Question 1

The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room? A)Child with chickenpox for the past 14 days; all lesions are crusted and dried B)Child with impetigo who has been on antibiotics for 3 days C)Child with leg rash secondary to poison ivy exposure D)Child with suspected pertussis who has paroxysms of coughing

Accepted Answer

Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease. (Option A) Chickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3 weeks. This client would not require isolation. (Option B) Impetigo is no longer contagious after 24 hours of antibiotics. This client would not require isolation. (Option C) Poison ivy rash is not considered contagious. A person develops the rash only on contact with the urushiol oil itself. The pustules do not contain this oil, and therefore the rash cannot be spread via person-to-person contact. Educational objective: Chickenpox is no longer contagious after the lesions have crusted and dried. Pertussis is a highly contagious disease that requires droplet precautions.

Question 2

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? A)"I need to have the entire house treated by pest control to ensure the bed bugs are gone." B)"I should concentrate on alleviating scratching as it can cause further complications." C)"My other family members and pets are at risk of bed bug bites." D)"This must have happened because I did not wash the bed sheets this week."

Accepted Answer

It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. (Option A) It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. (Option B) Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. (Option C) Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted. Educational objective: Bed bugs spread quickly and travel in bedding, clothing, and furniture. It is important to recognize bed bug bites and eliminate this pest from the home. Client treatment aims to minimize itching until the rash is gone.

Question 3

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia.  The client needs a peripheral IV line for fluid administration.  Which IV site should the nurse select to reduce the risk for infection?
A)Antecubital fossa
B)Dorsal surface of hand
C)Dorsum of foot
D)Lateral surface of wrist

Accepted Answer

11ecbb05_cb63_5cfb_b433_d5c046ea23ea_MD0009_00 Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. (Option A) The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. (Option C) The foot is not typically accessed in adults without a specific health care provider prescription. It is occasionally used in emergency situations; however, veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. (Option D) The radial vein is present on the lateral side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage. Educational objective: Peripheral IV sites should be selected in the hand or forearm to reduce the risk of catheter-related bloodstream infections. Sites on the upper extremities located at flexion sites (eg, wrist, bend of arm) and the lower extremities should be avoided.

Question 4

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. A)Ensuring the client wears an N95 respirator at all times B)Keeping the door of the client's room closed at all times C)Maintaining a log of everyone in and out of the client's room D)Removing both pairs of gloves before removing gown and mask E)Restricting visitors from entering the client's room

Accepted Answer

Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option B). Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option E). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option C). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. (Option A) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). (Option D) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last. Educational objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

Question 5

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply. A)Aim the nozzle at the base of the fire B)Pull out the pin on the handle C)Shake the canister prior to use D)Squeeze the handle to spray E)Sweep the spray from side to side

Accepted Answer

A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment (eg, fire extinguisher) is involved. The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher: P - Pull the pin on the handle to release the extinguisher's locking mechanism A - Aim the spray at the base of the fire S - Squeeze the handle to release the contents/extinguishing agent S - Sweep the spray from side to side until the fire is extinguished (Option C) The extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire. Educational objective: PASS is a mnemonic to help people remember the steps used in operating a fire extinguisher: P - Pull the pin; A - Aim the spray at the base of the fire; S - Squeeze the handle; and S - Sweep the spray.

Question 6

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priority for a private room assignment? A)Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C B)Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection C)Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis D)Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

Accepted Answer

A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. (Options A and C) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. (Option B) A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions. Educational objective: The Centers for Disease Control and Prevention recommends contact precautions and private room placement for a client who is colonized with methicillin-resistant Staphylococcus aureus, especially if the client can transmit the bacteria through body secretions or excretions.

Question 7

A client who has been prescribed several medications asks, "Can I take over-the-counter (OTC) medications with my prescriptions?" Which of the following statements by the nurse is appropriate? Select all that apply. A)"Always ask the health care provider or pharmacist before taking OTC medications." B)"Ingredients in some OTC medications may interact with prescription medications." C)"It is best to avoid OTC medications, but herbal and supplement products are usually safe." D)"Remember to discuss all medications, herbs, and supplements you take with your health care providers." E)"Taking OTC medications can sometimes hide symptoms of a serious disease or illness."

Accepted Answer

Over-the-counter (OTC) medications are available without a prescription and are used to treat common illnesses. It is estimated that nearly four times as many health conditions are independently managed with OTC medications as are managed under the supervision of a health care provider (HCP). Prior to taking OTC medications, the client should talk with an HCP or pharmacist, particularly if already taking prescribed medications (Option A). Even when taken as directed by the OTC medication label, interactions and adverse effects may occur when used in combination with prescription medications (Option B). All medications, herbal products, and supplements must be discussed with HCPs so that they can be reconciled and considered before changing or adding new treatments (Option D). When OTC medications are used to manage symptoms (eg, ibuprofen for back pain), the diagnosis and treatment of serious underlying medical conditions (eg, malignancy) may be delayed (Option E). (Option C) Herbal products and supplements, although they are prepared from plants or "all-natural" substances, may contain compounds that interact with prescription medications. These interactions may cause increased or decreased prescription medication effect, serious adverse effects, and medication toxicities. Educational objective: Nurses should instruct clients to talk with a health care provider (HCP) or pharmacist before taking over-the-counter medications as they may interact with prescription medications or hide symptoms of a serious condition. All medications, herbal products, and supplements taken should be discussed with HCPs.

Question 8

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate? A)Get the client out of bed and away from the radiation source B)Manually reinsert the implant and notify the health care provider C)Use long-handled forceps to secure the implant in a lead container D)Wrap the implant in the linens and place it in a biohazard bag

Accepted Answer

An internal radiation implant (ie, brachytherapy) emits radiation in or near a tumor to treat certain malignancies. When caring for clients undergoing brachytherapy, the nurse should monitor closely for evidence of implant dislodgment. The dislodged implant emits radiation that can be dangerous to health care workers at the bedside. Long-handled forceps and a lead-lined container should be kept in the room of the client who has a radioactive implant in case of dislodgment. If dislodgment occurs, the nurse should first use long-handled forceps to place the implant in a lead-lined container to contain radiation exposure (Option C). The nurse should also notify the health care provider (radiation oncologist). (Option A) Containing the source quickly is a priority as the implant continues to emit radiation that could be dangerous to the staff coming to evaluate the client and clean the room. (Option B) The nurse should not handle dislodged radiation implants without the use of forceps. Furthermore, device reinsertion should be performed only by the health care provider. (Option D) Wrapping the implant in linens and placing it within a biohazard bag does not reduce radiation exposure. Educational objective: If an internal radiation implant has dislodged, the nurse should use long-handled forceps to place it in a lead-lined container to contain radiation exposure.

Question 9

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply. A)Client is on a calorie-restricted diet for obesity B)Creatinine is 1.3 mg/dL (115 µmol/L) C)History of congenital heart disease D)International Normalized Ratio of 2.5 E)Presence of prosthetic valve

Accepted Answer

Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (eg, dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated International Normalized Ratio (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures (Options C, D, and F). (Option A) A history of obesity and a calorie-restricted diet are not significant for oral surgery. (Option B) This creatinine level is within normal limits (0.6-1.3 mg/dL [53-115 µmol/L]) and would not require reporting. Educational objective: Prior to oral surgery, it is necessary to report findings that will place a client at risk for the development of endocarditis (eg, presence of prosthetic valves, history of congenital heart disease) and bleeding (eg, elevated International Normalized Ratio).

Question 10

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome.  Which personal protective equipment will the nurse use when providing care to the client?
A)Gloves and gown
B)Gloves and mask
C)Gown and N95 respirator
D)Gown, gloves, N95 respirator, and eye protection

Accepted Answer

Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS. (Options A, B, and C) These options do not provide enough protection as each is missing a vital element that is recommended when caring for a client with MERS. Educational objective: Standard, contact, and airborne precautions with eye protection should be used when caring for a client with suspected or diagnosed Middle East respiratory syndrome.

Question 11

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. A)After insertion, secure the catheter with a sterile, semipermeable dressing B)Clean ports with an alcohol swab prior to accessing the catheter system C)Prior to insertion, apply chlorhexidine, using friction, to the venipuncture site D)Prior to insertion, shave excess hair over the selected venipuncture site E)Replace or remove the venous catheter every 48 hours

Accepted Answer

11ecbb05_cb63_0eda_b433_6b237766d824_MD0009_00 The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of catheter-related infections, the selected site should be cleaned with antiseptic solution using friction (preferably chlorhexidine, using a back-and-forth motion) and then allowed to air-dry completely (Option C). Chlorhexidine is preferred as it achieves an antimicrobial effect within 30 seconds, whereas povidone-iodine takes ≥2 minutes. After insertion, the catheter hub should be secured with a narrow strip of sterile tape to prevent accidental removal or excessive back-and-forth motion, which can introduce microorganisms into the vein. In addition, a sterile, transparent, semipermeable dressing (eg, Tegaderm) should be used to secure the catheter hub to reduce infection risk and allow visualization of the site (Option A). When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill externally colonized microorganisms (Option B). (Option D) Excessive hair may be clipped but never shaved as shaving may cause microabrasions and potential portals of entry for microorganisms. (Option E) Peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of complications (eg, infiltration, infection, phlebitis) occur. Educational objective: To reduce catheter-related infections from peripheral IV catheters, the nurse should clean the site with chlorhexidine in a back-and-forth motion using friction and allow it to dry completely. The catheter hub is secured with a sterile, semipermeable dressing, and access ports are cleaned with alcohol swabs prior to use.

Question 12

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse? A)Applying a warm compress to the affected extremity B)Maintaining the affected leg flat on the bed C)Marking and dating the reddened areas D)Wearing a gown and gloves while bathing the client

Accepted Answer

11ecbb05_cb63_ab1c_b433_55e2ac6b7f51_MD0009_00 Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection (eg, Staphylococcus aureus, group A Streptococcus) resulting from an insect bite, cut, abrasion, or open wound. Cellulitis is characterized by redness, edema, pain, and fever. Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated when the client is sitting or lying down to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays recovery and contributes to pain (Option B). In addition, clients with weeping or draining wounds must be protected from prolonged exposure to moist or soiled linens as this exposure promotes tissue injury and infection. (Option A) Applying warm compresses promotes circulation to the area of infection, alleviates discomfort, and helps reduce edema. (Option C) Daily marking and dating of reddened areas assist with monitoring improvement or worsening of the infection. Redness that progresses past the marked areas indicates ineffective antibiotic therapy and should be reported to the health care provider. (Option D) Although standard precautions are typically sufficient for cellulitis, a gown and gloves are worn when contact with body fluids (eg, urine, stool) or potentially infectious drainage is expected, such as during bathing. Educational objective: Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated to reduce edema. Additional nursing interventions include applying warm compresses, monitoring the size of the cellulitis, and using personal protective equipment to prevent infection transmission.

Question 13

A nurse is caring for a client who is intubated and has a subclavian central venous catheter. Which nursing intervention is most important to prevent the spread of infection to this client? A)Frequent hand hygiene B)No artificial nails C)Use of chlorhexidine bath wipes D)Wearing personal protective equipment

Accepted Answer

Hand hygiene is the most important factor in preventing infection transmission. The nurse should perform hand hygiene before and after client contact, before donning and after removing gloves, and after contact with bodily fluids (Option A). Principles for proper hand hygiene include: Apply alcohol-based hand rubs liberally, covering the entire surface of the hands, and allow hands to dry completely. Do not use an alcohol-based hand rub if hands are visibly soiled. When using soap and water, wet the hands; apply soap; scrub all hand surfaces, wrists, and beneath the nails for at least 20 seconds; rinse; dry hands with a paper towel; and then use a new, dry paper towel to turn off the faucet. (Option B) The nurse should not wear artificial nails, especially in high-risk areas (eg, intensive care unit), because artificial nails harbor microorganisms, even after hand washing. However, the priority intervention for infection prevention is hand hygiene. (Option C) The nurse should use chlorhexidine to bathe clients who are critically ill, have central venous catheters, or are scheduled for surgery; and for indwelling catheter care. However, the risk for infection transmission would remain high if the nurse implements client care without performing hand hygiene. (Option D) Personal protective equipment (eg, gloves) is appropriate but is not as important as (and does not replace) hand hygiene to prevent the spread of infection. Educational objective: Hand hygiene is the most important nursing intervention to prevent the spread of infection to clients.

Question 14

A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next? A)Discard potassium and document administration of a partial dose B)Exchange the IV pump with a different one C)Insert a new IV catheter in a different location D)Remove the pump and administer medication by gravity drip

Accepted Answer

IV infusion pumps display an occlusion alarm when IV solution cannot be infused due to pressure in the line. Common causes of occlusion include clamped or kinked IV tubing, clotting in the IV catheter, and kinking in the IV catheter with extremity movement (eg, elbow, wrist). The nurse should assess the tubing and IV site and flush the IV catheter to check patency. In the absence of identifiable occlusion, an alarming IV pump should be exchanged for a different one (Option B). Malfunctioning equipment may harm the client and should be removed from the care area. The malfunctioning equipment is labeled as out of service and is sent for maintenance. (Option A) An IV pump alarm does not indicate that a medication is no longer needed. The nurse should replace a malfunctioning pump and restart the medication. (Option C) An IV catheter that has no symptoms of occlusion (ie, resistance to flushing) or infiltration (eg, swelling, coolness, pain) does not need to be replaced. (Option D) IV pump infusion is more accurate than gravity drip. IV pumps are required when administering high-risk IV medications (eg, heparin, insulin, potassium). IV potassium should never be administered by gravity as it may cause lethal arrhythmias if administered too quickly. Educational objective: If an IV infusion pump displays an alarm without an identifiable problem, the nurse should replace the pump. Malfunctioning equipment may harm the client and should be removed from the care area. The equipment is labeled as out of service and sent for maintenance.

Question 15

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. A)Don gown, gloves, and N95 respirator when entering the client's room B)Ensure that pregnant staff members are not assigned to care for this client C)Place single-use, disposable thermometer and stethoscope in the room D)Place the client in a private room with negative air pressure E)Request discontinuation of isolation precautions once all lesions are dry and crusted

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. 11ecbb05_cb68_660e_b433_01fa9bbd9601_MD0009_00 Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) (Options A and C). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option E). Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway (Option D). Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities (Option B). Educational objective: Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

Question 16

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? A)Ask another nurse to help B)Delegate the task to unlicensed assistive personnel C)Premedicate the client for pain D)Verify the client's activity prescription

Accepted Answer

A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option A) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option B) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option C) The nurse should assess the client's pain level before providing pain medication. Educational objective: The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

Question 17

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? A)Femoral line inserted in emergency department post cardiac arrest 48 hours ago B)Internal jugular line inserted 6 days ago in operating room C)Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago D)Subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago

Accepted Answer

In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an occlusive dressing over these sites. A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage). The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection. (Option B) Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical need and no evidence of infection. (Option C) Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter. (Option D) The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not located at the insertion site. The femoral line is still at higher risk for infection. Educational objective: Femoral central venous catheters may be placed in emergency situations but should be removed/replaced as soon as possible due to the high risk of contamination and infection.

Question 18

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? A)4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows B)7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash C)12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose D)14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

Accepted Answer

Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients with airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome) should be isolated first using airborne precautions. These infections are spread via very small particles that circulate in the air. Clients with airborne infections are placed in an isolation room with negative pressure that provides air exchange or with a high-efficiency particulate air filtration system. (Option A) Clients with scabies will be placed in contact isolation. The 4-year-old is contagious, but only if direct contact is made. Therefore, isolating the client with airborne precautions is the priority. (Option C) Clients with influenza are placed on droplet precautions. The 12-year-old can spread pathogens via large droplets released into the air when coughing, sneezing, or talking. The client would be the second priority for isolation. (Option D) Clients with methicillin-resistant Staphylococcus aureus infection are placed on contact precautions. The 14-year-old is contagious, but only if direct contact is made. The client requires isolation but is not a priority over the client whose pathogens are airborne. Educational objective: Airborne infections (eg, measles, tuberculosis, varicella) are spread by air currents and are among the most contagious of diseases. Clients with these infections require airborne precautions and should be isolated first.

Question 19

The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention? A)Monitor gag and swallowing reflexes closely B)Provide for client assistance with ambulation C)Provide sensory stimulation D)Speak at a normal volume while facing the client directly

Accepted Answer

11ecbb05_cb66_914d_b433_75e7a696f453_MD0009_00 The Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation. (Option A) Damage to the glossopharyngeal and vagus nerves (cranial nerves IX and X) would cause problems with swallowing and the gag reflex. (Option C) Providing for sensory stimulation is important in many disorders of the neurologic system. However, this would not be needed for a client with a positive Romberg test. (Option D) Speaking at a normal voice while facing a client directly is a measure used for those with hearing loss. Educational objective: A client with a positive Romberg test has a loss of sense of self in space and needs assistance with ambulation to prevent injury and provide safety.

Question 20

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply. A)Flushing the line before and after each medication administration B)Pausing the parenteral nutrition prior to drawing blood from a different port C)Reinforcing a torn peripherally inserted central catheter line dressing with tape D)Scrubbing the port with alcohol for 5 seconds before use E)Taking the client's blood pressure in the left arm

Accepted Answer

A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option A). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity (Option E). All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels (Option B). (Option C) Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape. (Option D) The nurse should "scrub the hub" with alcohol or chlorhexidine/alcohol for 10-15 seconds. This should be done before flushing, drawing blood, or administering medication. Educational objective: Peripherally inserted central catheter lines provide central venous access for clients who require long-term medication administration or infusion of noxious substances. Maintaining the line integrity with aseptic technique and routine care (sterile dressing changes, flushing the line, blood pressures/venipunctures on unaffected arm) is important for continued use and prevention of central line-associated bloodstream infections.

Exam 4: Fundamentals

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A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply.