A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)
Planning and evaluating control and prevention strategies
Determining public health priorities
Ensuring proper medical treatment
Identifying endemic disease
Monitoring for common-source outbreaks
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.)
Place the client in a room that has negative air pressure of at least six exchanges per hour.
Wear a mask when providing care within 3 ft of the client.
Place a surgical mask on the client if transportation to another department is unavoidable.
Use sterile gloves when handling soiled linens.
Wear a gown when performing care that may result in contamination from secretions.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect?
Allergic reaction
Ringworm
Systemic lupus erythematosus
Herpes zoster
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
Prodromal
Incubation
Convalescence
Illness
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.)
Fever
Malaise
Edema
Pain or Tenderness
Increase in pules and respiratory rate
A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.)
Place a belt restraint on the client when he is sitting on the bedside commode.
Keep the bed in low position with full side rails up.
Ensure that the client’s call light is within reach.
Provide the client with nonskid footwear.
Complete a fall-risk assessment.
A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction?
“I will place the client on his side.”
“I will go to the nurses’ station for assistance.”
“I will administer medications as prescribed.”
“I will be prepared to insert an airway.”
A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse?
Extinguish the fire.
Pull the fire alarm.
Evacuate the clients.
Close all open doors on the unit.
A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse’s knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses’ station?
A 43-year-old client who is postoperative following a laparoscopic cholecystectomy
A 61-year-old client being admitted for telemetry to rule out a myocardial infarction
A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle
A 79-year-old client who is postoperative following a below-the-knee amputation
A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse?
Educate the client and family on fall risks.
Complete a physical assessment.
Survey the client’s belongings.
RACE is an mnemonic for remembering fire safety. In this mnemonic, "E" stands for
Escape
Exit
Extinguish
Evade
While on shift one day, one of your patients has a grand mal seizure. Which of the following practices should you avoid?
Protect the patient's head
Inspect environment for items that may cause injury
Administer medications
Restrain patient to avoid self-injury
How often does the healthcare provider need to re-order restraints if they are needed for an extended period of time?
Every 4 hours
Every hour
Every 2 hours
Every 8 hours
When a nurse has a patient in restraints, they need to be evaluating the safety devices and the patient's skin integrity every ____ minutes and removing the safety devices every ____ hour(s) to permit muscle exercise and to promote circulation.
30; 2
45; 4
15; 1
20; 3
