Exam (elaborations) NUR 1600 / NUR1600 (NUR 1600) NUR 1600 Safety

NUR 1600 Safety Question 1 See full question A 15-year-old adolescent confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response? You Selected:  "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." Correct response:  "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." Explanation: In situations in which a client is a threat to himself, the nurse can't honor confidentiality. Because this adolescent has said he has a specific plan to commit suicide, the nurse must take immediate action to ensure his safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the adolescent that she must do this, while at the same time conveying a sense of caring and understanding. The local authorities needn't be notified in this situation. Remediation: Question 2 See full question As a client is being released from restraints, he says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate? You Selected:  "I'd like to talk with you about your experience." Correct response:  "I'd like to talk with you about your experience." Explanation: After a client is released from restraints, he and the nurse need to process the experience by discussing why restraints were used and any other information the client wishes to discuss. Asking the client if he means what he says challenges or questions the validity of his statement. Simple reflection of the client's words may not open up discussion about the experience. Telling the client that the experience won't bother him in the future is judgmental and trivializes the client's remark. Remediation: Question 3 See full question Which instruction should a nurse include in an injury-prevention plan for a pregnant client? You Selected:  "Take rest periods during the day." Correct response:  "Take rest periods during the day." Explanation: The client should be instructed to avoid becoming fatigued and to take rest periods during the day. Fatigue can lead to injuries. The nurse should instruct the client to wear a seat belt below the tummy, not across it, and to position the steering wheel toward her chest, not her abdomen, to prevent injury to the fetus. Learning a new activity or sport while pregnant can lead to injury. Remediation: Question 4 See full question A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep his leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take? You Selected:  Ask the staffing coordinator to assign a nursing assistant to sit with the client. Correct response:  Ask the staffing coordinator to assign a nursing assistant to sit with the client. Explanation: The nurse should ask the staffing coordinator to assign a nursing assistant to sit with the client. This action promotes client safety while avoiding restraint use. Applying wrist restraints doesn't prevent injury to the lower leg. Also, restraints should be applied only after other less restrictive measures have been attempted. A client with stage II Alzheimer's disease has memory impairment that impedes his ability to remember repeated instruction. Sedation isn't indicated for this client. Remediation: Question 5 See full question A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the morning medications, "That is not my pill! My pill is blue, not green." What should the nurse tell the client? You Selected:  "I will go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color." Correct response:  "I will go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color." Explanation: It is important for the nurse to listen to the client and respect his or her knowledge about the medication. In the other options, the nurse dismisses the client’s concern or gives a possible explanation without checking out the specific situation. If the nurse has taken the wrong medication, the client can prevent a medication error, and if there has been a color change, the nurse can let the client know that information. In either case, helping a psychotic client deal with reality appropriately is therapeutic. Remediation: Question 6 See full question The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? You Selected:  droplet precautions Correct response:  droplet precautions Explanation: Bacterial meningitis is caused by one of three organisms, H. influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators. Remediation: Question 7 See full question The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? You Selected:  Good personal hygiene habits are most effective at preventing the spread of hepatitis B. Correct response:  The use of a condom is advised for sexual intercourse. Explanation: Hepatitis B is spread through exposure to blood or blood products and through high-risk sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk sexual activities include sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, and sexual activity with IV drug users. College students are at high risk for development of hepatitis B and are encouraged to be immunized. Alcohol intake by itself does not predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as unprotected sex. Good personal hygiene alone will not prevent the transmission of hepatitis B. Remediation: Question 8 See full question A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? You Selected:  Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Correct response:  Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Explanation: Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan. Remediation: Question 9 See full question While making rounds, the nurse enters a client’s room and finds the client on the floor between the bed and the bathroom. The nurse should first: You Selected:  activate the “Emergency Response” button. Correct response:  assess the client’s current condition and vital signs. Explanation: The nurse’s first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury. The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury. While it may be helpful to know what the client was doing out of bed in order to assess for potential confusion, the client’s immediate safety is first priority. The nurse would not activate the “Emergency Response” button until an initial assessment was done to determine the need. Remediation: Question 10 See full question A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do? You Selected:  Verify that the site, side, and level are marked. Correct response:  Verify that the site, side, and level are marked. .....Continued.....