Question 1

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client? A)An appropriate form must be signed, verifying refusal B)Complications, including death, could result C)The client will be billed for the equipment regardless D)The surgeon will be informed of the refusal

Accepted Answer

Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications (including the possible worst-case scenario, which is usually death) when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest (eg, wear the SCDs for a limited time). (Option A) This would occur, but it is more important to make the client aware of the potential implications of this refusal so that the client can make an informed refusal. (Option C) Safe, quality care is the priority, not financial concerns. The nurse should avoid discussing financial implications when a client is making care decisions. (Option D) Depending on the hospital policy, a refusal to wear the SCDs could result in an additional form being completed and the refusal documented in the medical record. Documentation should include the information given to the client and the client's understanding of that information. Even if the client refuses to sign the form, the nurse should obtain other witnesses and document the refusal in detail in the medical record. Educational objective: The most important aspect of a client's refusal for treatment is to make sure that the client is informed of the potential results of the refusal.

Question 2

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? A)Facilitate immediate removal of people from the area B)Inform the client that the client cannot act that way C)Pull the fire alarm to get additional immediate help D)State that the nurse can see the client is upset

Accepted Answer

When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (Option B) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option C) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option D) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective: Safety is the priority when violence occurs. People should leave the area and call security immediately.

Question 3

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. A)Assess abdominal distension every 4 hours B)Check gastric residual every 12 hours C)Keep head of the bed at ≥30 degrees D)Maintain endotracheal cuff pressure E)Use caution when administering sedatives

Accepted Answer

Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option A)Assess feeding tube placement at regular intervalsKeep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option C)Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H₂0) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option D)Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessaryUse caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option E)Avoid bolus tube feedings for clients at high risk for aspiration Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option A) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option C) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H₂0) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option D) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option E) Avoid bolus tube feedings for clients at high risk for aspiration (Option B) Gastric residual should be checked no less than every 4 hours in intubated clients. Educational objective: Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for gastric intolerance (ie, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, using sedation cautiously, and regular assessment of tube placement. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and suction appropriately.

Question 4

The nurse should consider which of the following client reports as an indication of an allergic reaction?
A)"I can't eat broccoli or cabbage when I take my warfarin."
B)"I get a headache when using my nitroglycerine patch."
C)"My feet swell when I take felodipine."
D)"My lips swell when I eat bananas or avocados."

Accepted Answer

People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: Allergic contact dermatitis (rash, itching, vesicles) developing 3-4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include: Glove use Procedures involving balloon-tipped catheters (eg, arterial catheterization) Blowing up toy balloons Use of bottle nipples, pacifiers Use of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. (Option A) Foods rich in vitamin K reduce the effects of warfarin (which works by inhibiting vitamin K-dependent clotting factors). Consumption of these foods decreases the effectiveness of warfarin; clients must be taught to eat the same amount of or avoid dark, green, leafy vegetables. (Option B) Nitroglycerine is a vasodilator and a headache from dilating cerebral vessels is an expected finding. The side effect is treated with acetaminophen (Tylenol). (Option C) Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and to use stockings. Educational objective: Latex allergy is suspected when there is a food allergy to banana, kiwis, or avocados. Peripheral edema is an expected side effect of peripherally acting calcium channel blockers. Headache is an expected side effect of nitroglycerine. Clients taking warfarin (Coumadin) should consume the same amounts of food high in vitamin K.

Question 5

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress.  The client's immediate family member refuses to leave the room.  How should the charge nurse handle this situation?
A)Call security to escort the family member to the waiting room
B)Have the family member stand or sit in an area that is not in the staff's way
C)Inform the family member that relatives are not allowed in rooms during emergency situations
D)Let the family member stay and assign a staff person to explain what is happening

Accepted Answer

If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The charge nurse should be prepared to escort family members from the room if they become disruptive. (Option A) Calling security is appropriate only if the family member is disruptive or abusive to the staff. (Option B) This could increase the family member's anxiety and result in a traumatizing experience if this person does not understand what is occurring during the resuscitation effort. (Option C) Many professional organizations support allowing a family member to stay during emergency situations, in accordance with specific hospital policy. Educational objective: The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

Question 6

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply. A)Apply color-coded, nonslip socks to the client's feet B)Move the client to a room closer to the nurses' station C)Place a bedside commode to the right of the client D)Raise all bed rails before leaving the room E)Use a bed alarm to alert staff when the client gets up

Accepted Answer

11ecbb05_cb51_d0bf_b433_e352cd40e2b7_MD0009_00 The client with right-brain damage following a stroke often experiences left-sided weakness, spatial-perceptual deficits, and impulsiveness, making this client at high risk for falls. Other factors that increase fall risk for older adults include: Unfamiliar surroundings Unsteady gait, decreased strength and coordination Altered mental status Orthostatic hypotension (related to dehydration) Bowel/bladder urgency and/or frequency Application of color-coded, nonslip socks helps prevent a client from slipping and alerts staff to a client's increased risk for falls (Option A). Placing a commode by the right (stronger) side of the bed decreases the number of steps and time needed to get to a toilet (Option C). It also decreases the chance of tripping on equipment (eg, IV pump, tubing). Moving the client to a room close to the nurses' station allows frequent observation and a faster response time to calls for assistance (Option B). A bed alarm alerts staff when the client attempts to get out of bed, which allows for prompt response (Option E). (Option D) Raising all bed rails may be constituted as an unlawful use of restraint. Clients with altered mental status may also attempt to climb the side rails and sustain a fall injury. Educational objective: Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

Question 7

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? A)Insist the client sign the AMA form B)Provide the client with a copy of hospital results C)Reassure that the client can return later D)Remove the intravenous catheter

Accepted Answer

A competent client can refuse medical treatment and leave against medical advice (AMA). The nurse should inform the health care provider (HCP) immediately. If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or cannot wait until the HCP speaks with the client, the client should be allowed to do so. It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter. (Option A) The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of that information. However, if the client refuses to sign, the client is still allowed to leave (failure to do so constitutes false imprisonment). The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign. (Option B) Discharge instructions, results, and prescriptions can be given despite the client leaving AMA. However, it is not essential to provide the clients with results. Removing the catheter is the priority. (Option C) Reassuring that a client can return is ethical as the desire is for the client to receive needed care. However, it is not a priority over removal of the catheter. Educational objective: When a client leaves against medical advice (AMA), it should be an informed refusal. The nurse should inform the health care provider immediately. The most important action is for the nurse to remove the IV catheter prior to discharge. A client cannot be held against his/her will if the client refuses to sign an AMA form.

Question 8

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. A)Age of 50 B)Diagnosis of ovarian cancer C)Lying pulse 80/min, standing pulse 110/min D)Osteoarthritis of knees E)Takes carbidopa/levodopa F)Uses a cane to ambulate

Accepted Answer

Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option C). Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk (Option D). Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option E). The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling (Option F). (Option A) Fall risk does not increase until age >65-75. (Option B) Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall. Educational objective: Fall risks include using assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70.

Question 9

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. A)Apply pads to the side rails B)Have oxygen supplementation available C)Prepare to insert a urinary catheter D)Remove all linen from the bed E)Set up bedside suction equipment

Accepted Answer

11ecbb05_cb4c_a09c_b433_d7627f410cf9_MD0009_00 Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include: Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option A). During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside (Options B and E). Some facilities also encourage the use of a continuous pulse oximeter. (Option C) Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract infection. (Option D) It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions. Educational objective: Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipment.

Question 10

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply. A)Cleanse periurethral area with antiseptics every shift B)Ensure each client has a separate container to empty collection bag C)Keep catheter bag below the level of the bladder D)Routinely irrigate the catheter with antimicrobial solution E)Use sterile technique when collecting a urine specimen

Accepted Answer

Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following: Wash hands thoroughly and regularlyPerform routine perineal hygiene with soap and water each shift and after bowel movementsKeep drainage system off the floor or contaminated surfacesKeep the catheter bag below the level of the bladderEnsure each client has a separate, clean container to empty collection bag and measure urineUse sterile technique when collecting a urine specimenFacilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladderAvoid prolonged kinking, clamping, or obstruction of the catheter tubingEncourage oral fluid intake in clients who are awake and if not contraindicatedSecure the catheter in accordance with hospital policy (tape or Velcro device)Inspect the catheter and tubing for integrity, secure connections, and possible kinks Wash hands thoroughly and regularly Perform routine perineal hygiene with soap and water each shift and after bowel movements Keep drainage system off the floor or contaminated surfaces Keep the catheter bag below the level of the bladder Ensure each client has a separate, clean container to empty collection bag and measure urine Use sterile technique when collecting a urine specimen Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder Avoid prolonged kinking, clamping, or obstruction of the catheter tubing Encourage oral fluid intake in clients who are awake and if not contraindicated Secure the catheter in accordance with hospital policy (tape or Velcro device) Inspect the catheter and tubing for integrity, secure connections, and possible kinks (Option A) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria. (Option D) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention. Educational objective: Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene, cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag, and using sterile technique when collecting urine specimens.

Question 11

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? A)Administer the medication and monitor client frequently B)Ask a nursing colleague if this drug amount is used C)Check hydromorphone dose that the client had previously D)Question the prescription with the prescriber

Accepted Answer

The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (Option A) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (Option B) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (Option C) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified. Educational objective: When a medication prescription is outside the safety range, the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

Question 12

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee.  Which information obtained by the nurse should be reported immediately to the prescribing health care provider?
A)The client ate a full breakfast that morning
B)The client has an implantable cardioverter defibrillator (ICD)
C)The client is allergic to povidone-iodine
D)The client took all prescribed cardiac medications before arriving

Accepted Answer

Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, avascular necrosis, ligament tears, cartilage tears, and osteomyelitis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will make loud tapping noises and may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. (Options A and D) MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. (Option C) No povidone-iodine (Betadine) is used during an MRI; gadolinium contrast is used. Educational objective: MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of an MRI can damage implantable devices or interfere with their function.

Question 13

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? A)"I bought a new nightlight for the hallway to the bathroom." B)"I feel so much more secure wearing my electronic fall alert device." C)"I walk in my stockings at home because it helps to relieve my bunion pain." D)"My daughter helped me secure the small, thin rug in my kitchen with strong tape."

Accepted Answer

According to the Centers for Disease Control and Prevention, 1 out of 3 adults aged >65 experience a fall every year. Walking barefoot or while wearing stockings increases the risk of slipping on slick surfaces. Shoes or slippers with non-skid soles should be worn inside and outside of the home. There are multiple simple strategies that can help reduce falls in the home environment and these include: Exercising regularly for 30 minutes 3 times/week increases strength, balance, coordination, and flexibility; therefore, decreasing fall risk. Maintaining a well-lit, clutter-free environment (eg, adding nightlights and removing or securing area rugs to the floor with double-sided tape) (Options A and D). Using grab bars and non-skid bath mats in the bathroom. Wearing shoes or slippers with non-skid soles, both inside and outside of the home. Periodically reviewing medications and side effects (eg, orthostatic hypotension) with a pharmacist and/or health care provider (HCP). Getting regular vision exams. Wearing an electronic fall alert device. The fear of falling increases fall risk and these devices provide the security of knowing help is available immediately if a fall occurs (Option B). Educational objective: Many falls in the home can be prevented by exercising regularly, getting regular vision exams, maintaining a well-lit, clutter-free environment, using grab bars in the bathroom, periodically reviewing medications and side effects with a pharmacist and/or HCP, and wearing an electronic fall alert device.

Question 14

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? A)Face shield/goggles B)Gloves C)Gown D)Mask/respirator

Accepted Answer

11ecbb05_cb4f_fbfd_b433_371692df1182_MD0009_00 Personal protective equipment (PPE) is necessary when a client is on contamination precautions (eg, droplet, airborne, contact). A gown is not normally required in an airborne precaution room; however, if contamination is probable (eg, dressing change, contact with bodily fluids), a gown is necessary. The proper removal of PPE limits self-contamination. The exact procedure for donning and removing PPE varies with the level of precautions and location of nursing practice. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials (Option B). To remove gloves: Grasp the first glove by its palmar surface and pull off inside out. Next, slide fingers of the ungloved hand under the second glove at the wrist and peel off over the first glove. Discard gloves in an infectious waste container. (Options A, C, and D) Face shield/goggles, gown, and mask/respirator can be removed after gloves, which are considered the most contaminated piece of PPE. Educational objective: The proper removal of personal protective equipment limits self-contamination. Gloves should be removed first and promptly after use to prevent contamination of other items or noncontaminated materials.

Question 15

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used. A)Assess for presence of adequate pulse B)Complete an incident report C)Get help and move the client to the bed D)Inspect the client for injuries E)Notify the client's health care provider (HCP)

Accepted Answer

Establishing the presence of the client's ABCs/physiological stability is first step as the client could have lost consciousness or had a cardiovascular event that caused the fall. The need for immediate resuscitation should be assessed first (Option A). The presence of gross injuries should be established prior to moving the client so that appropriate immobilization can be taken. If awake, clients should be asked what body parts were struck, how they fell, if they hit their head, and what currently hurts. The spine should be immobilized and a cervical collar used for any neck pain (Option D). Additional help should be obtained to move the client to proper position at the site and avoid injury to the staff. After emergent stabilization, the client should be returned to bed for vital signs and further assessment (Option C). The HCP should be notified of the incident and assessment findings (Option E). Documentation should be made in the client's chart and an incident report filed for risk management (Option B). Educational objective: The appropriate order of actions when a client is found on the floor is assessment of stability, assessment of injuries, moving the client, notifications, and documentation.

Question 16

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. A)Exercise programs B)Good room lighting C)Handrails in stairwell D)Smooth-soled shoes E)Staff hourly rounds

Accepted Answer

Falls are a leading predictor of mortality and morbidity in older adults. General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls (Option A). Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should ensure that clients are wearing needed prescription glasses (Option B). Handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls (Option C). Studies show that staff rounds at regular intervals (hourly or every other hour) decrease falls and call light use. The practice allows staff to intervene early in needs. Typically staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call light, water, tissues, urinal). A common reason clients get out of bed unassisted is to use the bathroom (Option E). (Option D) Non-slip rubber-soled shoes are recommended to prevent falls. Educational objective: Client falls can be prevented with exercise programs, good lighting, handrails, and hourly staff rounds.

Question 17

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery? A)Hemoglobin 15 g/dL (150 g/L), hematocrit 45% (0.45) B)International Normalized Ratio (INR) 1.3 C)Platelet count 295,000/mm³ (295 × 10⁹/L) D)Temperature 100.4 F (38 C) with cough

Accepted Answer

Low-grade temperature and cough could indicate the presence of an infection, and the nurse should report these findings to the HCP as soon as possible before surgery. The administration of anesthesia in a client with a fever and cough can exacerbate an unknown viral or bacterial condition, increase the risk for postoperative pneumonia, and interfere with the postoperative healing process. The HCP may prescribe further testing, consult the anesthesia professional, postpone the elective surgery, or proceed with the surgery depending on the individual situation and type of surgery scheduled. (Options A, B, and C) Hemoglobin (13.2-17.3 g/dL [132-173 g/L]), hematocrit (39%-50% [0.39-0.50]), and platelet count (150,000- 400,000/mm³ [150-400 × 10⁹/L]) levels are within normal ranges and do not indicate increased risk for a bleeding problem. Normal INR is 0.75-1.25; 1.3 is only borderline elevation and would not increase the bleeding risk. Educational objective: The HCP should be notified as soon as possible if a client scheduled for surgery develops manifestations that could indicate a possible infection. Anesthesia and the physiologic stress of surgery in the presence of fever and cough can cause potential intraoperative and postoperative complications.

Question 18

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? A)Contact the national database to see if the client has a healthcare proxy B)Contact the police to help identify the client and locate family members C)Obtain a court order for the client's surgical procedure D)Transport the client to the operating room under implied consent

Accepted Answer

Implied consent in emergency situations includes the following criteria: There is an emergency Treatment is required to protect the client's health It is impractical to obtain consent It is believed that the client would want treatment if able to consent In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed. (Option A) This client's name is not known and there is no national database of healthcare proxy names/power of attorney. (Option B) This should also be done but results may not be obtained in a timely manner. The client needs immediate surgery and this should proceed with the client as a "John Doe" (placeholder name) in the meantime. (Option C) This would cause considerable delay. Court orders are used for protective custody to take control of the care of a minor when the adult parent is refusing necessary life-saving care. Educational objective: Emergency life-saving care can proceed for a client who cannot give consent if it is essential and believed that the client would want treatment if able to consent. Care is rendered under the principle of implied consent.

Question 19

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? A)Assessing the clients' respiratory systems B)Decontaminating the clients C)Donning personal protective equipment D)Providing oxygen by nasal cannula

Accepted Answer

Nursing priorities when implementing a chemical contamination emergency response plan include the following: Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant Donning personal protective equipment to protect the nurse when providing care (Option C) Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option B). Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options A and D). Educational objective: The nurse should always protect other clients, staff, and the health care facility first in a chemical contamination. Personal protective equipment should be put on before decontamination. Victims should be decontaminated outside the facility before care is administered.

Question 20

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. A)Gloves B)Goggles or face shield C)Gown D)Hand hygiene E)Mask or respirator

Accepted Answer

11ecbb05_cb50_230e_b433_0b819571f21c_MD0009_00 PPE for the health care worker protects the mucous membranes, airways, skin, and clothing from contact with potentially infectious agents. The category of transmission-based precautions (eg, contact, droplet, airborne) required determines the type of PPE that the health care worker will wear. The exact procedure for donning and removing PPE varies with the level of precautions required. Guidelines are provided by the Centers for Disease Control and Prevention (CDC) and by institution policy and procedure. The sequence for donning PPE includes: Hand hygiene Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) Gloves - don and extend to cover wrist of isolation gown Educational objective: The CDC suggests the following sequence for donning PPE: hand hygiene, gown, mask or respirator, goggles or face shield, and gloves.

Exam 4: Fundamentals

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs) . What is most important for the nurse to communicate to the client?

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse?

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply.

The nurse should consider which of the following client reports as an indication of an allergic reaction?

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation?

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply.

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply.

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs) ? Select all that apply.

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take?

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider?

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed?

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first?

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used.

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next?

There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first?

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used.