SAFE EFFECTIVE CARE ENVIRONMENT

1. Which of these actions is the primary nursing intervention designed to limit

transmission of a client's Salmonella infection?
Wash hands thoroughly before and after client contact

Wear gloves when in contact with body secretions

Double glove when in contact with feces or vomitus

Wear gloves when disposing of contaminated linens

2. A client is scheduled to receive an oral solution of radioactive iodine (131I). In

order to reduce hazards, the priority information for the nurse to include in
client teaching is which of these statements?
"In the initial 48 hours, avoid contact with children and pregnant women,
and flush the commode twice after urination or defecation."

"Use disposable utensils for 2 days and if vomiting occurs within 10 hours
of the dose, do so in the toilet and flush it twice."

"Your family can use the same bathroom that you use without any special
precautions."

"Drink plenty of water and empty your bladder often during the
initial 3 days of therapy."

3. The nurse is assigned to a client newly diagnosed with active tuberculosis.

Which of these interventions would be a priority for the nurse to implement?
Have the client cough into a tissue and dispose in a separate bag

Instruct the client to cover the mouth with a tissue when coughing

Reinforce that everyone should wash their hands before and after
entering the room

Place client in a negative pressure private room and have all who
enter the room use masks with shields

4. A parent calls the hospital hot line and is connected to the triage nurse. The
caller proclaims: "I found my child with odd stuff coming from the mouth and
an unmarked bottle nearby." Which of these comments would be the best tool
for the nurse to determine if the child has swallowed a corrosive substance?
"Ask the child if the mouth is burning or throat pain is present."

"Take the child's pulse at the wrist and see if the child is has trouble
breathing lying flat."
 "What color is the child's lips and nails and has the child voided today?"

"Has the child had vomiting, diarrhea or stomach cramps?"

5. The parents of a toddler who is being treated for pesticide poisoning ask:
"Why is activated charcoal used? What does it do?" What is the nurse's best
response?
"Activated charcoal decreases the body's absorption of the poison from
the stomach."
"The charcoal absorbs the poison and forms a compound that doesn't hurt
your child."

"This substance helps to get the poison out of the body through the
gastrointestinal system."

"The action may bind or inactivate the toxins or irritants that are
ingested by children and adults."

6. Which of these nursing diagnoses, appropriate for elderly clients, would

indicate the client is at greatest risk for falls?
Sensory perceptual alterations related to decreased vision

Alteration in mobility related to fatigue

Impaired gas exchange related to retained secretions

Altered patterns of urinary elimination related to nocturia

7. Which approach is the best way to prevent infections when providing care to
clients in the home setting?

Handwashing before and after examination of clients

Wearing nonpowdered latex-free gloves to examine the client

Using a barrier between the client's furniture and the nurse's bag

Wearing a mask with a shield during any eye/mouth/nose examination

8. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse
should reinforce to the staff members that the most significant routine
infection control strategy, in addition to handwashing, is which of these?

Place appropriate signs outside and inside the room

Use a mask with a shield if there is a risk of fluid splash

 Wear a gown to change soiled linens from incontinence

Have gloves on while handling bedpans with feces

9. Several clients are admitted to an adult medical unit. For which client
condition(s) would the nurse institute airborne precautions?

Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV)

A positive purified protein derivative (PPD) test with an abnormal chest x-

ray
A tentative diagnosis of viral pneumonia with productive brown sputum

Advanced carcinoma of the lung with hemoptysis

10. A child is admitted to the pediatric unit with a diagnosis of suspected

meningococcal meningitis. Which admission orders should the nurse
implement first?

Institute seizure precautions

Monitor neurologic status every hour

Place in respiratory/secretion precautions

Cefotaxime IV 50 mg/kg/day divided q6h

11. A school nurse has a 10 year-old child with a history of epilepsy with tonic-
clonic seizures attending classes regularly. The school nurse should inform the
teacher that if the child experiences a seizure in the classroom, the most
important action to take during the seizure would be to

move any chairs or desks at least 3 feet away from the child

note the sequence of movements with the time lapse of the event

provide privacy as much as possible to minimize frightening the other

children

place the hands or a folded blanket under the head of the child

12. The school nurse is teaching the faculty the most effective methods to prevent
the spread of lice (Pediculus Humanus Capitis) in the school. The information
 that would be most important to include is reflected in which of these
statements?

"The treatment medication requires reapplication in 8 to 10 days."

"Bedding and clothing can be boiled or steamed to kill lice."

"Children should not share hats, scarves and combs."

"Nit combs are necessary to comb lice eggs (nits) out of children's
hair."

13. Which of these clients is the priority for the nurse to report to the public health
department within the next 24 hours?

An infant with a positive culture of stool for Shigella

An elderly factory worker with a lab report that is positive for acid-fast
bacillus smear

A young adult commercial pilot with a positive histopathological

examination from an induced sputum for Pneumocystis carinii

A middle-aged nurse with a history of varicella zoster virus and with crops
of vesicles on an erythematous base that appear on the skin

14. A nurse who is assigned to the emergency department needs to understand

that gastric lavage is a priority in which situation?

An infant who has been identified as suffering from botulism

A toddler who has eaten a number of ibuprofen tablets

A preschooler who has swallowed powdered plant food

A school aged child who has taken a handful of vitamins

15. A client is diagnosed with methicillin resistant staphylococcus aureus

pneumonia (MRSA). What type of isolation is most appropriate for this client?

Reverse

Airborne

Standard precautions

Contact