Nokea
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Immediately evacuate clients and personnel from the area.
- B. Don personal protective equipment (PPE) before cleaning up the spill.
- C. Contain the spill using non-absorbable sheets or pads.
- D. Complete an incident report.
- E. Discard all material used in cleanup in a trash bag.
- F. Implement droplet precautions after the spill has been cleaned.
Correct Answer: A,B,C,D
Rationale: Evacuation, PPE, containment, and incident reporting are standard for chemotherapy spills. Cleanup materials require biohazard disposal, not regular trash.
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The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.
The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
- A. naproxen
- B. alprazolam
- C. bumetanide
- D. verapamil
- E. allopurinol
- F. thiamine
Correct Answer: B,C,D
Rationale: Alprazolam (benzodiazepine) causes sedation and dizziness, bumetanide (diuretic) can cause orthostatic hypotension, and verapamil (calcium channel blocker) can cause hypotension, all increasing fall risk. Naproxen, allopurinol, and thiamine do not significantly contribute to falls.
Room Number Patient and Diagnosis
43-year-old male receiving intravenous antibiotics for Lyme disease
Contact
17 -year-old female receiving antiviral for varicella.
Airborne and Contact
3
89-year-old male diagnosed with Mumps.
Droplet
4
33-year-old male newly diagnosed with human immunodeficiency virus (HIV).
Standard
The infection control nurse is reviewing client room assignments. Which room assignment requires modification? Room Number Patient and Diagnosis: 1. 43-year-old male receiving intravenous antibiotics for Lyme disease - Contact; 2. 17-year-old female receiving antiviral for varicella - Airborne and Contact; 3. 89-year-old male diagnosed with Mumps - Droplet; 4. 33-year-old male newly diagnosed with human immunodeficiency virus (HIV) - Standard
- A. Room 1
- B. Room 2
- C. Room 3
- D. Room 4
Correct Answer: A
Rationale: Lyme disease is not typically transmitted person-to-person and does not require contact precautions; standard precautions are sufficient. Varicella requires airborne and contact precautions, mumps requires droplet precautions, and HIV requires standard precautions, making Room 1's assignment incorrect.
The nurse has attended a staff education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. Placing a client with Cryptococcosis pneumonia on standard precautions.
- B. Wearing a particulate respirator mask (N95) when caring for a client with pharyngeal diphtheria.
- C. Removing alcohol-based hand rubs from a client's room who has mononucleosis.
- D. Placing a client who is incontinent of stool with Hepatitis A on contact precautions.
- E. Instructing a client with latent pulmonary tuberculosis to wear a surgical mask while in the hallway.
Correct Answer: A,D
Rationale: Cryptococcosis requires standard precautions, and Hepatitis A with incontinence requires contact precautions due to fecal-oral transmission. N95 is needed for TB, not diphtheria; hand rubs are safe for mononucleosis; latent TB does not require masking.
The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student
- A. Asks the client to remain sitting upright for at least 30 to 60 minutes after a meal.
- B. Reminds the client to tilt their head backward when eating and drinking.
- C. Avoids mixing foods of different textures in the same mouthful.
- D. Places salt and pepper on the client's food at their request.
Correct Answer: B
Rationale: Tilting the head backward increases aspiration risk. Upright positioning, avoiding mixed textures, and seasoning food are appropriate.