the nurse gets a prescription for restraints and asks the AP to apply the
restraints to a client. which observation of unsafe application would indicate
further instruction is needed for the AP?
1. placing a safety knot in the device safety straps
2. safely securing the safety device straps to the side rails
3. applying safety device straps that do not tighten when force is applied
against them
4. securing so that 2 fingers can slide easily between the safety device and
the client's skin
2. safely securing the safety device straps to the side rails
Rationale: the device straps should be secured to the bed frame and never to
the side rails to avoid injury in the event of side rails being released. a safety
release buckle should be used because it does not tighten when force is
applied against it, and it allows quick and easy removal of the safety device
in case of an emergency. the safety device should be secure and allow 1-2
fingers to slide through it.
the community health nurse is providing a teaching session to members of
the community and asks participants about the methods of transmission.
which answers would indicate the teaching was effective? select all that
apply
1. bites from ticks or deer flies
2. inhalation of bacterial spores
3. through a cut or abrasion of the skin
4. direct contact with an infected individual
5. sexual contact with an infected individual
6. ingestion of contaminated undercooked meat
2, 3, 6
,Rationale: anthrax can be contracted through the digestive system,
abrasions in the skin, or through inhalation of spores. it can not be
contracted from person to person, and can not be passed from deer flies or
tick bites.
The nurse is giving report to an AP who will be caring for a client in
restraints. how frequently should the nurse tell the AP to check the tightness
of the restraints?
1. every 2 hours
2. every 3 hours
3. every 4 hours
4. every 30 minutes
4. every 30 minutes
Rationale: the AP should check the tightness of the safety devices every 30
minutes. the neurovascular and circulatory status of the affected extremity
should be check by the RN every 30 mins. the safety device should be
removed every 2 hours to allow muscle exercise and promote circulation.
the nurse is reviewing the plan of care for a client with an internal radiation
implant. which intervention, if noted in the plan, indicates the need for
revision of the plan?
1. wearing gloves when emptying the client's bedpan
2. keeping all linens in the room until the implant is removed
3. wearing a lead apron when providing direct care to the client
4. placing the client in a semiprivate room at the end of the hallway
4. placing the client in a semiprivate room at the end of the hallway
,Rationale: for a client with an internal radiation implant, a private room and
bathroom is necessary to prevent other clients from exposure to radiation.
the other options are correct care and protect the nurse from exposure.
contact precautions are initiated for a client with a hc-associated infection
caused by MRSA. the nurse prepares to provide colostomy care and should
obtain which protective item to perform this procedure?
1. gloves and gown
2. gloves and goggles
3. gloves, gown, and shoe protections
4. gloves, gown, goggles, and mask or face shield
4. gloves, gown, goggles, and mask or face shield
Rationale: splashes of body secretions can occur while providing colostomy
care. goggles and a mask or face shield should be worn to prevent contact
with the body secretions, and gown and gloves are required with contact
precautions. shoe protectors are not necessary.
the nurse enters a clients room and finds that the wastebasket is on fire. the
nurse assists the client out of the room. what is the next action?
1. call for help
2. extinguish the fire
3. activate the fire alarm
4. confine the fire by closing the room door
3. activate the fire alarm
Rationale: using the RACE acronym, this is the next step.
, Rescue --> Activate --> confine --> extinguish
a mother calls her nurse friend and states her 3 year old has just ingested
liquid furniture polish. the nurse should tell her to do what?
1. induce vomiting
2. call an ambulance
3. call the poison control center
4. bring the child to the ED
3. call the poison control center
the ED nurse gets a phone call and is told a nearby area has been hit with a
tornado and multiple casualties have occurred. the victims will be brought to
the ED. the nurse should take which initial action?
1. prepare the triage rooms
2. activate the emergency response plan specific to the facility
3. obtain additional supplies from the central supply department
4. obtain additional nursing staff to assist in treating the victims
2. activate the emergency response plan specific to the facility
the nurse is caring for a client with meningitis and implements which
transmission-based precaution?
1. private room or cohort client
2. personal respiratory protection device
3. private room with negative airflow pressure
4. mask worn by staff when the client needs to leave the room
restraints to a client. which observation of unsafe application would indicate
further instruction is needed for the AP?
1. placing a safety knot in the device safety straps
2. safely securing the safety device straps to the side rails
3. applying safety device straps that do not tighten when force is applied
against them
4. securing so that 2 fingers can slide easily between the safety device and
the client's skin
2. safely securing the safety device straps to the side rails
Rationale: the device straps should be secured to the bed frame and never to
the side rails to avoid injury in the event of side rails being released. a safety
release buckle should be used because it does not tighten when force is
applied against it, and it allows quick and easy removal of the safety device
in case of an emergency. the safety device should be secure and allow 1-2
fingers to slide through it.
the community health nurse is providing a teaching session to members of
the community and asks participants about the methods of transmission.
which answers would indicate the teaching was effective? select all that
apply
1. bites from ticks or deer flies
2. inhalation of bacterial spores
3. through a cut or abrasion of the skin
4. direct contact with an infected individual
5. sexual contact with an infected individual
6. ingestion of contaminated undercooked meat
2, 3, 6
,Rationale: anthrax can be contracted through the digestive system,
abrasions in the skin, or through inhalation of spores. it can not be
contracted from person to person, and can not be passed from deer flies or
tick bites.
The nurse is giving report to an AP who will be caring for a client in
restraints. how frequently should the nurse tell the AP to check the tightness
of the restraints?
1. every 2 hours
2. every 3 hours
3. every 4 hours
4. every 30 minutes
4. every 30 minutes
Rationale: the AP should check the tightness of the safety devices every 30
minutes. the neurovascular and circulatory status of the affected extremity
should be check by the RN every 30 mins. the safety device should be
removed every 2 hours to allow muscle exercise and promote circulation.
the nurse is reviewing the plan of care for a client with an internal radiation
implant. which intervention, if noted in the plan, indicates the need for
revision of the plan?
1. wearing gloves when emptying the client's bedpan
2. keeping all linens in the room until the implant is removed
3. wearing a lead apron when providing direct care to the client
4. placing the client in a semiprivate room at the end of the hallway
4. placing the client in a semiprivate room at the end of the hallway
,Rationale: for a client with an internal radiation implant, a private room and
bathroom is necessary to prevent other clients from exposure to radiation.
the other options are correct care and protect the nurse from exposure.
contact precautions are initiated for a client with a hc-associated infection
caused by MRSA. the nurse prepares to provide colostomy care and should
obtain which protective item to perform this procedure?
1. gloves and gown
2. gloves and goggles
3. gloves, gown, and shoe protections
4. gloves, gown, goggles, and mask or face shield
4. gloves, gown, goggles, and mask or face shield
Rationale: splashes of body secretions can occur while providing colostomy
care. goggles and a mask or face shield should be worn to prevent contact
with the body secretions, and gown and gloves are required with contact
precautions. shoe protectors are not necessary.
the nurse enters a clients room and finds that the wastebasket is on fire. the
nurse assists the client out of the room. what is the next action?
1. call for help
2. extinguish the fire
3. activate the fire alarm
4. confine the fire by closing the room door
3. activate the fire alarm
Rationale: using the RACE acronym, this is the next step.
, Rescue --> Activate --> confine --> extinguish
a mother calls her nurse friend and states her 3 year old has just ingested
liquid furniture polish. the nurse should tell her to do what?
1. induce vomiting
2. call an ambulance
3. call the poison control center
4. bring the child to the ED
3. call the poison control center
the ED nurse gets a phone call and is told a nearby area has been hit with a
tornado and multiple casualties have occurred. the victims will be brought to
the ED. the nurse should take which initial action?
1. prepare the triage rooms
2. activate the emergency response plan specific to the facility
3. obtain additional supplies from the central supply department
4. obtain additional nursing staff to assist in treating the victims
2. activate the emergency response plan specific to the facility
the nurse is caring for a client with meningitis and implements which
transmission-based precaution?
1. private room or cohort client
2. personal respiratory protection device
3. private room with negative airflow pressure
4. mask worn by staff when the client needs to leave the room
