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Question 2221Question →

A registered nurse has completed wound care for a client infected with Vancomycin-resistant Enterococcus (VRE) who also requires droplet precautions for a concurrent influenza infection. The nurse is currently wearing a disposable gown, gloves, a surgical mask, and a face shield. Arrange the steps for safely removing this personal protective equipment (PPE) in the correct chronological order.

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Answer

The correct sequence for doffing PPE is: 1) Remove gloves, 2) Remove face shield or goggles, 3) Remove gown, 4) Remove mask or respirator, 5) Perform hand hygiene.
According to the Centers for Disease Control and Prevention (CDC), the standard doffing sequence is designed to minimize cross-contamination. Gloves are the most contaminated item and must be removed first. Next, eye protection is removed by the clean headbands, followed by the gown. The mask is removed last to ensure the respiratory tract remains protected while the rest of the PPE is doffed. Finally, hand hygiene is mandatory to eliminate any incidental contamination.

Step-by-Step Solution

1
Identify and remove the most contaminated equipment first.
Gloves are removed and discarded.
Prevents the nurse from using heavily contaminated hands to touch other areas of the body or clean PPE ties.
2
Remove eye protection.
The face shield is removed by the clean ear pieces or head band.
Protects the mucous membranes of the eyes and is removed without touching the contaminated front surface.
3
Remove the gown.
The gown is rolled inward into a bundle and discarded.
Rolling the gown inward traps pathogens inside, protecting the nurse's scrub uniform.
4
Remove respiratory protection.
The surgical mask is removed by the ties.
The mask is kept on until the end to maintain respiratory protection while removing other contaminated items.
5
Perform immediate hand hygiene.
Hands are washed or sanitized.
Eliminates any residual contamination that occurred during the doffing procedure.

Key Concept

Standard sequence for removing (doffing) personal protective equipment (PPE)
Question 2222Question →

A registered nurse sustains a percutaneous injury from a contaminated hollow-bore needle immediately after administering an intramuscular medication to a client. Arrange the following actions the nurse must take in the correct priority sequence to minimize injury risk and adhere to evidence-based post-exposure protocols.

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Answer

The correct chronological sequence is to first cleanse the puncture site, then notify the charge nurse for unit coverage, report to occupational health for immediate medical evaluation, ensure the source client is tested, and finally complete the administrative incident report.
Following a percutaneous exposure, immediate physiological safety (cleansing the site) is the highest priority. This is followed by ensuring unit safety (notifying the charge nurse for coverage), obtaining personal medical intervention (occupational health/PEP evaluation), gathering critical risk data (source client testing), and finally completing administrative duties (incident report).

Step-by-Step Solution

1
Cleanse the punctured area immediately with copious amounts of soap and running water.
Decontamination of the immediate puncture wound.
This is the primary physiological intervention to reduce the presence of the pathogen and minimize systemic absorption. The site should not be squeezed or scrubbed vigorously.
2
Notify the charge nurse to report the exposure and secure coverage for the client assignment.
Unit leadership is informed and patient care is safely handed off.
The nurse cannot safely continue providing care or abruptly abandon their patients. Coverage must be secured before the nurse leaves the unit to seek treatment.
3
Report to the occupational health department or emergency department for a risk assessment and post-exposure prophylaxis (PEP) evaluation.
The nurse receives an immediate medical evaluation and baseline serology.
Time is critical. If indicated, HIV post-exposure prophylaxis (PEP) should be administered as soon as possible, ideally within 1 to 2 hours of the exposure.
4
Ensure facility protocols are initiated to obtain informed consent and test the source client for bloodborne pathogens.
The source client's blood is drawn for HIV, Hepatitis B, and Hepatitis C testing.
Identifying the source client's infection status determines the necessity, duration, and type of post-exposure treatment the nurse will require.
5
Complete a formal facility incident report detailing the exact circumstances of the exposure event.
An official administrative record of the workplace injury is created.
Incident reports are required for root cause analysis, facility safety metrics, and workers' compensation, but administrative paperwork must never delay urgent medical care.

Key Concept

Prioritization of occupational exposure management: immediate decontamination, unit safety, urgent medical prophylaxis, risk stratification, and administrative reporting.
Question 2223Question →

A registered nurse (RN) is planning to delegate the application of bilateral antiembolism stockings for a client with congestive heart failure to an unlicensed assistive personnel (UAP). According to the National Council of State Boards of Nursing (NCSBN) delegation process, arrange the RN's actions in the correct chronological order from first to last.

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Answer

The correct sequence follows the NCSBN delegation model: assess the client first, verify delegatee competency, provide specific communication, supervise the task, and finally evaluate the outcomes and provide feedback.
The National Council of State Boards of Nursing (NCSBN) delegation model requires a specific sequence to ensure client safety and safe practice. The RN must first assess and plan (evaluating client stability), then assess the delegatee (verifying competency). This is followed by communication (providing clear instructions), surveillance and supervision (observing the task), and finally evaluation and feedback.

Step-by-Step Solution

1
Assess the client's condition and determine if the task is appropriate for delegation.
The RN establishes that the client is clinically stable.
Client assessment is always the fundamental first step to ensure the 'Right Circumstance' for delegation.
2
Verify the UAP's competency and skills.
The RN confirms the UAP is qualified to apply the stockings.
The RN must ensure the 'Right Person' is selected before assigning the task.
3
Communicate directions clearly.
The UAP understands exactly how to perform the task and what clinical findings to report.
The 'Right Direction/Communication' ensures clear parameters are set before the task begins.
4
Supervise the delegated task.
The RN visually confirms the stockings are placed correctly without wrinkles.
The RN retains accountability and must provide the 'Right Supervision' to maintain client safety.
5
Evaluate the outcome and provide feedback.
The intervention is documented, and the UAP receives professional guidance.
Evaluation completes the delegation process, ensuring therapeutic goals are met and supporting staff development.

Key Concept

NCSBN Delegation Process
Estimated Time:1m 30s
Question 2224Question →

A 65-year-old competent client is recovering on the medical-surgical unit following a biopsy of a suspected malignant mass. The test results confirm terminal cancer. Before the healthcare provider discusses the findings with the client, the client's adult child pulls the nurse aside and states, "In our culture, we do not tell elders when they are dying because it destroys their spirit. Please tell my parent the tumor is benign." Shortly after, the nurse enters the room, and the alert client asks, "Did the results come back? Do I have cancer?"

Which of the following is the most appropriate ethical nursing action?

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Answer: Acknowledge the client's request for information and immediately collaborate with the healthcare provider to facilitate a joint discussion of the results.

Answer

The most appropriate action is to acknowledge the client's request for information and immediately collaborate with the healthcare provider to facilitate a joint discussion of the results.
The ethical principles of autonomy (the client's right to self-determination) and veracity (truth-telling) require that a competent client be informed of their medical status. While the family's cultural concerns should be approached with sensitivity, the competent client's direct question supersedes the family's request to withhold information. The nurse acts as an effective advocate by validating the client's inquiry and immediately collaborating with the healthcare provider. The provider must deliver the primary medical diagnosis, ensuring a coordinated and legally sound disclosure.

Step-by-Step Solution

1
Analyze the ethical conflict between the client's right to know and the family's request to withhold information based on cultural beliefs.
The competent client's right to veracity and autonomy takes precedence over the family's request.
Competent adults have a fundamental legal and ethical right to their own medical information to make informed healthcare decisions.
2
Identify the nurse's scope of practice regarding the disclosure of a new medical diagnosis.
The healthcare provider is responsible for delivering the initial medical diagnosis, while the nurse advocates, clarifies, and provides emotional support.
Delivering a new terminal diagnosis requires comprehensive medical knowledge to immediately address prognosis, pathology, and complex treatment options.
3
Evaluate the options to find the action that upholds the client's rights while maintaining professional boundaries and safe delegation.
Collaborating with the provider to facilitate the discussion is the best evidence-based action.
It ensures the truth is told by the appropriate interdisciplinary team member, rejects inappropriate delegation to unlicensed staff, and avoids non-therapeutic evasion.

Key Concept

Ethical principles of autonomy and veracity in the context of informed consent, interdisciplinary collaboration, and cultural competence.
Question 2225Question →

An emergency department triage nurse is evaluating four newly arrived clients. Arrange the clients in the order they should be triaged for medical evaluation, from highest priority to lowest priority.

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Answer

The correct sequence is: first, the client with stridor and facial swelling; second, the client with crushing chest pain; third, the client with severe flank pain; and finally, the client with chronic heart failure and pedal edema.
The prioritization sequence relies on the ABC (Airway, Breathing, Circulation) framework and the Acute vs. Chronic principle. The client with stridor has an imminent airway obstruction, making them the absolute first priority. The client with crushing chest pain requires immediate cardiac evaluation for a potential myocardial infarction (circulation), making them the second priority. The client with the suspected kidney stone is experiencing severe acute pain but has stable vital functions, placing them third. Finally, the client with chronic heart failure has expected, non-acute symptoms without signs of immediate respiratory distress, making them the lowest priority.

Step-by-Step Solution

1
Evaluate the clients for airway and breathing threats.
The client with stridor and wheezing after an insect sting has an immediate airway threat.
Airway is the first component of the ABC prioritization framework and takes absolute precedence to prevent immediate death.
2
Evaluate the remaining clients for circulation emergencies.
The client with crushing chest pain and diaphoresis has a critical circulation emergency indicating a potential myocardial infarction.
Circulation is the third component of the ABC framework and must be addressed immediately after the airway is secured.
3
Evaluate the remaining clients using the acute versus chronic framework.
The client with severe flank pain has an acute physiological need, whereas the client with heart failure has stable, expected chronic symptoms.
Acute physiological conditions and severe pain take priority over chronic, stable conditions that are not currently life-threatening.

Key Concept

Prioritization Framework: Airway, Breathing, Circulation (ABC) and Acute versus Chronic
Question 2226Question →

A nurse assumes care for a client experiencing acute delirium who continuously attempts to remove their peripheral intravenous (IV) catheter and indwelling urinary catheter. The client is currently alone in the room. Which intervention should the nurse implement first to protect the client from self-injury?

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Answer: Camouflage the catheter tubing under the client's gown and provide an activity apron for their hands.

Answer

The nurse should first camouflage the catheter tubing under the client's gown and provide an activity apron for their hands.
The correct answer represents the least restrictive alternative. By hiding the tubes from the client's view and providing a tactile distraction (the activity apron), the nurse addresses the behavior caused by delirium without infringing on the client's mobility or rights. This must always be the first step in the hierarchy of safety interventions.

Step-by-Step Solution

1
Assess the client's immediate safety risk.
The client is at risk for self-injury by removing necessary medical devices due to delirium.
Identifying the specific safety threat is necessary to determine the appropriate intervention.
2
Determine the least restrictive intervention available.
Concealing the tubes out of the client's line of sight and providing a safe physical distraction are the least restrictive options.
Nursing standards mandate that least restrictive alternatives must be attempted and documented before escalating to physical or chemical restraints.

Key Concept

Accident, Error, and Injury Prevention: Restraint Alternatives
Question 2227Question →

An oncology unit nurse is initiating care for a client undergoing induction chemotherapy for acute myeloid leukemia. The client has just developed a painful, newly erupted vesicular rash that is strictly localized to the right thoracic dermatome. Which infection control measures must the nurse implement? Select all that apply.

Select all that apply

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Answer: Place the client in a private room with monitored negative air pressure.; Don a fit-tested N95 respirator, disposable gown, and clean gloves prior to room entry.; Apply a standard surgical mask to the client if transport to the radiology department is required.

Answer

The correct measures are placing the client in a negative-pressure room, donning an N95 respirator with a gown and gloves before entry, and placing a surgical mask on the client during transport.
The correct choices accurately reflect the required Airborne and Contact precautions. Although the client has a localized rash (shingles), their severely immunocompromised state (undergoing induction chemotherapy) places them at a high risk for disseminated disease. Therefore, strict Airborne and Contact precautions are mandatory. This includes placing the client in a negative-pressure isolation room, donning an N95 respirator along with a gown and gloves for all room entries, and placing a standard surgical mask on the client to contain secretions during any essential transport outside the room.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client presents with a localized vesicular rash along a dermatome, which is the classic presentation of herpes zoster (shingles).
Identifying the infectious agent is the first step in determining the correct isolation category.
2
Evaluate the client's current immune status.
The client is undergoing induction chemotherapy for acute leukemia, indicating severe immunosuppression.
Immune status directly alters the standard infection control guidelines for certain pathogens.
3
Determine the appropriate transmission-based precautions based on the findings.
Because the client is immunocompromised, localized herpes zoster is treated as a high risk for dissemination. Therefore, strict Airborne and Contact precautions must be implemented until the lesions are fully crusted.
Applying the specific exception to the general rule ensures clinical safety and prevents healthcare-associated transmission.

Key Concept

While localized herpes zoster in an immunocompetent client requires only standard precautions (with lesions covered), an immunocompromised client with localized herpes zoster requires strict Airborne and Contact precautions due to the high risk of viral dissemination.
Question 2228Question →

A registered nurse is preparing a client for a scheduled surgical procedure. The healthcare provider has just left the room after explaining the surgery. As the nurse presents the consent form, the client states, 'I am still not sure I understand what the risks are.' In what order should the nurse perform the following actions to protect the client's legal right to informed consent? Arrange the actions from first to last.

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Answer

The nurse must first assess the specific knowledge deficit, contact the healthcare provider to explain the risks, wait for the provider to clarify the information, witness the consent signature once the client is informed, and finally document the entire process.
The correct sequence ensures that the client's legal rights are protected while keeping the nurse within their scope of practice. Assessment comes first to understand the gap in knowledge. Because the provider is legally responsible for explaining surgical risks, the nurse must contact them and wait for their clarification. Witnessing the signature can only happen after the client is fully informed. Documentation occurs last as a record of the completed legal process.

Step-by-Step Solution

1
Assess the exact nature of the client's knowledge deficit.
The nurse identifies what specific information the client is missing regarding the surgery.
Assessment guides the subsequent nursing actions and provides specific information to relay to the provider.
2
Notify the healthcare provider of the client's statement.
The provider is made aware that the legal requirement for informed consent has not yet been met.
It is outside the nurse's legal scope of practice to be the primary person explaining surgical risks; this is the provider's legal duty.
3
Allow the provider to clarify the risks directly with the client.
The client receives the necessary medical information to make an informed decision.
Direct communication between the provider and client ensures accurate disclosure of medical risks and alternatives.
4
Witness the client signing the informed consent document.
The consent form is legally executed.
The nurse's signature validates that the client is the person signing, is doing so voluntarily, and appears competent to give consent.
5
Document the events in the medical record.
A permanent legal record of the consent process is established.
Documentation protects the client's legal rights and provides evidence that the nurse and provider adhered to legal standards.

Key Concept

Informed Consent and Scope of Practice
Question 2229Question →

During a morning shift on a pulmonary care unit, a registered nurse (RN) is dividing client care tasks among a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the following tasks should the RN assign to the LPN/VN?

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Answer: Administering scheduled oral and inhaled bronchodilators to a clinically stable client with chronic obstructive pulmonary disease (COPD)

Answer

The task involving the administration of scheduled oral and inhaled bronchodilators to a clinically stable client with COPD.
The correct answer involves administering scheduled oral and inhaled bronchodilators to a clinically stable client with COPD. LPN/VNs are trained and licensed to administer routine, non-intravenous medications to clients who have chronic, stable conditions with predictable outcomes.

Step-by-Step Solution

1
Analyze each proposed task against the NCSBN delegation model and the specific scope of practice for an LPN/VN.
Identify that the LPN/VN can safely perform routine medication administration for stable clients, but cannot perform initial assessments, initial teaching, or evaluation of unstable clients.
Safe delegation requires ensuring the right task is assigned to the right person based on their educational preparation and legal scope of practice.
2
Evaluate the clinical acuity of each client described in the options.
The client with chronic COPD is clinically stable, making routine medication administration safe and appropriate for the LPN/VN. The other clients are unstable, newly admitted, or require new comprehensive education.
The RN must retain care for unstable clients and tasks requiring advanced clinical judgment, delegating only predictable and stable tasks.

Key Concept

Delegation of tasks to LPN/VN based on scope of practice
Question 2230Question →

A registered nurse is responding to a request from a law enforcement officer who has arrived at the unit seeking a client's medical records related to a recent mandatory abuse report. Arrange the following actions in the correct chronological order to ensure compliance with HIPAA regulations and information security protocols.

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Answer

The correct sequence for disclosing Protected Health Information (PHI) to law enforcement is: verifying the officer's credentials, validating the legal mandate, extracting only the minimum necessary information, providing the documents in a secure setting, and finally documenting the disclosure in the audit log.
When an external entity requests Protected Health Information (PHI) without patient authorization, the nurse must follow a strict security protocol. First, identity and legal authority must be established to prevent fraudulent access. Next, the 'minimum necessary' principle is applied to limit the scope of the disclosure. The physical transfer must be secured to prevent incidental breaches, and finally, a formal accounting of the disclosure must be logged to maintain an accurate audit trail as required by federal regulations.

Step-by-Step Solution

1
Verify identity and credentials.
The requester is authenticated as a legitimate law enforcement officer.
Prevents unauthorized individuals from fraudulently obtaining sensitive medical records.
2
Validate legal authority.
The legal basis for bypassing standard HIPAA authorization is confirmed.
Ensures the facility is legally protected and required to release the information under mandatory reporting rules or judicial orders.
3
Extract minimum necessary PHI.
Only legally required data is compiled from the chart.
HIPAA strictly prohibits releasing a complete medical record if only specific details are mandated by the warrant or reporting law.
4
Provide documents securely.
Information changes hands without public exposure.
Maintains physical information security and prevents incidental disclosures to others on the unit.
5
Document in the disclosure log.
An official audit trail of the release is created.
Maintains compliance with HIPAA's accounting of disclosures requirement for unconsented PHI releases.

Key Concept

HIPAA Exceptions and Secure Information Disclosure Workflows
Question 2231Question →

A pediatric nurse is coordinating the interdisciplinary care plan for a 4-year-old client with autism spectrum disorder who is hospitalized for an acute asthma exacerbation. The client currently exhibits mild expiratory wheezing. The parents express feeling profoundly overwhelmed by the new home nebulizer regimen. Additionally, they report the child has been losing weight at home due to frequently dropping utensils and refusing to eat foods with mixed textures. Which action by the nurse demonstrates appropriate interdisciplinary collaboration and care management?

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Answer: Request an occupational therapy consultation to evaluate the child's fine motor skills for utensil use and provide interventions for the sensory-based food aversions.

Answer

Request an occupational therapy consultation to evaluate the child's fine motor skills for utensil use and provide interventions for the sensory-based food aversions.
Occupational therapists specialize in promoting independence with activities of daily living (ADLs). Their scope of practice specifically includes evaluating and treating fine motor deficits (such as difficulty grasping utensils) and implementing sensory integration strategies for clients with autism spectrum disorder who experience aversions to food textures. Collaborating with occupational therapy directly addresses the root causes of the child's weight loss in this scenario.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the parents' reported concerns.
The client has respiratory needs (wheezing, new nebulizer regimen) and developmental/nutritional needs (dropping utensils, sensory food aversions, weight loss).
Identifying all active physiological and psychosocial issues is the first step in care coordination.
2
Evaluate the proposed interdisciplinary actions against the principles of prioritization and delegation.
Airway needs (wheezing) must be prioritized over psychosocial needs. Assessments and teaching cannot be delegated to UAPs.
Safe nursing practice requires adherence to the ABCs and legal delegation guidelines.
3
Differentiate between the scopes of practice for allied health professionals regarding the child's feeding difficulties.
Occupational therapy addresses fine motor deficits (utensil use) and sensory processing aversions.
Appropriate interdisciplinary collaboration requires matching the client's specific deficit to the correct specialist's scope of practice.

Key Concept

Collaboration with Interdisciplinary Team
Question 2232Question →

A registered nurse (RN) is coordinating care on a cardiovascular step-down unit with the assistance of an unlicensed assistive personnel (UAP). Which clinical task is most appropriate for the RN to delegate to the UAP?

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Answer: Emptying the urinary catheter drainage bag and recording the output for a client receiving a continuous intravenous infusion of furosemide.

Answer

Emptying the urinary catheter drainage bag and recording the output for a client receiving a continuous intravenous infusion of furosemide.
The scope of practice for an unlicensed assistive personnel (UAP) includes routine, standard procedures such as obtaining vital signs, assisting with activities of daily living (ADLs), and measuring intake and output. For a client receiving continuous intravenous diuretics, emptying the urinary catheter bag and recording the volume is a standard data collection task that does not require clinical judgment. The RN safely delegates this physical task while retaining the responsibility of evaluating the total fluid balance and interpreting the client's physiological response to the medication.

Step-by-Step Solution

1
Analyze the client's condition and the nature of the task in each option.
Identify whether the task involves assessment, clinical judgment, teaching, or evaluation (which cannot be delegated).
The National Council of State Boards of Nursing (NCSBN) guidelines prohibit delegating nursing judgment or complex assessments to a UAP.
2
Evaluate the clinical stability of each client.
The clients in three of the scenarios have unstable conditions or are experiencing acute changes (recent angina, new chest tube, initial post-procedure ambulation).
Safe delegation to a UAP requires the client to be medically stable with predictable outcomes.
3
Select the task that falls strictly within the routine scope of practice for a UAP.
Emptying a urinary drainage bag and recording the volume is identified as the appropriate task.
While the client is receiving continuous IV diuretics, the physical act of measuring and recording the output does not require clinical judgment. The RN retains the responsibility for interpreting the fluid balance data.

Key Concept

Delegation of routine data collection to Unlicensed Assistive Personnel (UAP)
Question 2233Question →

Correlate each distinct clinical presentation with the most appropriate and comprehensive infection control protocol required to ensure staff and patient safety.

Click a left item, then click its matching right item

Items

Unvaccinated pediatric patient exhibiting coryza, conjunctivitis, and small white papules on the buccal mucosa.
Adult currently receiving chemotherapy who develops a unilateral, painful vesicular eruption across the right thoracic region.
Patient with suspected Neisseria meningitidis who is actively undergoing an aerosol-generating procedure (e.g., endotracheal intubation).
Elderly resident with frequent, uncontained watery stools requiring physical care, with pending tests for a spore-forming enteric pathogen.

Matches

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Answer

Match the measles presentation to the airborne protocol (N95 and negative pressure); the immunocompromised patient with zoster to combined airborne and contact precautions; the meningitis patient undergoing intubation to upgraded respiratory protection (N95); and the spore-forming pathogen presentation to contact precautions with soap and water hygiene.
Each protocol explicitly mitigates the transmission risks associated with its paired clinical presentation: airborne precautions for the classic signs of measles; combined airborne and contact protocols for zoster in an immunocompromised host due to the risk of dissemination; upgraded respiratory protection for droplet pathogens during high-risk aerosol-generating interventions; and contact precautions with rigorous soap-and-water hygiene to physically remove enteric spores.

Step-by-Step Solution

1
Analyze the first clinical presentation to identify the pathogen and its specific mode of transmission.
Coryza, conjunctivitis, and buccal mucosal papules (Koplik spots) indicate measles (rubeola), transmitted via airborne droplet nuclei.
Identifying the highly contagious airborne disease allows for the selection of the corresponding airborne precaution protocol.
2
Evaluate the second presentation, specifically noting the patient's immune status and dermatologic findings.
The patient has localized herpes zoster, but is actively receiving chemotherapy and is thus immunocompromised.
Immunocompromised patients with localized zoster are at a significantly higher risk for disseminated disease, mandating both airborne and contact precautions rather than standard precautions.
3
Assess the third presentation involving a droplet-transmitted pathogen combined with a high-risk medical intervention.
Neisseria meningitidis requires droplet precautions, but endotracheal intubation is an aerosol-generating procedure.
Aerosol-generating procedures convert larger droplets into smaller airborne aerosols, necessitating a temporary upgrade to airborne-level respiratory protection (N95) to protect staff.
4
Determine the appropriate precautions for the fourth presentation involving an uncontained, specific type of enteric pathogen.
The patient has uncontained diarrhea from a suspected spore-forming pathogen, indicative of Clostridioides difficile.
Spore-forming bacteria require strict contact precautions and specifically necessitate soap and water for hand hygiene, as alcohol-based hand sanitizers are not sporicidal.

Key Concept

Advanced application of transmission-based precautions, focusing on immunocompromised states, aerosol-generating procedures, and spore-forming pathogens.
Question 2234Question →

A nurse is admitting a client who has a high risk for falls due to frequent episodes of orthostatic hypotension. Which of the following safety measures should the nurse implement? Select all that apply.

Select all that apply

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Answer: Place the client's bed in the lowest position.; Ensure the client's call light is placed within reach.; Instruct the client to rise slowly from a lying to a sitting position.

Answer

The correct safety measures are placing the bed in the lowest position, ensuring the call light is within reach, and instructing the client to rise slowly.
Standard safety precautions for fall prevention require keeping the bed in the lowest position and ensuring the call light is within easy reach so the client can request help. Furthermore, for a client with orthostatic hypotension, providing instructions to rise slowly is a critical targeted intervention that allows blood pressure to stabilize, preventing dizziness and subsequent falls.

Step-by-Step Solution

1
Identify the client's primary safety risk factor.
The client has a high risk for falls specifically related to orthostatic hypotension.
Understanding the specific cause of the fall risk ensures interventions are targeted and appropriate.
2
Select interventions that create a safe environment and directly address position changes.
Lowering the bed, providing the call light, and teaching the client to change positions slowly are identified as appropriate actions.
These are standard, evidence-based nursing interventions that protect the client while directly addressing the physiological issue of orthostatic hypotension.
3
Exclude inappropriate, unsafe, or out-of-scope interventions.
Using smooth-soled slippers, raising four side rails, and delegating the initial assessment are excluded.
These actions either increase injury risk, represent inappropriate use of restraints, or violate delegation guidelines.

Key Concept

Fall Prevention and Safety Precautions
Question 2235Question →

A charge nurse is reviewing infection control protocols with a group of newly hired nurses on a medical-surgical unit. Match each client clinical scenario with the most appropriate infection control precaution, personal protective equipment (PPE) requirement, or room assignment.

Click a left item, then click its matching right item

Items

A client with disseminated herpes zoster and weeping vesicular lesions.
A client with active Clostridioides difficile experiencing frequent, uncontained diarrhea.
A client with suspected Haemophilus influenzae type b (Hib) epiglottitis, admitted 6 hours ago.
A client with confirmed pulmonary tuberculosis being transported out of the room for a stat CT scan.

Matches

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Answer

The correct matching pairs each clinical scenario with its precise transmission-based precaution, considering high-acuity nuances like combined airborne and contact precautions for disseminated viral infections, specific soap-and-water hand hygiene for spores, and proper source control during patient transport.
Each clinical scenario corresponds to a highly specific infection control requirement based on the pathogen's mode of transmission, physical characteristics (e.g., spore formation), or current clinical phase (e.g., active transport out of the unit).

Step-by-Step Solution

1
Analyze the transmission route for disseminated herpes zoster.
Identify that the virus can spread via aerosols and direct contact.
Unlike localized zoster in a healthy adult (which requires only standard/contact precautions), disseminated zoster requires strict Airborne and Contact isolation.
2
Determine the specific pathogen characteristics of Clostridioides difficile.
Identify the need for enteric contact precautions.
C. difficile spores are highly resistant to alcohol; therefore, friction with soap and water is required to physically remove them from the healthcare worker's hands.
3
Evaluate the transmission route and timeframe for Haemophilus influenzae epiglottitis.
Identify the need for Droplet precautions.
Hib is transmitted via large respiratory droplets. Because the client is still well within the 24-hour window of initiating targeted antibiotics, droplet precautions remain active.
4
Assess the protocol for transporting a client on airborne precautions (Tuberculosis).
Identify that the client must wear a surgical mask.
The client wearing a standard surgical mask acts as source control, containing infectious respiratory droplets and allowing staff to use standard precautions while in the hallways.

Key Concept

Standard and Transmission-Based Precautions
Question 2236Question →

While managing client assignments on an orthopedic surgical unit, a team leader must distribute care tasks between the registered nurse (RN) and the unlicensed assistive personnel (UAP). Which specific interventions can safely be delegated to the UAP? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Obtaining routine morning vital signs for a clinically stable client awaiting a scheduled arthroscopy; Helping a client who had a lumbar laminectomy to log-roll when turning in bed; Emptying a bedside commode and recording the output volume for a client with restricted mobility

Answer

The tasks that can be safely delegated include obtaining routine morning vital signs for a stable client, helping a client log-roll in bed, and emptying a bedside commode to record output volume.
The correct selections represent tasks that involve routine care, activities of daily living, and basic data collection on stable clients. These tasks follow predictable steps, carry minimal risk, and do not require clinical decision-making or nursing judgment, making them appropriate and safe to delegate to a UAP.

Step-by-Step Solution

1
Analyze the scope of practice for Unlicensed Assistive Personnel (UAP).
Identify that UAPs can perform standard, unchanging procedures that do not require clinical judgment, such as activities of daily living (ADLs), routine vital signs, and measuring intake and output.
Understanding the limits of the UAP's role is necessary to ensure safe delegation.
2
Apply the principles of safe delegation (avoiding EAT).
Determine that the RN must retain tasks involving Evaluation, Assessment, and Teaching (EAT), as well as any task requiring clinical judgment.
These core nursing responsibilities cannot be safely or legally delegated to unlicensed personnel.
3
Evaluate each task against the delegation criteria.
Vital signs, log-rolling, and measuring output are routine tasks for stable clients. Evaluating pain medication, teaching about compartment syndrome, and assessing a wound require nursing judgment.
This process isolates the safe, delegable tasks from the nursing-only responsibilities.

Key Concept

Delegation of care to Unlicensed Assistive Personnel (UAP)
Question 2237Question →

A client receiving intravenous (IV) antibiotics on a general medical unit repeatedly touches and attempts to pull at the IV insertion site. Which action should the nurse implement first to protect the IV line?

Show answer & explanation

Answer: Cover the IV insertion site with a breathable, flexible sleeve to conceal it from view.

Answer

Cover the IV insertion site with a breathable, flexible sleeve to conceal it from view.
Covering the IV site with a sleeve or bandage is a safe, non-restrictive alternative to physical restraints. It relies on the principle of 'out of sight, out of mind,' which is frequently effective in preventing clients from picking at medical devices while fully maintaining their freedom of movement.

Step-by-Step Solution

1
Identify the primary clinical problem.
The client is at risk of dislodging their IV catheter, requiring an intervention to maintain the medical device.
Establishing the problem guides the selection of appropriate safety measures.
2
Recall the legal and ethical principles regarding restraint use.
Nurses must always employ the principle of least restrictive intervention, exhausting and documenting alternative measures before using physical restraints.
Restraints carry significant physical and psychological risks and are legally restricted to being a measure of absolute last resort.
3
Evaluate the available interventions against the least restrictive principle.
Concealing the IV line is a non-restrictive alternative. Restraining the client, delegating assessment to a UAP, and threatening the client are unsafe, illegal, or unethical actions.
Selecting the non-restrictive option ensures client safety while complying with healthcare regulations and standards of care.

Key Concept

Restraint Alternatives and Least Restrictive Environment
Question 2238Question →

A nurse has completed wound care for a client isolated on Airborne and Contact precautions due to active pulmonary tuberculosis and a Clostridioides difficile infection. The nurse is currently wearing an N95 respirator, a face shield, a disposable gown, and gloves. The gown and gloves are visibly soiled. Arrange the following actions for doffing personal protective equipment (PPE) and exiting the area in the correct chronological order.

Drag items to arrange them in the correct order

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Answer

The correct sequence is: remove gloves, remove face shield, remove gown, exit the room, remove N95 respirator, and wash hands with soap and water.
The CDC guidelines dictate that PPE should be removed in an order that minimizes the risk of self-contamination. Gloves are the most contaminated and are removed first. The face shield is removed next by the clean headband, followed by the gown, which is rolled inside out. Because the patient requires Airborne precautions for tuberculosis, the nurse must leave the negative-pressure room and close the door before removing the N95 respirator. Finally, because the patient has C. difficile, hand hygiene must be performed using soap and water rather than alcohol-based hand rub.

Step-by-Step Solution

1
Remove gloves
Hands are freed from the most heavily contaminated PPE.
Gloves touch the client and environment most directly; removing them first prevents cross-contamination to the head and neck area.
2
Remove face shield
Face shield is discarded without contaminating the hands.
The headband is considered clean, allowing removal without transferring pathogens to the nurse's hands.
3
Remove gown
Gown is safely bundled and discarded.
Rolling the gown inside out contains the gross contamination (such as C. difficile spores) present on the exterior.
4
Exit the isolation room
Nurse is in a clean area (anteroom or hallway) with the door closed.
The N95 respirator must remain on while inside the room to protect against aerosolized Mycobacterium tuberculosis.
5
Remove N95 respirator
Respirator is discarded safely outside the patient environment.
Handling only the straps prevents contamination of the hands from the potentially pathogen-laden filter.
6
Wash hands with soap and water
Hands are thoroughly decontaminated.
C. difficile forms spores that are resistant to alcohol-based hand rubs; mechanical friction with soap and water is required.

Key Concept

Standard and Transmission-Based Precautions: PPE Doffing Sequence
Question 2239Question →

A clinical nursing supervisor is conducting safety rounds on an intensive care unit. Each of the following actions observed by the supervisor represents a protocol violation. Which observation requires the MOST immediate intervention to prevent severe client injury?

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Answer: Disabling the high-pressure limit alarm on a mechanical ventilator to stop it from repeatedly sounding.

Answer

The correct observation requiring immediate intervention is disabling the high-pressure limit alarm on a mechanical ventilator.
Disabling critical equipment alarms, such as a ventilator's high-pressure limit, removes the nurse's ability to detect life-threatening airway obstructions (e.g., mucus plugs, pneumothorax, or kinked tubing). According to the ABCs (Airway, Breathing, Circulation) framework, addressing an immediate threat to the airway and breathing is always the highest priority to prevent severe client injury or death. Alarm fatigue is a major cause of preventable hospital mortality.

Step-by-Step Solution

1
Analyze the scenario requirements.
The question requires prioritizing among four different clinical safety violations to determine which poses the most immediate risk of severe injury or death.
Prioritization questions demand identifying the 'worst-case scenario' that will cause harm the fastest if not immediately corrected.
2
Evaluate the clinical impact of each observed action.
The options present a restraint protocol violation, an equipment alarm safety breach, a delegation error, and an isolation precaution error.
Understanding the specific nature of each error is necessary to rank their severity.
3
Apply a prioritization framework (ABCs).
Disabling the ventilator alarm directly compromises Airway and Breathing. The other violations relate to legal guidelines, RN scope of practice, and infection transmission.
The ABCs (Airway, Breathing, Circulation) dictate that unmonitored airway threats take precedence over all other risks.
4
Determine the highest priority.
Intervening to reactivate the ventilator alarm and assess the cause of the high pressure is the highest priority.
Failure to rescue a client from an airway obstruction leads to imminent hypoxia and cardiac arrest.

Key Concept

Prioritization of Safety Hazards and Equipment Alarms
Estimated Time:2m 0s
Question 2240Question →

A nurse hears a loud thud and rushes into the room of a client receiving a continuous intravenous heparin infusion for a pulmonary embolism. The nurse finds the client lying on the floor, confused, attempting to stand, and bleeding profusely from a laceration on the temporal area of the head. Arrange the following nursing actions in the priority order they should be performed.

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Answer

The correct sequence is: Instruct the client to remain still, call for assistance, apply direct pressure to the wound, delegate pausing the heparin, perform a neurological assessment, and finally notify the healthcare provider.
In emergency scenarios involving falls and trauma, the nurse must prioritize immediate threats to life based on safety principles and the ABCs (Airway, Breathing, Circulation). The very first priority is to stop the client from standing to prevent a secondary fall or spinal injury. The nurse must then immediately call for help, as managing a bleeding, confused client requires multiple personnel. Next, the nurse addresses the severe circulatory threat by applying direct pressure to the wound, which is critically urgent given the continuous heparin infusion. Once help arrives, the nurse delegates stopping the heparin to prevent further hemorrhagic complications. Only after these immediate physical and circulatory threats are stabilized should the nurse conduct a thorough neurological assessment. Finally, the healthcare provider is contacted with a complete clinical picture to obtain emergency orders, such as a STAT CT scan.

Step-by-Step Solution

1
Ensure immediate physical safety
Client remains flat on the floor
Prevents secondary traumatic injury from a subsequent fall.
2
Secure emergency resources
Additional nursing staff arrives
Team assistance is required to manage a bleeding, confused patient without abandoning them.
3
Control hemorrhage
Direct pressure applied to the temporal laceration
Active bleeding on systemic heparin is a life-threatening circulation compromise that supersedes immediate assessment.
4
Mitigate pharmacological risk
Heparin infusion is paused
Prevents exacerbation of intracranial or external hemorrhage.
5
Evaluate neurological status
Glasgow Coma Scale and pupillary response documented
Establishes a baseline post-trauma to detect signs of intracranial bleeding.
6
Facilitate medical intervention
Healthcare provider notified with complete SBAR
Allows for emergency orders such as a STAT head CT scan and potential administration of reversal agents.

Key Concept

Emergency prioritization and injury prevention for falls in clients receiving systemic anticoagulation.
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