Chapter 5: Safety and Infection Control

Question 1

In which order will the nurse take these actions before doing wound irrigation and a dressing change for a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA)?

1. Don gloves.
2. Put on gown.
3. Perform hand hygiene.
4. Place goggles over eyes.
5. Put on mask to cover nose and mouth.

Answer 1

Ans: 3, 2, 5, 4, 1
Centers for Disease Control and Prevention guidelines recommend initially hand hygiene and then donning of gown, mask, goggles, and finally gloves to protect staff members and limit the spread of contamination. Goggles and a mask (or use of a face shield) will be needed with this dressing change because of the possibility of splashing during wound irrigation. Focus: Prioritization.

Question 2

A client who has had recent exposure to Ebola while traveling in Africa arrives in the emergency department with fever, headache, vomiting, and multiple ecchymoses. Which action should the nurse take first?

1. Place the client in a private room.
2. Obtain heart rate and blood pressure.
3. Notify the hospital infection control nurse.
4. Ask the client to describe type of Ebola exposure.

Answer 2

Ans: 1
Centers for Disease Control and Prevention guidelines recommend that the initial action be to place the client in a private room and implement standard, contact, and droplet precautions. Further assessment of the type of possible Ebola exposure, obtaining vital signs, and notification of the infection control nurse will also be needed but should be done after measures to minimize transmission of Ebola are implemented. Focus: Prioritization; Test Taking Tip: When caring for a client with a communicable disease, consider that prevention of disease transmission to other clients, staff, and visitors is usually the highest priority, even when the client is critically ill and needs rapid implementation of other actions.

Question 3

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first?

1. Give acetaminophen 650 mg PO.
2. Administer ondansetron 4 mg IV.
3. Infuse normal saline at 500 mL/hr.
4. Increase oxygen flow rate to 6 L/min.

Answer 3

Ans: 3
Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been demonstrated to improve outcomes, the nurse’s first action will be to infuse normal saline. Treatment of nausea and headache are appropriate and should be implemented next. There is no indication that this client is hypoxemic, although clients with Ebola may develop multiorgan failure and require respiratory support. Focus: Prioritization.

Question 4

The nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza (“bird flu”). Which of these prescribed actions will the nurse implement first?

1. Start oxygen using a nonrebreather mask.
2. Infuse 5% dextrose in water at 100 mL/hr.
3. Administer the first dose of oral oseltamivir.
4. Obtain blood and sputum specimens for testing.

Answer 4

Ans: 1
Because the respiratory manifestations associated with avian influenza are potentially life threatening, the nurse’s initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client’s respiratory problems. Focus: Prioritization.

Question 5

The nurse is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will the nurse perform the following actions?

1. Remove N95 respirator.
2. Take off goggles.
3. Remove gloves.
4. Take off gown.
5. Perform hand hygiene.

Answer 5

Ans: 3, 2, 4, 1, 5
This sequence will prevent contact of the contaminated gloves and gown with areas (e.g., the hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to the nurse and to other clients. If the nurse is wearing a disposable gown, the gown and gloves can be removed simultaneously by grasping the front of the gown and breaking the ties and then peeling the gloves off while removing the gown. The correct method for donning and removal of PPE has been standardized by agencies such as the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration. Focus: Prioritization.

Question 6

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the client? Select all that apply.

1. Surgical face mask 2. N95 respirator
2. Gown
3. Gloves
4. Goggles
5. Shoe covers

Answer 6

Ans: 2, 3, 4
Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and do not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions. Focus: Prioritization

Question 7

Four clients arrive simultaneously at the emergency department. Which client requires the most rapid action by the triage nurse to protect other clients from infection?

1. A 3-year-old client who has paroxysmal coughing and whose sibling has pertussis
2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection
3. A 62-year-old client who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection
4. A 74-year-old client who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

Answer 7

Ans: 2
Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the emergency department. The child with the rash should be quickly isolated from the other clients through placement in a negative-pressure room. Droplet or contact precautions (or both) should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization.

Question 8

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection?

1. Client with an implanted port in the right subclavian vein
2. Client who has a midline IV catheter in the left antecubital fossa
3. Client who has a nontunneled central line in the left internal jugular vein
4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

Answer 8

Ans: 3
According to Centers for Disease Control and Prevention guidelines, several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection. Focus: Prioritization.

Question 9

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN?

1. Planning ways to improve the client’s oral protein intake 2. Teaching the client about home care of the leg ulcer
2. Obtaining wound cultures during dressing changes
3. Assessing the risk for further skin breakdown

Answer 9

Ans: 3
LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN. Focus: Assignment.

Question 10

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take first?

1. Notify the health care provider about the stools.
2. Obtain stool specimens for culture.
3. Instruct the client about correct hand washing.
4. Place the client on contact precautions.

Answer 10

Ans: 4
The client’s age, history of antibiotic therapy, and watery stools suggest that he may have C. difficile infection. The initial action should be to place him on contact precautions to prevent the spread of C. difficile to other clients. The other actions are also needed and should be taken after placing the client on contact precautions. Focus: Prioritization; Test Taking Tip: Remember that implementation of infection control policies and precautions is an independent nursing action, and it is your responsibility to promptly implement appropriate precautions and use of personal protective equipment to prevent disease transmission.

Question 11

The nurse notes white powder on the arms and chest of a client who arrives at the emergency department and reports possible anthrax contamination. Which action included in the hospital protocol for possible anthrax exposure will the nurse take first?

1. Notify hospital security personnel about the client.
2. Escort the client to a decontamination room.
3. Give ciprofloxacin 500 mg PO.
4. Assess the client for signs of infection.

Answer 11

Ans: 2
To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering are the initial actions in possible anthrax exposure. Assessment of the client for signs of infection should be performed after decontamination. Notification of security personnel (and local and regional law enforcement agencies) is necessary in the case of possible bioterrorism, but this should occur after decontaminating and caring for the client. According to the Centers for Disease Control and Prevention guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax. Focus: Prioritization.

Question 12

A pregnant client in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important?

1. Arrange for testing for Zika virus infection.
2. Discuss need for multiple fetal ultrasounds during pregnancy.
3. Describe potential impact of Zika infection on fetal development.
4. Assess for symptoms such as rash, joint pain, conjunctivitis, and fever.

Answer 12

Ans: 1
Current guidelines recommend that pregnant women who are exposed to Zika virus be tested for infection. Fetal ultrasonography is recommended for any pregnant woman who has had possible Zika virus exposure, but multiple ultrasound studies will not be needed unless test results are positive. Education about the effects of Zika infection on fetal development may be needed, but this is not the highest priority at this time. The nurse will assess for Zika symptoms, but testing for the virus will be done even if the client is asymptomatic. Focus: Prioritization.

Question 13

The nurse at the infectious disease clinic has four clients waiting to be seen. Which client should the nurse see first?

1. Client who has a 16-mm induration after a tuberculosis (TB) skin test
2. Client who has human immunodeficiency virus and a low CD4 count
3. Client who has swine influenza (H1N1) and reports increased dyspnea
4. Client who has been exposed to Zika virus and has a rash and joint pain

Answer 13

Ans: 3
The client with increased dyspnea should be seen first because rapid actions such as oxygen administration and IV fluids may be needed. The other clients will require further assessment, counseling, or treatment, but they do not have potentially life-threatening symptoms or diagnoses. Focus: Prioritization.

Question 14

The nurse notices that the health care provider omits hand hygiene after leaving a client’s hospital room. Which action by the nurse is best at this time?

1. Report the health care provider to the infection control department.
2. Offer the health care provider an alcohol based hand sanitizing fluid.
3. Provide the health care provider with a list of upcoming inservices on hand hygiene.
4. Remind the health care provider about the importance of minimizing infection spread.

Answer 14

Ans: 2
Because the most immediate need is to ensure that hand hygiene is accomplished, the nurse should offer an alcohol-based cleaner to the health care provider. The other actions may also be needed, especially if there is a pattern of nonadherence to hand hygiene, but further assessment is necessary before these actions are taken. Focus: Prioritization.

Question 15

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client’s care?

1. Teaching the client and family members about means to prevent transmission of VRE
2. Communicating with other departments when the client is transported for ordered tests
3. Implementing contact precautions when providing care for the client
4. Monitoring the results of ordered laboratory culture and sensitivity tests

Answer 15

Ans: 3
All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data. Focus: Delegation.

Question 16

A client who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first?

1. Place the client in an airborne isolation room.
2. Initiate infusion of 500 mL of normal saline bolus.
3. Ask the client about any recent travel to Asia.
4. Obtain sputum specimen and nasal cultures.

Answer 16

Ans: 1
The initial action should be to prevent transmission of avian influenza to other clients, visitors, or health care personnel through the use of airborne, contact, and standard isolation precautions. Initiating IV fluids, determining whether the client has been exposed to avian influenza through travel, and obtaining cultures are also appropriate, but the highest priority is to prevent spread of infection. Focus: Prioritization.

Question 17

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)?

1. Screening clients for upper respiratory tract symptoms
2. Asking clients about the use of immunosuppressant medications
3. Demonstrating correct hand washing to the clients’ visitors
4. Disinfecting blood pressure cuffs after clients are discharged

Answer 17

Ans: 4
The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses. Focus: Delegation.

Question 18

The nurse is preparing to change the linens on the bed of a client who has a sacral wound infected by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) items will be used? Select all that apply.

1. Gown
2. Gloves
3. Goggles
4. Surgical mask
5. N95 respirator

Answer 18

Ans: 1, 2
A gown and gloves should be used when coming in contact with linens that may be contaminated by the client’s wound secretions. The other PPE items are not necessary because transmission by splashes, droplets, or airborne means will not occur when the bed is changed. Focus: Prioritization.

Question 19

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN/LVN?

1. Performing ongoing assessments to determine the client’s hydration status
2. Explaining the purpose of ordered stool cultures to the client and family
3. Administering the prescribed metronidazole 500 mg PO to the client
4. Reviewing the client’s medical history for any risk factors for diarrhea

Answer 19

Ans: 3
LPN/LVN scope of practice and education include administration of medications. Assessment of hydration status, client and family education, and assessment of client risk factors for diarrhea should be done by the RN. Focus: Assignment.

Question 20

Which action by the infection control nurse in an acute care hospital will be most effective in reducing the incidence of health care–associated infections?
1. Require nursing staff to don gowns to change wound dressings for all clients.
2. Ensure that dispensers for alcohol-based hand rubs are available in all client care areas.
3. Screen all newly admitted clients for colonization or infection with methicillin-resistant Staphylococcus aureus (MRSA).
4. Develop policies that automatically start antibiotic therapy for clients
colonized by multidrug-resistant organisms.

Answer 20

Ans: 2
Because the hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Wearing a gown to care for clients who are not on contact precautions is not necessary. Although some hospitals have started screening newly admitted clients for MRSA, this is not considered a priority action according to current national guidelines. Because administration of antibiotics to individuals who are colonized by bacteria may promote development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection. Focus: Prioritization.

Question 21

When the nurse is educating a group of women of childbearing age about
the Zika virus, which information will be included? Select all that apply.
1. Women who are pregnant will be asked about possible Zika exposure at
each prenatal visit.
2. Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika.
3. There is a high risk for maternal death when women are infected with the Zika virus during pregnancy.
4. Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission.
5. Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure.

Answer 21

Ans: 1, 2, 4, 5
National guidelines recommend that all pregnant women be assessed for Zika exposure at each prenatal visit, that women who may have been exposed be tested, that women who are anticipating pregnancy should avoid travel to areas where they might be exposed to Zika, and that barrier methods be used if the sex partner has been exposed to Zika infection. Congenital defects to the fetus occur if there is Zika infection during pregnancy, but the maternal infection is usually mild and nonfatal. Focus: Prioritization.

Question 22

When the community health nurse is counseling a client who has an acute Zika virus infection, which information is most important to include?

1. Drink fluids to prevent dehydration.
2. Use acetaminophen to reduce pain and fever.
3. Apply insect repellant frequently to prevent mosquito bites.
4. Symptoms of Zika infection include fever, red eyes, rash, and joint pain

Answer 22

Ans: 3
Prevention of Zika transmission is the priority because Zika infection usually causes a relatively mild and short-duration illness. Because mosquitos spread Zika infection from infected individuals to others, it is essential that the client use insect repellant consistently during the active infection. The other information is correct but will not assist in decreasing the risk to the community. Focus: Prioritization.

Question 23

Which policy implemented by the infection control nurse will most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)?

1. Limit the use of indwelling urinary catheters in all hospitalized clients.
2. Ensure that clients with catheters have at least a 1500-mL fluid intake daily.
3. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria.
4. Require the use of antimicrobial/antiseptic-impregnated catheters for catheterization.

Answer 23

Ans: 1
According to the Centers for Disease Control and Prevention (CDC), CAUTIs are the most common health care–acquired infection in the United States. Recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible. Although a high fluid intake will also help to reduce the risk for CAUTIs, 1500 mL may be excessive for some clients. The CDC recommends against routine screening for asymptomatic bacteriuria. Antimicrobial catheters are a secondary recommendation and may be appropriate if other measures are not effective in reducing the incidence of CAUTIs. Focus: Prioritization.

Question 24

The nurse admits four clients with infections to the medical unit, but only one private room is available. Which client is most appropriate to assign to the private room?

1. Client with diarrhea caused by C. difficile
2. Client with vancomycin-resistant enterococcus (VRE) infection
3. Client with a cough who may have active tuberculosis (TB)
4. Client with toxic shock syndrome and fever

Answer 24

Ans: 3
Clients with infections that require airborne precautions (e.g., TB) need to be in private rooms. Clients with infections that require contact precautions (e.g., those with C. difficile VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with toxic shock syndrome. Focus: Prioritization.

Question 25

Which information about a client who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions?

1. Pupils are equal and reactive to light.
2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus.
3. Temperature is lower than 100°F (37.8°C).

Answer 25

Ans: 2
Current Centers for Disease Control and Prevention evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client’s condition is improving but does not indicate that droplet precautions should be discontinued. Focus: Prioritization.

Question 26

While administering vancomycin 500 mg IV to a client with a methicillin- resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the client’s neck and face are becoming flushed. Which action should the nurse take next?

1. Discontinue the vancomycin infusion.
2. Slow the rate of the vancomycin infusion.
3. Obtain an order for an antihistamine.
4. Check the client’s temperature.

Answer 26

Ans: 2
“Red man” syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes to avoid vasodilation. Although the client’s temperature will be monitored, a temperature elevation is not the most likely cause of the client’s flushing. Focus: Prioritization.

Question 27

A healthy 65-year-old client who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations but tells the nurse, “I hate shots! I will only take one today.” Which immunization is most important to give?

1. Influenza
2. Herpes zoster
3. Pneumococcal
4. Tetanus, diphtheria, pertussis

Answer 27

Ans: 4
Individuals who have contact with infants should be immunized against pertussis to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, before the influenza season. The herpes zoster vaccine is important to prevent shingles in the client but does not need to be administered today. Focus: Prioritization.

Question 28

The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client’s risk for ventilator-associated pneumonia (VAP)? Select all that apply.

1. Keep the head of the client’s bed elevated to at least 30 degrees.
2. Assess the client’s readiness for extubation at least daily.
3. Ensure that the pneumococcal vaccine is administered.
4. Use a kinetic bed to continuously change the client’s position.
5. Provide oral care with chlorhexidine solution at least daily.

Answer 28

Ans: 1, 2, 5
The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential. Focus: Prioritization.

Question 29

The nurse is preparing to insert a peripherally inserted central catheter (PICC) in a client’s left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion?

1. 70% isopropyl alcohol
2. Povidone-iodine solution
3. 0.5% chlorhexidine in alcohol
4. Betadine followed by 70% isopropyl alcohol

Answer 29

Ans: 3
Current Institute for Healthcare Improvement guidelines indicate that chlorhexidine is more effective than the other options at reducing the risk for central line–associated bloodstream infections. The other solutions provide some decrease in the number of microorganisms on the skin but are not as effective as chlorhexidine. Focus: Prioritization.

Question 30

The nurse has received a needlestick injury after giving a client an intramuscular injection, but has no information about whether the client has human immunodeficiency virus (HIV) infection. What is the most appropriate method of obtaining this information about the client?

1. The nurse should personally ask the client to authorize HIV testing.
2. The charge nurse should tell the client about the need for HIV testing.
3. The occupational health nurse should discuss HIV status with the client.
4. HIV testing should be performed the next time blood is drawn for other tests.

Answer 30

Ans: 3
The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about how to obtain a client’s HIV status and/or order HIV testing is the occupational health nurse. It is unethical for the nurse to personally ask the client to consent to HIV testing or to perform unauthorized HIV testing. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health). Focus: Prioritization.

Question 31

Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing health care provider before administration?

1. Warfarin 1.0 mg PO
2. Morphine 2 to 4 mg IV
3. Cephalexin 250 mg PO
4. Heparin infusion at 900 units/hr

Answer 31

Ans: 1
The Institute for Safe Medication Practices guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case,
10 mg). The order should be clarified before administration. The other orders are appropriate based on the client’s diagnosis. Focus: Prioritization.

Question 32

A client with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells the nurse, “I feel really dizzy.” Which action should the nurse take first?

1. Help the client to sit down.
2. Check the client’s apical pulse.
3. Take the client’s blood pressure.
4. Have the client breathe deeply.

Answer 32

Ans: 1
The first priority for an ambulating client who is dizzy is to prevent falls, which could lead to serious injury. The other actions are also appropriate but are not as high a priority. Focus: Prioritization.

Question 33

The nurse is supervising an LPN/LVN who says, “I gave the client with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!” In which order should the nurse perform the following actions?

1. Assess the client’s heart rate.
2. Complete a medication error report.
3. Ask the LPN/LVN to explain how the error occurred.
4. Notify the health care provider of the incorrect medication dose.

Answer 33

Ans: 1, 4, 3, 2
The first action after a medication error should be to assess the client for adverse outcomes. The nurse should evaluate this client for symptoms such as bradycardia and excessive salivation, which indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The health care provider should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report. Focus: Prioritization.

Question 34

The nurse is caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can be assigned to an LPN/LVN?

1. Determining whether the client’s mental status justifies the continued use of restraints
2. Undoing and retying the restraints to improve client comfort
3. Reporting the client’s status and continued need for restraints to the health care provider
4. Explaining the purpose of the restraints to the client’s family members

Answer 34

Ans: 2
Hospital staff who have been trained in the appropriate application of restraints may reposition the restraints. Evaluation of the continued need for restraints, communication with the provider about the client’s status, and teaching of the family require RN-level education and scope of practice. Focus: Assignment.

Question 35

The nurse is checking medication prescriptions that were received by telephone for a client with hypertensive crisis and tachycardia. Which medication is most important to clarify with the health care provider?

1. Carvedilol 12.5 mg PO BID daily
2. Hydrochlorothiazide 25 mg PO daily
3. Labetalol 20 mg IV over a 2-min time period now
4. Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg

Answer 35

Ans: 4
Hydroxyzine is a first-generation antihistamine that is used to treat patients with anxiety and pruritus. It is likely that the correct medication is hydralazine, a vasodilator that is used to treat hypertension. Hydroxyzine and hydralazine are “look-alike, sound-alike” drugs that have been identified by the Institute for Safe Medication Practices (ISMP) as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the health care provider; however, the most important order to clarify is the hydroxyzine, which is likely an error. Focus: Prioritization.

Question 36

A 70-kg client who has had unprotected sexual intercourse with a partner who has hepatitis B is to receive 0.06 mL/kg of hepatitis B immune globulin. The immune globulin is available in a 5-mL vial. The nurse will plan to administer ____________________ mL.

Answer 36

Ans: 4.2 mL

0.06 mL × 70 kg = 4.2 mL Focus: Prioritization.

Question 37

A 88-year-old client who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is most important for the nurse to administer at this time?

1. Oseltamivir 75 mg PO
2. Guaifenesin 600 mg PO
3. Acetaminophen 650 mg PO
4. Influenza vaccine 180 mcg IM

Answer 37

Ans: 1
Because antivirals are most effective when used early in influenza infection, the nurse should administer the oseltamivir as soon as possible to decrease the severity of the infection and risk of transmission to others. Guaifenesin and acetaminophen will help with the symptoms of cough and muscle aching but will not shorten the course of the client’s illness or decrease risk of transmission. The influenza vaccine may still help in preventing future influenza caused by another virus. Focus: Prioritization.