Princeton NCLEX review

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VATI M

78 terms jaza safety and infection control

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The nurse is caring for a client who is receiving the first dose of a newly prescribed intravenous antibiotic. Which finding observed by the nurse would indicate an allergic reaction?Development of oral thrush A decrease in heart rate from 80 to 72 Development of swelling in the lips An increase in systolic blood pressure from 102 to 115 Development of swelling of the lips Rationale: A sign of allergic reaction is swelling of the lips, mouth, and tongue. Other symptoms include the development of tachycardia and hypotension. Oral thrush, or candidiasis, is a yeast infection that can develop when a client is taking antibiotics.

The charge nurse is observing a newly hired nurse use a fire extinguisher for a small fire in a client's room. Which action by the newly hired nurse would require intervention by the charge nurse?Aiming the hose at the top of the fire Pulling out the fire extinguisher's safety pin Squeezing the handle to discharge material onto the fire Sweeping the hose from side to side until the fire is extinguished Aiming the hose at the top of the fire Rationale: Correct technique for use of a fire extinguisher includes pulling out the safety pin, aiming the hose at the base of the fire, squeezing the handle to discharge the material, and sweeping the hose from side to side. It requires intervention if the nurse is observed aiming the hose at the top of the fire instead of the base.A nurse is teaching a client with a hearing impairment about reporting adverse effects of intravenous therapy. Which action will promote client understanding of the instructions?Repeating the instructions to the client several times Sitting at eye-level in front of the client Speaking very loudly to the client Providing all instructions to the client in writing Sitting at eye-level in front of the client Rationale: Clients with a hearing impairment benefit from lip reading and facial cues. Sitting close enough to the client will promote effective communication. Repeating the instructions several times may not guarantee understanding. Lack of client feedback may require rewording of the instructions. Speaking very loudly to the client does not promote effective communication. Clients with a hearing impairment benefit from visual cues, not a higher pitched voice. Providing all instructions to the client in writing does not promote therapeutic communication. The nurse should not assume the client is unable to communicate.A nurse is reviewing the medical record for a client with a urethral stricture. Which prescription should the nurse clarify with the healthcare provider?Monitor intake and output Schedule a pelvic ultrasound Obtain a urine sample Insert an indwelling catheter Insert an indwelling catheter Rationale: A urethral stricture is a narrowing of the urethra that restricts the flow of urine from the bladder. Insertion of an indwelling catheter may cause further trauma to the urethra if the stricture has not been dilated. Strict intake and output is not an invasive procedure and cannot cause harm to the client. A pelvic ultrasound is an expected diagnostic procedure to visualize the volume of urine present in the bladder. A urinalysis is an expected prescription to assess for signs of infection or blood in the urine.

The nurse is reviewing the plan of care with a client who has a prescription to remain supine for 24 hours following a procedure. Which statement should the nurse make to the client regarding positioning?"Keep your knees flexed." "Place a pillow under your legs." "Rotate your hips side to side to relieve pressure." "Raise your arms over your head to stretch." "Place a pillow under your legs." Rationale: When caring for a client with a prescription for the supine position, the nurse should implement interventions to prevent pressure injuries. The supine position increases pressure on the client's heels and coccyx. To alleviate this pressure, the nurse should instruct the client to keep a pillow under their legs, this will float the heels off the bed and prevent pressure. Instructing the client to keep knees flexed will increase pressure on heels. Raising arms above the head does not reduce pressure. Rotating hips can increase pressure.A nurse is implementing seizure precautions for a client with tonic-clonic seizures. Which action should the nurse take?Raise all side rails on the bed Your Answer Instruct client to ambulate slowly to the restroom Ensure patency of the saline lock Position the overbed table in front of the client Ensure patency of the saline lock Rationale: Clients with tonic-clonic seizures are at risk for injury due to rhythmic jerking of the extremities and changes in breathing patterns. The nurse should ensure intravenous access is patent in case pharmacologic treatment is required. Raising all of the siderails is considered a restraint. Clients should be instructed to call for assistance with ambulation. The client may fall and injure themselves during a seizure.Positioning the overbed table in front of the client can cause injury if the client experiences a seizure.A nurse is verifying a prescription for an intravenous antibiotic on the client's electronic medical record. Before administering the medication, which action will the nurse perform first?Disinfect the injection port on the intravenous line Program the infusion pump with the prescribed rate Flush the intravenous line with normal saline Scan the bar code on the client's wristband Scan the bar code on the client's wristband Rationale: Client identification should occur before performing interventions. The client's bar code can be used as one identifier. Two identifiers are required. Disinfecting the injection port should be done after the client is identified. Programming the infusion pump is a step performed after the nurse verifies the client's identity. Flushing the intravenous line with normal saline is considered medication administration and cannot occur until the client has been properly identified.

The charge nurse is required to recommend a client that can be discharged in the next hour due to a disaster plan activation. The nurse should recommend which client for discharge?A client post-laparoscopic cholecystectomy with a prescription for a soft diet A client with a comminuted pelvic fracture who is taking oral analgesics A client with atelectasis on oxygen via nasal cannula A client with a foot ulcer who is receiving intravenous antibiotics A client post-laparoscopic cholecystectomy with a prescription for a soft diet Rationale: A postoperative client who is tolerating oral intake is considered stable for discharge. A laparoscopic cholecystectomy is minimally invasive, and clients are usually discharged within a day. A client with a comminuted pelvic fracture cannot be mobilized until treated. A client with atelectasis who requires oxygen therapy is not stable for discharge within an hour. A client receiving intravenous antibiotics is not ready for discharge. Intravenous therapy requires care management collaboration prior to discharge.The nurse is making client care assignments during a facility disaster drill. Which action by the nurse indicates correct understanding of assignments during a disaster?Assigning a nursing administrator to care for clients in the post-anesthesia care unit Assigning a nurse on the medical-surgical floor to perform triage on disaster victims in the emergency department Assigning a critical care nurse to care for emergent clients in the emergency department Assigning unlicensed assistive personnel to monitor a group of clients on a medical-surgical floor Assigning a critical care nurse to care for emergent clients in the emergency department Rationale: Mass casualty events often require nurses to practice outside of their normal daily duties. Nursing administrators may be assigned to client care on units; however, they should be assigned to stable, predictable clients. Clients who are immediately post-operative in the post- anesthesia unit are in critical condition and should not be assigned to the nursing administrator. Nurses on the medical-surgical floor may be assigned to care for stable clients in the emergency department so that emergency room nurses can perform triage on critical patients. Critical care nurses may be reassigned to care for critical patients in the emergency department. Unlicensed assistive personnel cannot perform regular nursing assessments or interventions even in a disaster situation and should not be assigned to monitor or manage a group of medical-surgical clients.