the patient’s chart and make a note stating the night nurse will write her note separately.
- Call the night shift nurse and have her finish her note verbally over the phone.
- Leave enough space for the night nurse to write her note and then chart the day note.
Just as verbal orders can be taken, the night nurse can verbally finish the note over the phone.
- The home health nurse visits the home of a client diagnosed with moderate-stage Alzheimer’s disease. The patient is pleasantly confused and lives with his son-in-law and daughter. Which of the following observations, if made by the nurse, is MOST concerning?
- The door has a lock with a bolt.
- There are extension cords on the floors behind furniture.
- The stovetops do not turn on without activation of a hidden switch in the nearby drawer.
- The rugs are secured safely to the floor.
Doors need to have locks in atypical locations (eg, tops of doors) to prevent the patient from nighttime confused wandering.
- The nurse is caring for a patient with pneumonia using ________ precautions.
Pneumonia requires droplet precautions.
- The client with an undisplaced midshaft fracture of the left tibia was placed in a long leg cast after experiencing a car accident. Overnight the client returned to the emergency department and is now complaining of unrelenting severe pain and feeling as if the toes are asleep. When the cast is removed and the patient still complains of severe pain, the nurse suspects that the client is experiencing which of the following conditions?
- Compartment syndrome.
- Pressure ulcer under cast.
- Fat embolism.
Compartment syndrome is a complication in which swelling of the muscle fascia cuts off circulation and must be relieved through a fasciotomy.
- The nurse is correctly implementing the prescribed transmission-based precaution when she does the following:
- The nurse assigned the child in a semi-private room.
- The nurse sends specimens to the laboratory in a zip-closure biohazard bag.
- The nurse wipes the thermometer with alcohol every after use.
- The nurse placed a supply of clean masks in the child’s room.
The zip-closure prevents contamination of the environment during transportation.
- A patient arrives in the ER with suspected appendicitis. Which of the following actions, if performed by the UAP (unlicensed assistive personnel) caring for the patient, would require further teaching in regard to safety?
- The UAP reminds the patient to stay in bed.
- The UAP allows the patient to lay in whatever position is most comfortable.
- The UAP does not give the patient any fluids or food.
- The UAP gives the patient a heat pack for comfort.
Remember that heat packs are not appropriate for patients with suspected appendicitis- cold packs or ice only.
- The nurse is caring for a client after an ECT treatment. The nurse is MOST concerned if which of the following is observed?
- The client is unable to remember what she ate for breakfast.
- The client complains of backache.
- The client is unable to recall her name.
- The client complains of headache.
Temporary short term and long term memory loss is common after ECT, as well as a headache. Backaches are not expected and therefore needs to be further investigated.
- The doctor orders a 24-hour ambulatory electrocardiography using a Holter monitor to a client with frequent fainting spells. To prevent electrical interference with the Holter monitor, the nurse should instruct the client to avoid which of the following?
- Driving under overhead power lines.
- Standing close to a microwave oven.
- Using a cellular telephone.
- Shaving with an electric razor.
Using electrical devices, such as electric razors and toothbrushes, may alter the data recorded with a Holter monitor. The other activities are not known to cause electrical interference with a Holter monitor.
- A 4-year-old child is seen in the emergency department with rashes mostly found on his torso. The nurse obtained a medical history from the mother and she said her child had fever before the rashes appeared. Other symptoms include loss of appetite and he began coughing and complains of a sore throat. With these objective data at hand, the nurse suspects that the child is having?
- German measles.
- Chicken pox.
The rash is the telltale indication of chickenpox. Other signs and symptoms, which may appear one to two days before the rash, include: fever, loss of appetite, headache, cough and sore throat. Characteristics of chicken pox rash:
- Raised pink or red bumps (papules), which break out over several days.
- Fluid-filled blisters (vesicles), forming from the raised bumps over about one day before breaking and leaking.
- Crusts and scabs, which cover the broken blisters and take several more days to heal.
- The nurse is caring for a confused patient with an IV catheter. The patient habitually tugs at the IV tubing with his left hand and has almost dislodged it. What is the LEAST amount of restraint that will still maintain the patient’s safety?
- 4-point restraints for maximum safety.
- 2-point restraints on the arms only.
- Safety “mitts” for both hands.
- Safety “mitt” for the left hand.
A safety mitt still allows for movement of the arm, but negates the patient’s ability to grasp the IV tubing and disrupt it. This is the least restrictive method that will still maintain patient safety.
- A licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the LPN to intervene?
- The assistant praises the client for attempting to perform ADLs independently.
- The assistant places the client on the back with the client’s head to the side.
- The assistant places her hand under the client’s right axilla to help him/her move up in bed.
- The assistant places a gait belt around the client’s waist prior to ambulating.
This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. All the other actions are appropriate.
- A hospital has been notified that an alleged inhalation anthrax exposure has occurred at the local post office. Which of the following below is the correct personal protective equipment (PPE) that the response team would wear?
This is categorized as Level A protection and is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. In this situation of possible inhalation of anthrax, such protection is required.
- A patient is ordered to undergo a CT scan with contrast dye. The most important action for the nurse to take in regard to patient safety is to:
- Encourage fluids when the patient returns from the scan.
- Check the patient’s allergy list.
- Raise the side rails of the patient’s bed.
- Confirm that the consent form is signed.
Although encouraging fluids is important to flush out the dye, checking for linked dye allergies is more important for safety. The dye has iodine, which is linked to shellfish allergy.
- A nurse cares for a patient who cannot turn by using an overhead lift. The nurse knows that which of the following is the MOST important actions to follow in terms of safety?
- Allow the patient to hook themselves up to the sling so that they feel involved in their care.
- When using the lift, raise the patient above the bed before laterally positioning the lift over the intended chair.
- Ensure the sling is removed from the patient after they are seated in the chair.
- Tell the patient to rock back and forth to propel themselves.
Making sure the patient is safely encased in the sling BEFORE raising them higher above the bed or laterally is most important for patient safety. Patients do not know how to hook themselves up in slings and it is dangerous to rock back and forth. You should leave the sling in the chair in order to move the patient back to bed later.
- Two days after a coronary artery bypass graft (CABG), a patient is sitting up in a chair by the side of the bed. The nurse walks in and discovers the patient is cold, pale, and responds only to tactile stimulation. Which of the following actions does the nurse take NEXT?
- Review charts to see if anything like this has ever happened before.
- Administer oxygen 2L by nasal cannula.
- Help the client back to bed.
- Take the client’s vital signs.
Safety first before the patient falls! Then oxygen.
- The nurse cares for a patient with AIDS who has acquired jiroveci pneumonia. Which of the following precautions levels is appropriate for this patient?
- Standard precautions.
- Contact precautions.
- Droplet precautions.
- Airborne precautions.
Jiroveci pneumonia is an opportunistic infection that only occurs in immunocompromised patients. Anyone with normal immune system function cannot “catch” this infection.
- The nurse is caring for a patient with Meniere’s disease. The nurse knows that the most important consideration in regard for patient safety is to:
- Raise the side rails on the patient’s bed.
- Remind the patient to wash her hands frequently, especially after voiding or before meal times.
- Ask the nursing assistant to walk with the patient when she needs to use the bathroom.
- Offer the patient alternative meal choices from the cafeteria.
Patients with Meniere’s disease can get attacks of vertigo very suddenly, so a nursing assistant can provide stability. Raising the side rails counts as a restraint.
- A patient comes into the ER with the complaint of inability to void. The nurse performs a bladder scan and receives a result of 2,000 mL. The nurse prepares to catheterize the patient and knows that the most important part of the procedure relies on:
- Allowing the patient to attempt to void after 500mL has been drained.
- Educating the patient about possible causes of inability to void.
- Clamping the tubing after every 500mL is drained and waiting five minutes.
- Teaching the patient how to self-catheterize themselves at home.
Clamping the tubing after each 500mL prevents bladder spasms, which are painful and not good for the bladder.
- A patient diagnosed with SIADH is ordered by the physician to receive 3% NaCl 500mL at a rate of 60mL/hr. Which of the following actions, if taken by the nurse, is most important in regard to patient safety?
- Call the nursing supervisor to question the order.
- Ask another nurse to cosign and check the order before administering the solution.
- Call the physician and verify the order.
- Check the patient’s name and date of birth before administering the solution.
Hypertonic saline requires two nurses to cosign because it can be dangerous to give this to the wrong patient. Checking the patient’s name and date of birth is second in importance.
- The medical/surgical nurse cares for a middle-aged patient with a wound infected with MRSA (Methicillin-resistant Staphylococcus aureus). Which of the following protective safety items, if worn by the nurse, would be considered appropriate?
- Shoe covers, a gown, and gloves.
- A gown and gloves.
- A mask, gown, and gloves.
- Gloves only.
A patient infected with MRSA requires contact precautions. Gown and gloves constitute contact precautions.
- Which of the following assessments, performed on a patient after a myelogram, is most important in regard to patient safety?
- Check the popliteal pulses bilaterally.
- Perform a neurological assessment.
- Ensure the consent form for the procedure was signed.
- Ensure the patient lays flat for two hours after the procedure.
A myelogram is where contrast dye is injected into the spine. Because a needle entered the spinal cord, it is important to check for impaired/altered sensation and neurological malfunction.
- The herpes zoster virus requires a nurse to follow ________ precautions at all times.
Airborne precautions are added for clients who have illnesses that are transmitted by airborne droplet nuclei, such as chickenpox during the early stage of infection.
- A patient is scheduled for a cardiac catheterization this afternoon. Which of the following, if noted in the patient’s chart by the nurse, is a contraindication to the test?
- The patient has a history of asthma.
- The patient is allergic to eggs.
- The patient is unable to lie on her right side for more than 15 minutes.
- The patient is allergic to clams.
Cardiac catheterizations require dye, which is made of iodine. Iodine’s cross-allergy is shellfish!
- Which of the following actions, if made by the student nurse, are examples of primary prevention?
SELECT ALL THAT APPLY:
- The student nurse gives Bactrim to a patient with a UTI.
- The student nurse administers a PPD test for employment.
- The student nurse administers a flu vaccine.
- The student nurse gives a presentation on diet and exercise.
- The student nurse prepares a sterile field before cleaning the inner cannula of a tracheostomy.
- The student nurse administers Acyclovir to a patient diagnosed with hepatitis C.
The flu vaccine, the sterile field, and the presentation on diet/exercise are examples of primary prevention. The PPD test is secondary prevention. Giving Bactrim and giving Acyclovir are examples of tertiary prevention.
- What is the primary responsibility of the nurse and radiology staff when assisting a client with multiple myeloma who is ordered to receive a bone scan and a chest x-ray?
- Assess the client for episodes of difficulty of breathing.
- Explain the entire procedure including the reasons for doing it.
- Allow the client to rest in between the procedures.
- Handle the client with supportive movements.
Pathologic fracture is a common complication of multiple myeloma due to bone erosion; therefore the most important action is to assist the client with care.
- A patient being treated for uterine cancer has just had an internal radiation implant placed. The fire alarm sounds and, without thinking, the patient stands up. The radiation implant falls out and onto the floor. What is the NEXT action the nurse should take?
- Call the physician.
- Retrieve tongs, place the dislodged implant in a lead-lined container, and call the radiation specialist.
- Use a fork to push the implant into a specimen jar and close it.
- Call the radiation specialist.
It is the nurse’s responsibility to contain the radioactive implant before calling the radiation specialist.
- After a cardiac catheterization, the nurse instructs the patient to lie in which of the following positions?
The patient needs to be on bedrest, on their back, to avoid moving their leg and possibly restarting bleeding in the femoral artery.
- When evaluating the growth and development of a 6 month-old infant, a nurse expects the infant to be able to perform which of the following actions?
- Transfer a toy from one hand to the other, crawl, and display fear of strangers.
- Release a toy by choice, pull self to a standing position, and play peek-a-boo.
- Sit for a moment without support, turn over completely, and reach to be picked up.
- Display pincer grasp, sit alone, and wave.
These abilities are age appropriate for a 6 month-old infant. The other items are abilities that should be developed by a 10 month-old infant.
- The nurse on the surgical unit receives a call from the operating room to administer a preoperative medication to a client scheduled for surgery. After giving the ordered medication, the nurse discovers the consent form for the surgery has not been signed. Which of the following actions should the nurse take NEXT?
- Call the physician.
- Transfer the client to the operating room.
- Call the operating room and inform them that the surgery must be canceled.
- Inform the nursing supervisor.
Always go up the chain of command to your superior- nursing supervisor.
- During report, the previous nurse emphasized that one of the newly admitted patients is on seizure precautions. The incoming nurse is correct when she performs which of the following actions to the client?
- Move the client to a room closer to the nurses’ station.
- Ensure that soft limb restraints are applied to upper extremities.
- Maintain the client’s bed in the lowest position.
- Serve the client’s food in paper and plastic containers.
To protect a client with a known or suspected seizure disorder, the bed should be kept in the lowest position, decreasing the chance of injury from falling to the floor during seizure activity.
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