Nokea
The nurse recognizes which of the following is considered an external disaster?
- A. Computer system failure
- B. A walkout and strike by nursing staff
- C. Mass shooting at a nearby park
- D. Chemical leak in the critical care units
Correct Answer: C
Rationale: A mass shooting at a nearby park is an external disaster, as it occurs outside the facility and impacts hospital operations. The others are internal disasters.
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The nurse conducts safety rounds within the nursing unit. Which observation requires followup? Select all that apply.
- A. The client's armband was affixed to the bedside table.
- B. The client's telephone number and name were used as identifiers.
- C. Multiple blood specimen tubes are labeled before specimen collection.
- D. A room number is used as an identifier during medication administration.
- E. Verifies client's name, date of birth, consent, site, and procedure during a time out process.
Correct Answer: A,B,C,D
Rationale: Armbands on tables, using telephone numbers, pre-labeling tubes, and room numbers as identifiers risk errors. Verifying name, date of birth, and procedure details is correct.
The nurse is discussing infection control practices in the nursing unit. Which client requires droplet precautions? A client with Select all that apply.
- A. Diagnosed with rubella.
- B. A new diagnosis of pharyngeal diphtheria.
- C. Receiving chemotherapy via an implanted port.
- D. Pulmonary tuberculosis receiving nebulizer treatments.
- E. A skin abscess that tested positive for Klebsiella.
Correct Answer: A,B
Rationale: Rubella and pharyngeal diphtheria require droplet precautions due to respiratory transmission. TB requires airborne, chemotherapy does not require isolation, and Klebsiella abscess requires contact precautions.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply.
- A. Use smoke detectors instead of carbon monoxide detectors
- B. Teach your child what the smoke detector sounds like and what to do when one is heard
- C. Teach children how to light a candle in the event of power failure
- D. Practice escaping from your home at least twice a year
- E. Ensure that electrical wiring is under rugs, not above them
- F. If a house fire occurs, call emergency services before evacuating
Correct Answer: B,D
Rationale: Teaching children about smoke detector sounds and escape actions, and practicing escape plans twice yearly, enhance fire safety. Both types of detectors are needed, candles pose risks, wiring under rugs is hazardous, and evacuation precedes calling services.
The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.