Safety/Infection
A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?
1) Report the incident to the charge nurse.
2) Wash the area of the puncture thoroughly with soap and water.
3) Complete an incident report.
4) Go to employee health services.
2) Wash the area of the puncture thoroughly with soap and water.
Answer Rationale:
The greatest risk to this client is injury from any bloodborne pathogens on the needle; therefore, the first action the nurse should take is to provide immediate first aid by scrubbing the area thoroughly with soap and water.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
1) Mix the three medications together prior to administering.
2) Dilute each medication with 10 mL of tap water.
3) Maintain the head of the bed in a flat position for 30 min following medication administration.
4) Flush the NG feeding tube with 30 mL of water immediately following medication administration
What is:
4) Flush the NG feeding tube with 30 mL of water immediately following medication administration
Answer Rationale:
The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.
A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?
1) "I need to talk to you about unit expectations regarding delegating and completing tasks."
2) "Several staff members have commented that you don't do your fair share of the work."
3) "If you don't do your share of the work, I will have to inform the nurse manager."
4) "You have been very inconsiderate of others by not completing your share of the work."
What is:
1) "I need to talk to you about unit expectations regarding delegating and completing tasks."
Answer Rationale:
This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
1) Administer diuretics.
2) Restrict the client's intake of fluids.
3) Reduce the client's intake of protein.
4) Administer vitamin K.
What is:
3) Reduce the client's intake of protein.
Answer Rationale:
Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended.
A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include?
1) A family history increases your risk for acquiring hepatitis A.
2) Hepatitis A infects the kidneys.
3) Manifestations of the virus are similar to flu-like symptoms.
4) The incubation of the virus is 5 days.
What is:
3) Manifestations of the virus are similar to flu-like symptoms.
Answer Rationale:
The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client’s pulse. Which of the following actions should the nurse take?
1) Wear an N95 respirator mask.
2) Wear sterile gloves.
3) Wear clean gloves.
4) Wear protective eyewear.
3) Wear clean gloves.
Answer Rationale:
The nurse should wear clean gloves to prevent the transmission of MRSA.
A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?
1) "To prevent dehydration, drink an additional liter of fluid during preparation time."
2) "Expect bowel movements to begin 3 hr following completion of solution."
3) "Abdominal bloating might occur."
4) "Drink 400 mL every hour until bowel movements are clear."
What is:
3) "Abdominal bloating might occur."
Answer Rationale:
While PEG is well-tolerated, adverse effects include nausea, bloating, and abdominal discomfort.
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
1) The nurse identifies a broken piece of equipment.
2) A staff member does not show up to work her assigned shift.
3) A client discovers that his dentures are missing.
4) The nurse has a disagreement with the nursing supervisor about inadequate staffing.
3) A client discovers that his dentures are missing.
Answer Rationale:
This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures.
A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?
1) Thyroid stimulating hormone (TSH)
2) Free T4
3) Serum T4
4) Serum T3
What is:
1) Thyroid stimulating hormone (TSH)
Answer Rationale:
The nurse should anticipate that TSH will be elevated.
A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?
1) Massage the client’s red bony prominences.
2) Assess the client’s skin for increased coolness.
3) Reposition the client every 2 hr.
4) Keep the client’s skin moist.
What is:
3) Reposition the client every 2 hr.
Answer Rationale:
The nurse should change the client’s position every 2 hr to stimulate circulation and prevent pressure ulcers.
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
1) Secure the restraints using a quick-release tie.
2) Ensure four fingers fit under the restraints to prevent constriction.
3) Secure the restraints to the lowest bar of the side rail.
4) Anticipate removing the restraints every 4 hr.
What is:
1) Secure the restraints using a quick-release tie.
Answer Rationale:
The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
1) Check the client's vital signs.
2) Request a dietitian consult.
3) Suggest that the client rests before eating the meal.
4) Request an order for an antiemetic.
What is:
1) Check the client's vital signs.
Answer Rationale:
It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm.
A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client’s provider, and completes an incident report, which of the following actions should the nurse take?
1) Make a copy of the incident report for the provider.
2) Submit the incident report to the risk manager.
3) Place the incident report in the client's chart.
4) Document in the chart that an incidence report has been filed.
What is:
2) Submit the incident report to the risk manager.
Answer Rationale:
The purpose of an incident report is to provide information to the risk manager who will investigate the incident and work with other members of the health care team to control risks of client injury.
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
1) Check the client's vital signs.
2) Assess the client's pain level.
3) Cover the wound with a moist, sterile gauze dressing.
4) Obtain a culture and sensitivity of the wound drainage.
What is:
3) Cover the wound with a moist, sterile gauze dressing.
Answer Rationale:
The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?
1) History of smoking
2) Obesity
3) History of hypertension
4) Race
What is:
4) Race
Answer Rationale:
Race is a nonmodifiable risk factor, which the client is unable to control.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
1) A room with air exhaust directly to the outdoor environment
2) A room with another nonsurgical client
3) A room in the ICU
4) A room that is within view of the nurses' station
What is:
1) A room with air exhaust directly to the outdoor environment
Answer Rationale:
A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.
A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
1) "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
2) "I will call the provider to get a prescription for discontinuing the IV heparin today."
3) "Both heparin and warfarin work together to dissolve the clots."
4) "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."
What is:
1) "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."
Answer Rationale:
Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and INR are within therapeutic range, the heparin can be discontinued.
A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?
1) Assessing the current health status of the client
2) Explaining the operative procedure, risks, and benefits
3) Reviewing preoperative laboratory test results
4) Ensuring that a signed surgical consent form was completed
What is:
2) Explaining the operative procedure, risks, and benefits
Answer Rationale:
Explaining the procedure and any risks that may be associated with it is the responsibility of the person performing the procedure. This is not a nursing responsibility.
A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
1) The laboratory values are within the expected reference range.
2) The laboratory values are prolonged.
3) The laboratory values are decreased.
4) The laboratory values are the same as the previous test values.
What is:
2) The laboratory values are prolonged.
Answer Rationale:
These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.
A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client?
1) 1.5 oz raisins
2) 8 oz black tea
3) 1 cup canned black bean
4) 8 oz whole milk
What is:
3) 1 cup canned black beans
Answer Rationale:
The nurse should recommend canned black beans as they contain the greatest amount of iron at 4.56 mg per serving.
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
1) Bradycardia
2) An increase in neutrophils
3) An increase in RBCs
4) An increase in platelets
5) Localized edema
What is:
2) An increase in neutrophils
5) Localized edema
Answer Rationale:
An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms.
Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.
A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a staphylococci infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
What is:
100 mL/hr
A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)
1) Demonstrate the technique to instill eye drops.
2) Ambulate a client who has a cane.
3) Irrigate a wound.
4) Transfer a client to a stretcher.
5) Record urinary output
What is:
2 4 5
Answer Rationale:
Demonstrate the technique to instill eye drops is incorrect. It is not within the scope of practice for an AP to demonstrate medication administration. An RN should perform a task that requires client teaching.Ambulate a client who has a cane is correct. Ambulating a client who has a cane is within the scope of practice for an AP.Irrigate a wound is incorrect. It is not within the scope of practice for an AP to irrigate a wound. An RN should perform this task.Transfer a client to a stretcher is correct. Transferring a client to a stretcher is within the scope of practice for an AP.Record urinary output is correct. Recording urinary output is within the scope of practice for an AP.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
1) Poor nutritional state
2) Altered mental status
3) Obesity
4) Pain medication administration
5) Wound infection
What is:
1 3 5
Answer Rationale:
Poor nutritional state is correct. A client who is in a poor nutritional state is at risk for dehiscence due to impaired healing.
Altered mental status is incorrect. Altered mental status is not a risk factor for dehiscence.
Obesity is correct. A client who is obese is at risk for dehiscence due to poor healing abilities of adipose tissue and the constant strain placed on the incision.
Pain medication administration is incorrect. A client who is taking pain medication is not at risk for dehiscence.
Wound infection is correct. A client who has a wound infection is at risk for dehiscence due to delayed healing.
A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)
1) BMI of 20
2) Oral contraceptive use
3) Hypertension
4) High calcium intake
5) Immobility
What is:
Oral contraceptive use and Immobility
Answer Rationale:
BMI of 20 is incorrect. The nurse should identify obesity as a risk factor for a DVT.Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives.Hypertension is incorrect. The nurse should identify trauma as a risk factor for clot formation.High calcium intake is incorrect. The nurse should identify trauma as a risk factor for clot formation.Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation.