Question 1

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure. Select all that apply. A)Discard the first 6-10 mL of blood drawn from the line B)Flush the line with sterile normal saline before and after collection C)Perform hand hygiene D)Place the specimen in a biohazard bag E)Scrub the catheter hub with antiseptic prior to use

Accepted Answer

Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards (eg, biohazard bag) (Option D). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Other procedures to prevent transmission of infection include: Meticulous hand hygiene (Option C) Use of disposable gloves during collection and handling of specimen Cleaning the specimen bag with a disinfecting wipe Proper and immediate transport of specimen to the lab Avoiding placing specimen in clean areas (eg, nursing station) An appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client (Option E). (Option A) When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. (Option B) Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission. Educational objective: When handling blood or body fluid specimens, the nurse should adhere strictly to protocols that will prevent the transmission of infection, including meticulous hand hygiene and use of gloves. All body fluid specimens should be transported immediately in a container labeled with the biohazard symbol.

Question 2

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP)? A)"I haven't had anything to eat or drink since 8 PM yesterday." B)"I took my prasugrel this morning with just a tiny sip of water." C)"I'm really nervous about this surgery." D)"It always takes several attempts to start my IV."

Accepted Answer

Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week. (Option A) Nothing by mouth for at least 6-8 hours prior to surgery is typical. (Option C) The nurse can assist the client in discussing reasons for the anxiety. Anxiety is common prior to surgery; unless the client refuses to go through with the surgery or requests to speak with the HCP, the nurse can usually deal with this issue. (Option D) Difficult IV sticks can be handled by the nurse. Educational objective: Medications that cause increased risk for bleeding include anticoagulants (eg, warfarin, heparin) and antiplatelets (eg, aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole).

Question 3

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? A)Ask the client to explain the bruises on the torso B)Assess the client's general hygiene and nutritional status C)Report the bruises to the client's health care provider (HCP) D)Talk to the client's child about the injuries

Accepted Answer

The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso (trunk). In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. (Option A) Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. (Option C) Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client's status and situation. (Option D) Talking to the client's child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client's status to determine needed interventions. Further assessment for indications of elder abuse is the priority. Educational objective: When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

Question 4

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? A)51-year-old client who received a permanent pacemaker 48 hours ago B)60-year-old client who had a myocardial infarction 24 hours ago C)74-year-old client with stroke and an indwelling urinary catheter for 3 days D)75-year-old client with dementia and dehydration who is on IV fluids

Accepted Answer

A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. (Option A) This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. (Option B) This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. (Option D) This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter. Educational objective: The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions.

Question 5

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take. All options must be used. A)Remove gloves B)Go to employee health clinic C)Notify the nurse's supervisor D)Take postexposure prophylaxis E)Wash area with soap and water

Accepted Answer

Following a needlestick injury, the nurse's immediate actions should be to remove their gloves and thoroughly wash the affected area with soap and water. Exposure should be reported to the nurse's supervisor and the facility exposure hotline as soon as possible to facilitate the evaluation process. The nurse should then seek evaluation and treatment from the employee health clinic or emergency department. Blood should be drawn for baseline testing, and postexposure prophylaxis will be given based on the risk of exposure. Postexposure prophylaxis for HIV infection is most effective when given within two hours of an exposure incident. Educational objective: After a needlestick injury, the nurse should remove gloves, wash the area, report the incident to the facility exposure office, and proceed to employee health for baseline blood draw and possible postexposure prophylaxis.

Question 6

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely? A) B) C) D)

Accepted Answer

11ecbb05_cb57_9d25_b433_03accdca0db5_MD0009_00 To determine the most appropriate method to transfer a client safely for the first time, the nurse should assess 2 factors: Whether the client can bear weight: Neurological deficits (eg, paralysis, paresis [weakness]) Decreased muscle strength (eg, prolonged immobility, multiple sclerosis, muscular dystrophy) Trauma (eg, amputee, hip fracture) Whether the client is cooperative and able to follow instructions: Altered mental status (eg, delirium, drug intoxication) Decreased cognitive ability (eg, dementia, head injury) Given this client's weakness and inability to cooperate with instructions during the transfer, a pivot transfer would be unsafe. A standing-assist lift may also be unsafe as it also requires the client to follow directions. Therefore, a full-body sling with mechanical lift should be used to safely transfer this client (Option D). This prevents musculoskeletal injuries to the health care worker and provides the safest method of transfer for this client. (Option A) A 1-person standby assistance is appropriate for a client with full weight-bearing ability who is either uncooperative or at high risk for falls. (Options B and C) A pivot transfer or standing-assist lift transfer requires client cooperation with instructions to promote safety during the transfer. Educational objective: A client who can bear weight partially but is unable to cooperate with instructions requires a full-body sling with mechanical lift and 2 caregivers for safe transfer.

Question 7

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety.  Which prescription should the nurse question before administering?
A)Haloperidol for a client with a fall history who keeps getting out of bed without assistance
B)Lorazepam for a client who is in alcohol withdrawal and is extremely agitated
C)Olanzapine for a client with schizophrenia who is exhibiting violent behavior
D)Propofol for a client who is intubated and receiving mechanical ventilation

Accepted Answer

Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or to control socially disruptive behavior in clients who have no medical indications for them. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (Option A). (Option B) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (Option C) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (Option D) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort. Educational objective: Medications that are standard treatments for specific conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are not considered chemical restraints. The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety.

Question 8

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response? A)"Call the poison control center. I will give you the number." B)"Give your child about a cup of water to dilute the mouthwash." C)"How did your child get hold of the mouthwash?" D)"What is your child doing right now?"

Accepted Answer

Many mouthwashes have an ethanol (alcohol) content ranging from the equivalent of wine to half the strength of hard liquor. Because children's bodies absorb alcohol quickly, the symptoms of alcohol poisoning can occur within 30 minutes or less after consumption. Clinical indications include confusion, vomiting and seizures, difficulty breathing, flushed or pale skin, and coma secondary to low blood sugar. The exact amount of alcohol that this child presumably ingested is unknown. It is most important to assess the child's condition (eg, behavior, mental status, physical signs and symptoms) to determine if immediate emergency measures (eg, calling 911, cardiorespiratory support) are necessary or if the parent should be instructed to contact the poison control center (Option D). (Option A) It is the nurse's professional responsibility to provide instruction and guidance to the parent. Although caregivers should have the number of the poison control center readily available, referral might delay care and place the child at further risk of a negative outcome if the child is already deteriorating. If the child's condition is stable, the nurse should instruct the parents to contact the center for further evaluation and instructions. (Option B) Giving the child water or any other liquid will not change the amount of alcohol ingested. In addition, alcohol can impair swallowing, placing the child at risk for choking and aspiration. Parents should be advised not to perform any interventions before contacting the poison control center. (Option C) This response does not address the immediacy of the situation and suggests that the parent is to blame for the child's possible ingestion. Educational objective: When a child accidentally ingests a poisonous substance, it is most important to assess the child's condition, including physical signs and symptoms, mental status, and behavior. Based on the condition of the child, the nurse can provide guidance and instructions to contact the appropriate agency (eg, emergency services, poison control center).

Question 9

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision.  Which actions should the nurse take?
A)Have the client remove the existing dressing while the nurse prepares sterile supplies
B)Wear clean gloves for removal and application of a new dressing
C)Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing
D)Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

Accepted Answer

The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination. (Option A) It would be better for the nurse to perform the dressing change as the wound is already infected. The client may be able to assist in the home setting. (Option B) Clean gloves can be used for removal but not for application of a new dressing. (Option D) Sterile gloves are not needed to remove the existing dressing. A gown and goggles may be required if splashing is possible. Educational objective: When changing the dressing of a surgical incision, the nurse may wear clean gloves to remove the existing dressing but should wear sterile gloves to apply a new one.

Question 10

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery? A)"I didn't take the clopidogrel pill for my heart yesterday or today." B)"I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today." C)"I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk." D)"I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead."

Accepted Answer

Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding. The client took this drug 48 hours ago. Therefore, the nurse must notify the HCP. The surgery may be postponed due to the increased risk for intra- and post-operative bleeding (Option A). (Option B) All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems. (Option C) The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding. (Option D) Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery. Educational objective: Medications (eg, anticoagulants, antiplatelets, NSAIDS, herbal drugs) that increase the risk for excessive bleeding should be discontinued at least 5-7 days before surgery.

Question 11

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. A)Open a sterile container of 4 x 4's using the outermost corner to peel back the cover B)Pull glove off over the soiled dressing to encase it before disposal C)Save unused sterile 4 x 4's by taping original package shut for the next dressing change D)Wash hands prior to putting on gloves and after removing them E)Wrap soiled dressing in paper towels before disposing of it in the trash can

Accepted Answer

11ecbb05_cb59_71e6_b433_c7dbb2cd3860_MD0009_00 The nurse is responsible for observing the home health aide periodically during delegated tasks. The aide should wash the hands prior to gloving and after glove removal (Option D). Sterile dressing supplies should be opened prior to the dressing change; this should be done by carefully peeling from the outermost corner of the package to expose the contents without contaminating the sterile product (Option A). A contaminated used dressing should be placed in impervious plastic or a paper bag before disposal in the household trash (Option B). (Option C) Unused sterile supplies should not be saved as it is not possible to ensure their sterility. (Option E) Paper towels are not impervious and infectious waste from the dressing can seep through and into other items in the trash can. Educational objective: In the home care setting, infection control procedures for changing a dressing include washing the hands before and after gloving, opening sterile supplies carefully to avoid contamination, and placing old dressings inside a glove or plastic bag before disposal in the household trash.

Question 12

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? A)1-person stand and pivot with gait belt and walker B)1-person standby assist with walker C)2-person motorized stand-assist lift D)2-person stand and pivot with gait belt and walker

Accepted Answer

11ecbb05_cb57_00e0_b433_f5c815b9a805_MD0009_00 To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: Whether the client can bear weight Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift (Option A). If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance (Option B). (Option C) This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. (Option D) If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible. Educational objective: If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

Question 13

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? A)Apply a gauze wrap and elastic stockinette around the IV site B)Apply a mitt on the right hand C)Apply a soft wrist restraint on the right wrist D)Apply an arm board to the left arm

Accepted Answer

A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line. (Options B, C, and D) Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action. Educational objective: The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint.

Question 14

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. A)Disinfect surfaces with diluted bleach solution B)Hand hygiene with alcohol-based hand rub C)Wear a face mask D)Wear a protective gown E)Wear nonsterile gloves

Accepted Answer

C difficile poses a unique hazard in health care settings. This infection of the colon may develop/spread through contact with the organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C difficile overgrowth. Clients with C difficile infection should be placed on strict contact precautions in private rooms. These precautions require staff to wear protective gowns and gloves when entering the client's room (Options D and E). Hand hygiene using soap and water is the only effective method for removing C difficile spores (Option B). In addition, alcohol is not an effective agent for killing C difficile spores; therefore, a diluted bleach solution must be used to disinfect contaminated equipment and surfaces (Option A). (Option C) Contact precautions require the caregiver to wear a gown and gloves. A face mask must be worn as personal protective equipment if an organism is spread via droplets. However, it is not required to prevent the spread of a contact-transmissible infection. The nurse should not wear a mask solely to avoid the unpleasant odor associated with C difficile diarrhea as this may be offensive and embarrassing to the client. Educational objective: C difficile infection requires strict contact precautions, including wearing a gown and gloves at all times. Alcohol cannot kill C difficile spores, so caregivers must use soap and water in place of alcohol-based hand sanitizers. Contaminated surfaces and equipment should be disinfected using a diluted bleach solution.

Question 15

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement? A)A bed near the nursing station B)Four-point leather restraints C)Minimizing environmental stimuli D)One-on-one supervision from a sitter

Accepted Answer

Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. One-on-one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help. (Option A) Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others. (Option B) Four-point leather restraints are one of the most restrictive restraint options. These are not appropriate as a first-line option for promoting safety. (Option C) Reducing environmental stimuli is important for an agitated client, but these alone are not most helpful. Educational objective: When caring for clients with behavioral issues that may compromise safety, less restrictive restraint and safety options should be implemented before more restrictive restraint options are used.

Question 16

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? A)1-person safety standby with walker B)2-person full-body sling lift C)2-person standing-assist lift D)4-person full-body sling lift

Accepted Answer

When determining the most appropriate method to transfer a client safely, the nurse should assess: Whether the client can bear weight Whether the client is cooperative This client is able to bear full weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear full weight, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff. When working with bariatric clients, equipment that has the capacity to bear the client's full weight and accommodate their size should be used while maintaining the client's dignity throughout the process. (Options B and C) These would not be necessary as this client can fully bear weight and cooperate with caregiver instructions during the transfer. (Option D) A 4-person sling lift transfer is appropriate for the bariatric client who cannot bear weight or cooperate with the transfer. Educational objective: A client who is able to fully bear weight and cooperate can transfer independently with standby assistance for safety. If there is any concern for caregiver or client safety during the transfer of a bariatric client, the type of equipment should be reconsidered and the number of caregivers should be increased.

Question 17

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan.  When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room.  Which instruction should the nurse give the transporter?
A)Have the client wear a mask
B)Have the client wear gloves
C)Wear a mask
D)Wear an isolation gown

Accepted Answer

Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room. (Option B) Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients on droplet precautions. (Option C) The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to prevent transmission of infection. (Option D) An isolation gown is not required for droplet precautions. Educational objective: Droplet precautions require the use of regular masks to prevent the transmission of infection. A mask should be worn by the client when outside the hospital room and by staff when in the client's room.

Question 18

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? A)Document a description of the injury B)Question the mother about where the infant sleeps C)Report the injury per facility protocol D)Separate the mother from the infant

Accepted Answer

The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada (Option C). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, Mongolian spots) mimicking maltreatment. After reporting suspected maltreatment, the nurse should: Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) Document facts and observations objectively, using medical terms when possible (Option A). Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. Perform a review of child-care practices with the caregiver (Option B). (Option D) A child and caregiver should only be separated when the child is in immediate physical danger or if authorities must interview a verbal child without the parent present. Educational objective: Injuries in a nonambulatory child, especially fractures, warrant suspicion. The nurse has a duty to report suspected child maltreatment to the appropriate authorities as required by law.

Question 19

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply. A)Belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest B)Elbow restraints used temporarily for a toddler while drawing blood C)Full padded side rails in the raised position for a client during a seizure D)Long leg immobilizer used for a client with a fractured tibia E)Soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization

Accepted Answer

A physical restraint is a device or method used to immobilize or limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint. Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a health care provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so. The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-release knot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily (Option A). Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently (Option E). Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity. (Option B) Elbow restraints used as a protective device to temporarily immobilize a child (<30 minutes) to perform a medical, diagnostic (eg, drawing blood), or surgical procedure are not considered a physical restraint. (Option C) The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury; these are not considered a restraint. (Option D) An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint. Educational objective: Common physical restraint devices include limb (eg, ankle, wrist) and belt restraints. The client situation, rather than the device, determines whether it is classified as a restraint.

Question 20

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. A)Client admitted with white blood cell count of 28,000 mm³ (28.0 × 10⁹/L) and dies from sepsis B)Client receives 1 mg morphine instead of prescribed 0.5 mg morphine C)Client refuses pneumonia vaccination and contracts pneumonia D)Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse E)Provider was not notified of client's positive blood culture results

Accepted Answer

An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option B is a treatment error. Option D is a communication error as well as inadequate follow-up. Option E is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option A) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option C) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship. Educational objective: Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems.

Exam 4: Fundamentals

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure. Select all that apply.

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP) ?

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action?

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take. All options must be used.

The nurse is preparing to transfer a client from the bed to the chair for the first time. The client has generalized weakness and is unable to follow instructions. Which would be the most appropriate method for the nurse to use to transfer this client safely?

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering?

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response?

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery?

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client?

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely?

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.