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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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When an infant car seat is properly installed, the infant should face
- A. forward, so child may look out window
- B. backward, so child faces the seat
- C. the side window, to increase urinary stimulation
- D. upward, as child lies on back with seat installed sideways
Correct Answer: B
Rationale: Infants should be positioned reclining and facing the rear until their leg muscles are strong enough to kick away from the backseat (about 10-12 months-old) for the greatest protection.
The experienced nurse is observing the new nurse providing care to the hospitalized cheat. Which action requires the experienced nurse to intervene to ensure client safety?
- A. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep
- B. Checks the client's room number and name on the name band to verify client identity prior to giving a medication
- C. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia
- D. Delays the HCP from performing a thoracentesis by calling "a timeout" to verify the client's identity, consent, procedure, and site
Correct Answer: B
Rationale: Room number is not a unique client identifier. The nurse should use two unique identifiers, such as the client's name and medical record number, to verify identity before medication administration.
The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Test blood sugar every 2 hours by Accu-Check
- B. Review with family and client signs of hyperglycemia
- C. Monitor for mental status changes
- D. Check skin condition of lower extremities
Correct Answer: A
Rationale: The UAP can do standard, unchanging procedures. Testing blood sugar with an Accu-Check is a routine task that does not require clinical judgment, making it appropriate for delegation to a UAP.
A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?
- A. Her pregnancy is threatened, and the fetus is at risk for teratogenesis.
- B. She has a reportable condition, and the pregnancy must be terminated.
- C. Accutane is a Category D drug, which means it is unsafe in pregnancy.
- D. Her pregnancy must be followed carefully by a genetic specialist.
Correct Answer: A
Rationale: Accutane is a Category X drug, which means pregnancy is contraindicated due to teratogenesis associated with the medication.
After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.