Safety
The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action?
1. Initiate the IV line without the use of a pump.
2. Contact the electrical maintenance department for assistance.
3. Plug in the pump cord in the available plug above the room sink.
4. Use an extension cord from the nurses' lounge for the pump plug.
2.
Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.
The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?
1. Milk
2. Chicken
3. Broccoli
4. Legumes
4.
The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Legumes are especially rich in this vitamin. Other good food sources include nuts, whole-grain cereals, and pork. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid.
The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?
1. "I cannot have surgery."
2. "I cannot have any medicine."
3. "I believe the soul lives on after death."
4. "I cannot have any food containing or prepared with blood."
4.
Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. For a Jehovah's Witness, administration of medication is an acceptable practice except if the medication is derived from blood products. This religious group believes that the soul cannot live after death. Jehovah's Witnesses avoid foods prepared with or containing blood.
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?
1. Wearing gloves when emptying the client's bedpan
2. Keeping all linens in the room until the implant is removed
3. Wearing a lead apron when providing direct care to the client
4. Placing the client in a semiprivate room at the end of the hallway
4.
A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.
The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?
1. Check for medication interactions.
2. Determine whether there are medication duplications.
3. Determine whether a family member supervises medication administration.
4. Call the prescribing primary health care provider (PHCP) and report polypharmacy.
2.
Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the PHCP is the intervention after all other information has been collected.
The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?
1. Reassess the client.
2. Conduct a staff meeting to describe the fall.
3. Contact the nursing supervisor to update information regarding the fall.
4. Document in the nurse's notes that an occurrence report was completed.
1.
After a client's fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An occurrence report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the occurrence, the supervisor will contact the nurse if status update is necessary.
The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?
1. Nuts and milk
2. Coffee and tea
3. Cooked rolled oats and fish
4. Oranges and dark green leafy vegetables
4.
Dark green leafy vegetables are a good source of iron, and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.
A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?
1. Have one of the client's family members interpret.
2. Have the Spanish-speaking triage receptionist interpret.
3. Page an interpreter from the hospital's interpreter services.
4. Obtain a Spanish-English dictionary and attempt to triage the client
3.
The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non–health care provider acts as interpreter.
The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?
1. Placing a safety knot in the safety device straps
2. Safely securing the safety device straps to the side rails
3. Applying safety device straps that do not tighten when force is applied against them
4. Securing so that 2 fingers can slide easily between the safety device and the client's skin
2.
The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.
A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?
1. Induce vomiting.
2. Call an ambulance.
3. Call the Poison Control Center.
4. Bring the child to the emergency department.
3.
If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.
Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?
1. Gloves and gown
2. Gloves and goggles
3. Gloves, gown, and shoe protectors
4. Gloves, gown, goggles, and a mask or face shield
4.
Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
1. Peas
2. Raisins
3. Potatoes
4. Cantaloupe
5. Cauliflower
6. Strawberries
2, 3, 4, 6
The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.
Which car safety device should be used for a child who is 8 years old and 4 feet tall?
1. Seat belt
2. Booster seat
3. Rear-facing convertible seat
4. Front-facing convertible seat
2.
All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet, 9 inches in height (145 cm) and are between 8 and 12 years of age. Infants should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds (9 kg) and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kilograms (20 pounds) and 1 year of age.
The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?
1. Private room or cohort client
2. Personal respiratory protection device
3. Private room with negative airflow pressure
4. Mask worn by staff when the client needs to leave the room
1.
Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.
The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?
1. Finish the bed bath and then administer the pain medication to the other client.
2. Ask the AP to find out when the last pain medication was given to the client.
3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete.
4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
4.
The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.
The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply.
1. Complete and file an occurrence report.
2. Right-click on the entry and modify it to reflect the correct information.
3. Document the correct information and end with the nurse's signature and title.
4. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg.
5. Document in a nurse's note in the client's record detailing the corrected information.
2, 3, 4, 5
Electronic health records (EHR) will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error in the MAR, the nurse should follow agency policies to correct the error. In the MAR, the nurse can click on the entry (usually right-click) and modify it to reflect the corrected information. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication, to validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the EHR. An occurrence report is not necessary in this situation.
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.
1. Broth
2. Coffee
3. Gelatin
4. Pudding
5. Vegetable juice
6. Pureed vegetables
1, 2, 3
A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.
The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply.
1. Asthma
2. Claustrophobia
3. Sleep problems
4. Bipolar disorder
5. Aggressive behavior
6. Attention-deficit hyperactivity disorder (ADHD)
3, 4, 5, 6
Foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, post-traumatic stress disorder, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder. Claustrophobia and asthma are not specifically associated with foster children.
The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?
1. Taking a rectal temperature for a client who has undergone nasal surgery
2. Taking an oral temperature for a client with a cough and nasal congestion
3. Taking an axillary temperature for a client who has just consumed hot coffee
4. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic
2.
An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If electronic equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.
The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.
1. The acuity level of the clients
2. Specific requests from the staff
3. The clustering of the rooms on the unit
4. The number of anticipated client discharges
5. Client needs and workers' needs and abilities
1, 5
There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.
The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply.
1. Use night-lights.
2. Remove scatter rugs.
3. Use staircase railings.
4. Remove wall-to-wall carpeting.
5. Place hand rails in the bathroom
1, 2, 3, 5
Home modifications to reduce the risk for falls include using railings on all staircases, providing ample lighting, removing scatter rugs, and placing hand rails in the bathroom. Removing wall-to-wall carpeting is not necessary as long as it is in good condition.
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.
1. Oranges
2. Broccoli
3. Margarine
4. Cream cheese
5. Luncheon meats
6. Broiled haddock
3, 4, 5
Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.
The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.
1. Sunscreen should be applied every 8 hours.
2. Use sunscreen when participating in outdoor activities.
3. Wear a hat, opaque clothing, and sunglasses when in the sun.
4. Avoid sun exposure in the late afternoon and early evening hours.
5. Examine your body monthly for any lesions that may be suspicious.
2, 3, 5
The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be applied 30 minutes to 1 hour before sun exposure, and reapplied every 2 to 3 hours, and after swimming or sweating; otherwise, the duration of protection is reduced.
The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.
1. Bites from ticks or deer flies
2. Inhalation of bacterial spores
3. Through a cut or abrasion in the skin
4. Direct contact with an infected individual
5. Sexual contact with an infected individual
6. Ingestion of contaminated undercooked meat
2, 3, 6
Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies.
The nurse is reviewing a primary health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.
1. Restrict fluid intake.
2. Position for comfort.
3. Avoid strain on painful joints.
4. Apply nasal oxygen at 2 L/minute.
5. Provide a high-calorie, high-protein diet.
6. Give meperidine, 25 mg intravenously, every 4 hours for pain.
1, 6
Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.