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Which of these clients is at highest risk for contracting a tuberculosis infection?
- A. A nurse who is immune-suppressed from chemotherapy
- B. A nursing student with a negative purified protein derivative (PPD) test
- C. An elderly client in a nursing home who has never been tested for TB
- D. A health care worker who has a positive PPD test but negative chest x-ray
Correct Answer: A
Rationale: The immune-suppressed nurse undergoing chemotherapy is at the highest risk for contracting tuberculosis due to a weakened immune system, which reduces the ability to fight infections like TB.
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The client with a right femoral arterial line is confused, thrashing about in bed, and picking at the tubing. The HCP prescribes wrist restraints. Based on this information, what should the nurse plan to do?
- A. Apply the wrist restraints as prescribed
- B. Request an order for a right ankle restraint also
- C. Request an order for sedation instead of restraints
- D. Question the order; restraints will increase the client's agitation
Correct Answer: B
Rationale: An ankle restraint is needed to prevent leg movement that could dislodge the femoral arterial line, which wrist restraints alone cannot address.
The mother calls the nurse to ask when her newborn will be brought back to her room to finish feeding. The mother states that a doctor came about 30 minutes ago to take the baby for an examination and has not returned with her baby. Which action should be taken by the nurse first?
- A. Check the unit for the infant
- B. Initiate procedures for possible newborn abduction
- C. Ask other staff if they saw any physicians on the unit
- D. Check to see if the doctor is still examining the Infant
Correct Answer: B
Rationale: The suspicious circumstance of a doctor taking the baby for 30 minutes warrants immediate initiation of abduction procedures to ensure the newborn's safety.
The orientation nurse educator reviewing the biohazard legend with a class of new employees states that the emblem is affixed to containers whenever:
- A. there is presence of blood and body fluids.
- B. there is the need for droplet precaution.
- C. there is contact isolation.
- D. there is the potential for airborne transmission.
Correct Answer: A
Rationale: When body substances are handled, the potential for transmission is increased; therefore, federal regulations require warning labels to communicate with other employees and/or waste collectors. The biohazard alert is a three-ring symbol overlaying a central concentric ring. Blood, drainage from wounds, feces, and urine are all body fluids that can transfer infection and disease to others.
The nurse is planning care for an 18 month-old child. Which action should be included in the child's care?
- A. Hold and cuddle the child frequently
- B. Encourage the child to feed himself finger food
- C. Allow the child to walk independently on the nursing unit
- D. Engage the child in games with other children
Correct Answer: B
Rationale: Encourage the child to feed himself finger food. According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow the toddler to assert his budding sense of control.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
- A. Explain to the client that the dentures must come out as they may get lost or broken in operating room
- B. Ask the client if there are second thoughts about having the procedure
- C. Notify the anesthesia department and the surgeon of the client's refusal
- D. Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Answer: D
Rationale: Ask the client if the preference would be to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.