Lesson 28: Providing a Secure and Safe Environment
Lesson 29: Emergency Response Plans, Disasters, and Triage
Lesson 30: Standard and TransmissionBased Precautions and Surgical
Asepsis Lesson 31: Use of Restraints and Safety Devices
Questions
1. 1.ID: 383718129
A nursing instructor is observing a nursing student who is practicing the use of standard
precautions in the nursing laboratory. Which of the following observations by the instructor indicates a
need for further teaching?
A. The nursing student changes gloves between tasks and procedures.
B. The nursing student washes hands before making contact with the client.
C. The nursing student wears a gown to change the bed of an incontinent client.
D. The nursing student washes her hands before glove removal after emptying a Foley
bag. Correct
2. A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent
exacerbation of symptoms and injury. Which instructions should the nurse provide to the
client? Select all that apply.
A. “Change positions slowly.” Correct
B. “Remove clutter from your home.” Correct
C. “Use public transportation as much as possible.”
D. “Drive your car only if you’re not feeling dizzy.”
E. “Turn your head slowly when someone speaks to you.”
3. Contact precautions are initiated for a client with methicillinresistant Staphylococcus
aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant
about caring for the client, tells the assistant:
A. To transfer the client to a semiprivate room
B. That gloves only are needed to care for the client
, C. To wear gloves and a gown when changing the client's bed linen. Correct
D. To wear a gown when caring for the client and remove the gown immediately after
leaving the client’s room
4. An industrial nurse at a large factory provides information to the employees in the mailroom
and shipping department about the signs of skin (cutaneous) anthrax. For which early sign
of cutaneous anthrax does the nurse tell the employees to check their skin?
A. An open ulcer
B. An itchy bump Correct
C. A weeping blister
D. A black skin area of skin
5. A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The
client is also receiving subcutaneous (SC) injections of heparin. Which precaution does
the nurse understand is most appropriate to help ensure the safety of this client?
A. Doubling the dose of anticoagulant
B. Applying a pressure bandage to the site after each IM injection
C. Applying prolonged pressure to the sites of the IM and SC sites Correct
D. Decreasing the sizes of the needles used for the IM and SC injections
6. A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital.
During the collection of data from the client, which of the following considerations is
especially important?
A. The religious affiliation or church of preference
B. The names of close friends and family members Correct
C. What medications have been prescribed and what the client knows about their side
effects
D. The name of the person from whom the client contracted TB, so that the person
may be reported for followup care
,7. Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy
tube. Which of the following findings does the nurse, developing a care plan, recognize as
unexpected outcomes related to the use of restraints? Select all that apply.
A. The client is agitated. Correct
B. The skin under the restraint is red. Correct
C. The client’s left hand is pale and cold. Correct
D. The client verbalizes the reason for the restraints.
E. The client is unable to reach the gastrostomy tube with his hands.
F. The client slips his hand from its restraint and pulls at his gastrostomy tube.
Correct
8. A nurse, assessing a client’s readiness for discharge, is performing a home safety
assessment to determine whether there are any environmental hazards in the home.
Which of the following statements, if made by the client, would prompt the nurse to
investigate further? Select all that apply.
A. “I live in a singlestory house.”
B. “I don’t have any nightlights in the house.” Correct
C. “I’ve removed the scatter rugs from the house.”
D. “I keep my personal items within reach when I sit in my easy chair.”
E. “I haven’t changed the batteries in the smoke detectors in my home for quite a few years
now.” Correct
, 9. The nurse plans to wear this protective mask (see figure) when caring for clients with certain
disorders. What are these disorders? Select all that apply.
F. Scabies
G. Hepatitis A
H. Tuberculosis
I. Pharyngeal diphtheria Correct
J. Streptococcal pharyngitis Correct
K. Meningococcal pneumonia Correct
10. A nurse caring for a client who is under airborne precautions notes that the client
is scheduled for a nuclear scan. Which action on the part of the nurse is
appropriate?
a. Planning to have the nuclear scan performed at the bedside
b. Asking the technicians in the nuclear scan department to wear masks
c. Placing a surgical mask on the client for transport and for contact with other
individuals Correct
d. Calling the nuclear medicine department and telling the technician that the test will
have to be delayed until airborne precautions have been discontinued
11. A nurse is reading the history and physical examination findings of an older client who
has just been admitted to the hospital. Which findings documented in the history
indicate an increased risk for accidents? Select all that apply.
a. The client’s range of motion is limited. Correct
b. Transmission of hot impulses is delayed. Correct