1.The nurse determines a new mother is in greatest need of more education about infant care and safety

Module 01 Chapter 6 1.The nurse determines a new mother is in greatest need of more education about infant care and safety when the mother makes which statement?

1.“I am pretty sure that I am going to breastfeed my baby.” 2.“After feeding, I should put my baby on her tummy to prevent choking.” 3.“Solid foods are unnecessary during the baby’s first 4–6 months.” 4.“I should wake my baby up every 3–4 hours for feeding.” 2.The result of a toddler’s lead screening is 12 mg/dL. What would the nurse say to the mother at this time?

1.“His lab values are just fine.” 2.“Have you noticed any blood in his stools?” 3.“When were his last immunizations?” 4.“Tell me about where you live.” 3.A newborn is scheduled for discharge from the birthing center tomorrow. When teaching the new parents about car seats, which characteristics of infant restraint systems would the nurse include as essential for the newborn? Select all that apply.

1.Forward-facing 2.Rear-facing 3.In the back seat 4.In the front seat 5.Of a solid and neutral color 4.Which snack would the nurse appropriately offer the hospitalized toddler?

1.Crackers 2.Peanuts 3.Grapes 4.Cereal bar 5.What is the best method for the nurse to use to encourage the use of bicycle helmets by school-age children?

1.Advocate for legislation on helmet laws.

2.Teach parents to role-model helmet use while riding bicycles.

3.Verbally reprimand children who report not wearing helmets while riding.

4.Recommend the parents purchase stylish helmets to increase compliance.

6.A school nurse is planning a health class on accidents and injuries for high school students. Which topic is most important to include?

1.Occupational-related injuries at work 2.Motor vehicle–related injuries 3.Fall-related injuries 4.Injury due to residential fires 7.The home health nurse is visiting an older adult client with diabetes mellitus. The nurse becomes concerned and implements safety education when which of the following occurs?

1.Neighbors bring a warm lunch to client 2.Children install air conditioners in kitchen and bedroom 3.Grandchildren place baskets of folded laundry by bedroom door 4.Client stores diabetic testing supplies on kitchen table 8.The nurse preceptor observes the new RN administering medications. The preceptor concludes there is a risk for medication error when the new RN takes which action?

1.Answers a healthcare provider’s page while passing medications 2.Uses military time for documentation 3.Asks for help with a dosage calculation 4.Does not give a medication that the client questions 9.The nurse would ask a client scheduled for a venogram about allergy to which substance before the procedure?

1.Peanuts 2.Iodine

3.Eggs 4.Meat tenderizer 10.Which of the following medication prescriptions should the nurse question?

1.Morphine sulfate 4 mg IV every 3–4 hours as needed for pain 2.Ceftriaxone IVPB every 8 hours 3.Furosemide 40 mg po daily 4.Metoprolol 50 mg po twice a day 11.The nurse has applied elbow splints on a confused client to prevent the client from removing the intravenous (IV) line. Which of the following interventions is required?

1.Document appearance of client’s IV site every hour.

2.Remove elbow splints every 8 hours.

3.Ask for renewal of prescription for restraint every 72 hours.

4.Assess and document client’s condition at least every hour.

12.A Code Red (fire) has been announced on the hospital unit. What is the nurse’s first response?

1.Remove clients in danger from the fire.

2.Contain the fire.

3.Report fire to other staff.

4.Extinguish the fire.

13.A client on the hospital unit has fallen. Place the nursing interventions in order of priority. All options must be used.

1.Identify all witnesses.

2.Call the healthcare provider.

3.Assess and provide urgent care.

4.Notify the charge nurse.

5.Fill out the incident report.

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Answer:

14.Which information would the nurse omit from written documentation when a reportable incident has occurred?

1.Names of witnesses on incident report 2.Nursing interventions in medical record 3.Time healthcare provider was called about incident report 4.That an incident report was submitted in medical record 15.Public health nurses have been activated to open a shelter due to an approaching hurricane. What most important items should families be encouraged to take to the emergency shelter?

1.Food and extra clothing 2.Cats and small dogs 3.Medication and vital records 4.Radios and small personal electronics 16.A major portion of a construction project has collapsed. The emergency department (ED) has been notified that numerous victims are being transported to the ED. What should be the first action of the ED nurses?

1.Assess department for resources—staff, beds, equipment.

2.Implement personnel recall system.

3.Discharge stable clients.

4.Set up a temporary morgue.

17.A young man is brought to the emergency department as a victim of a multivehicle accident that caused multiple casualties. The man is awake and alert. He has a fracture of his right tibia and several small lacerations on his face. How will the triage nurse categorize this client?

1.Priority 1 (red tag) 2.Priority 2 (yellow tag) 3.Priority 3 (green tag) 4.Priority 4 (black tag)

18.The nurse should explain to the mother of a 10-month-old infant that a rear-facing car safety seat should continue to be used until the child exceeds the weight limit or is months of age. Record your answer rounding to the nearest whole number.

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months 19.The nurse is treating a client who continues to return to a violent relationship saying, “There is nothing I can do.” What is the nurse’s best response?

1.“You do have some choices; let’s sit together and explore them.” 2.“If you return you are at risk for further abuse.” 3.“Here is the number of the crisis hotline.” 4.“Do you have family or friends who can help?” 20.The nurse is assessing a school-age child. Which finding by the nurse may indicate physical neglect?

1.Not following instructions well 2.Boisterous activity 3.Stealing or hoarding food 4.Sudden onset of enuresis 21.The nurse admits a female client to the emergency department who arrives with a black eye and reports of headache, chronic pain, GI problems, menstrual irregularities, and anxiety. A previous physical workup was negative. The nurse should assess the client for which priority problems? Select all that apply.

1.Premenstrual syndrome 2.Physical or sexual abuse 3.Irritable bowel syndrome 4.Self-destructive potential Module 01 Chapter 7 1.The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply.

1.Wash hands with the hands held higher than the elbows.

2.Adjust temperature of water to the hottest possible.

3.Scrub hands and nails with a scrub brush for 5 minutes.

4.Use a clean paper towel to turn water off.

5.Rub vigorously using firm circular motions.

2.The nurse’s forearm becomes splattered with blood while inserting an intravenous catheter. What action should the nurse take?

1.Wash blood away with isopropyl alcohol.

2.Wipe blood away with a tissue.

3.Flush forearm with hot water, letting water flow from elbow toward fingers.

4.Wash forearm with soap and water.

3.The nurse would take which action to protect the client from infection at the portal of entry?

1.Place sputum specimen in a biohazard bag for transport to the lab.

2.Empty Jackson-Pratt drain using sterile technique.

3.Dispose of soiled gloves in waste container.

4.Wash hands after providing client care.

4.Which actions by the nurse comply with core principles of surgical asepsis? Select all that apply.

1.Wash hands before and after client care.

2.Keep sterile field in view at all times.

3.Wear personal protective equipment.

4.Add contents to sterile field holding package 15 cm (6 in.) above field.

5.Consider outer 3.8 cm (1.5 in.) of sterile field as contaminated.

5.Which precaution would the nurse implement when admitting a client with herpes zoster to the nursing unit?

1.Airborne precautions 2.Contact precautions 3.Droplet precautions

4.Neutropenic precautions 6.A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate?

1.“Everyone who enters your room must wear a mask to protect themselves from tuberculosis.” 2.“Masks would not be necessary for visitors who have had tuberculosis before.” 3.“It is less important for your family to wear masks, since they live in close contact with you.” 4.“Only visitors who are at risk for tuberculosis need to wear a mask.” 7.The nurse is leaving the room of a client who has methicillin-resistant Staphylococcus aureus(MRSA) microorganisms in a wound and the urine. Place the following personal protective equipment in order of removal.

1.Eye protection 2.Gloves 3.Mask 4.Gown

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Answer:

8.A client with suspected severe acute respiratory syndrome (SARS) arrives at the emergency department.Which healthcare provider prescription should the nurse implement first?

1.Airborne and contact precautions 2.IV D5NSD5NS at 100 mL/hr 3.Nasopharyngeal culture for reverse-transcriptase polymerase chain reaction 4.Sputum for enzyme immunoassay testing 9.A client with vancomycin-intermediate-resistant Staphylococcus aureus (VISA) is admitted to the nursing unit. What type of precautions should the nurse institute?

1.Standard precautions 2.Neutropenic precautions 3.Droplet precautions 4.Contact precautions 10.The nurse would implement which of the following as a requirement of care specific to the client who has tuberculosis?

1.Disposal of needles and syringes in a rigid, puncture-proof container 2.Handwashing after removing contaminated gloves 3.Wearing a gown if splashing is possible 4.A private room with negative air flow 11.The nurse would expect to institute transmission-based precautions for a client with which infection?

1.Pneumonia caused by Pseudomonas aeruginosa 2.Pneumocystis jiroveci pneumonia 3.A sacral wound contaminated by Escherichia coli 4.A draining leg wound with methicillin-resistant Staphylococcus aureus 12.A client asks, “How did I get scarlet fever?” What would be the nurse’s best response?

1.“Scarlet fever is transmitted through sexual intercourse.” 2.“You can get scarlet fever if you share contaminated needles or get a blood transfusion.” 3.“Most people get it by eating contaminated food.” 4.“You inhaled infected droplets in the air.” 13.The nurse is assisting a client who has methicillin-resistant Staphylococcus aureus in the urine to collect a clean-catch urine specimen. Which protective equipment is unnecessary?

1.N95 particulate respirator 2.Gown 3.Eye protection 4.Clean gloves 14.The nurse is preparing to irrigate a wound infected with vancomycin-resistant enterococci. What personal protective equipment (PPE) would the nurse wear?

1.Gloves, gown, and particulate respirator