Chapter 2

Which of the following situations require the nurse to don gloves? 1\. taking vital signs on a post operative client 2\. giving a bed bath to a client who has had a myocardial infarction 3\. small cuticle irritation on nurse’s hand 4\. combing the hair of a patient with fulminating AIDS infection

Which of the following statements defines Standard Precautions? 1\. precautions taken in all situation involving blood and body fluids 2\. control measures taken when a client is known to be infectious 3\. control measures taken any time there is a suspicion of an infectious client 4\. precautions taken when directly contacting clients

Which of the following situations require the nurse to don gloves? 1\. taking a tympanic temperature on a post operative client 2\. giving a sub cutaneous injection to a client on Heparin 3\. assessing the heart rate of a patient with tuberculosis 4\. assisting a patient to the bedside commode

The nurse is splashed in the face by gastric secretions while aspirating a gastrostomy tube. What action should be taken first? 1\. Wash her face with soap and water avoiding the eyes. 2\. Report to the infection control/employee health department immediately. 3\. Obtain a venapuncture from the nurse and the client for Hepatitis and HIV status. 4\. Document an incident report.

The nurse is teaching a client about communicable diseases and explains that a portal of entry could be: 1\. vector. 2\. a source like contaminated water. 3\. food. 4\. the respiratory system.

Which of the following microorganisms are considered normal body flora? 1\. Staphylococcus on the skin 2\. Streptococcus in the nares 3\. Candida albicans in the vagina 4\. Pseudomonas in the blood

The spread of active or primary tuberculosis is primarily by what means? 1\. blood 2\. droplet 3\. airborne 4\. contact

The nurse teaching the client about Hepatitis and its transmission will explain that one type of Hepatitis does not produce a carrier state after its acute phase? Which type will she review? 1\. Hepatitis A 2\. Hepatitis B 3\. Hepatitis C 4\. Hepatitis D

A pediatric client is diagnosed with acute glomerulonephritis. The nurse recalls that the disease is associated with which of the following? 1\. a recent case of impetigo 2\. a coexisting sore throat 3\. a chronic cough 4\. Dysuria

A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is: 1\. Kawasaki disease. 2\. Rheumatic disease. 3\. Lupus erythematosus. 4\. Fifth disease

Ethical and moral issues concerning restraints are all except: 1\. emotional impact on patients/family. 2\. informed consent. 3\. quality of life. 4\. standards of restraints and ethics.

Moving a restraint to a side rail or an immovable part of the bed can: 1\. do nothing to the patient. 2\. injure patients if the rail or bed is moved and they have restraints in place. 3\. help the patient stay in the bed without falling out. 4\. help the patient with better posture.

7\. Padding on the restraint helps: 1\. to distribute pressure so bony prominences do not receive pressure when the patient pulls against the restraints. 2\. to tie with padding on buttock and under hips, so patient will feel more secure. 3\. to keep infection and wounds down. 4\. to keep the restraints in place.

What does communication/education with the patient and family, concerning restraints do? 1\. confuse both groups more 2\. helps coping and the stress level 3\. provides more cooperation with patient and family 4\. helps to put the responsibility on the patient/family and not nurse

The nurse working with older adults keeps in mind that falls are most likely to happen to older adults that are: 1\. in their 80s. 2\. living at home. 3\. hospitalized. 4\. living on only social security income.

The nurse assesses a client for physiological risk factors for falls. The nurse would conclude that the client is at no further risk if which of the following were discovered? 1\. history of dizziness 2\. need for wheelchair due to reduced mobility 3\. weakness and fatigue noted when clinging stairs 4\. intact recent and remote memory

Clients who are at risk from alcohol or drug consumption or who have a cerebrovascular accident, cardiac arrest, are at most risk for: 1\. infection. 2\. immobility. 3\. falls. 4\. fire hazards

Potential hazards for falls in the home are all except: 1\. missing or broken steps. 2\. presence of throw rugs. 3\. inadequate lighting. 4\. lifestyle that promotes health.

Which of the following statements describes the purpose of patient restraint? 1\. a nursing measure to maintain client control 2\. an emergency intervention taken as a last resort to protect a patient from imminent danger 3\. a therapeutic measure designed to positively reinforce patient behavior 4\. an emergency measure that can only be taken by a nurse under the direct supervision of a physician

The nurse will perform which intervention when the client is restrained? 1\. Remove the restraints and provide skin care hourly. 2\. Document the condition of skin every 3 hours. 3\. Assess the restraint every 30 minutes. 4\. Tie the restraint to the side rails.

Which of the following parameters for the use of restraints is incorrect? 1\. discipline 2\. maintain safe environment for other patients 3\. prevent harm to the patient or others 4\. emergency situation with no other safe alternative

A nurse should attempt which of the following measures first prior to restraining a client? 1\. Determine whether there could be a more convenient way of managing the client. 2\. Obtain consent from the client or the client’s guardian. 3\. Assess the client’s skin and vital signs. 4\. Document the circumstances surrounding the need for restraints in the medical record and ensure a physician’s order.

Which of the following statements describes the purpose of patient restraint? 1\. A nursing measure to maintain client control. 2\. An emergency intervention taken as a last resort to protect a patient from imminent danger. 3\. A therapeutic measure designed to positively reinforce patient behavior. 4\. An emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Parameters for the use of restraints involve all of the following except: 1\. discipline of an unruly client. 2\. maintaining a safe environment for other patients. 3\. preventing harm to the client or others. 4\. in an emergency situation with no other safer alternative.

The nurse recognizes which correct principle guiding the use of side rails? 1\. Side rails are used most frequently as a precaution against falls in the elderly. 2\. Side rails are a form of restraint. 3\. Side rails should be up anytime a patient is at risk for falling. 4\. No special consent is necessary for the use of side rails.

The legal offense committed by the unpermitted touching of another is: 1\. assault. 2\. battery. 3\. coercion. 4\. intimidation

The nurse will select a “poncho” or torso-type vest restraint for what client? 1\. a 3 year old undergoing suturing of a scalp laceration 2\. a teenager who is admitted after drug overdose with altered mental state and is intubated 3\. a frail, elderly client diagnosed with “Senile Dementia of Alzheimer’s” who wanders 4\. a middle aged adult with psychosis who has fallen previously

The nurse will select a “belt” or safety-strap restraint for what type of client? 1\. clients being moved 2\. clients in seclusion 3\. clients in surgery and special procedure areas 4\. pediatric clients

A 65-year-old client is hospitalized with shortness of breath and seizure precautions. He is unable to ambulate without help but becomes disoriented at times and tries to get out of bed. What is the most appropriate safety measure for this client? 1\. Restrain the bed. 2\. Ask a family member to stay with the client. 3\. Check the client every 15 minutes. 4\. Use a bed exit safety monitoring device.

Before selecting a restraint, the nurse needs to understand all except: 1\. the purpose clearly. 2\. the health problem or treatment is not impaired. 3\. it is a safe procedure. 4\. the family visitors can easily see the restraint.

Restraints are used as: 1\. protective devices. 2\. relaxation devices. 3\. holistic devices. 4\. injury devices.

Under standards and policies of an institution, who is designated to have the responsibility for using restraints? 1\. Client must request restraints. 2\. Family must request restraints. 3\. Physician must request restraints. 4\. The roommate of client can requests restraints.

What organizations does the nurse need to know about before applying restraints? 1\. County Health Department policies 2\. U.S. Centers for Medicare and Medicaid Services 3\. National Drug and Alcohol Centers 4\. American Nurses’Association

The role of the incident report in risk management is which of the following? 1\. protects from liability 2\. analyzed by a risk manager to determine how future problems can be avoided 3\. for disciplining staff for errors 4\. all of the above

A risk management program within a hospital is responsible for all of the following except: 1\. identifying risks. 2\. controlling financial loss due to malpractice claims. 3\. making sure that staff follow their job descriptions. 4\. analyzing risks and trends to guide further interventions or programs.

How is the information documented on incident reports used? 1\. analyzing risk categories 2\. making sure procedures are in compliance with regulations 3\. identifying the educational needs of the staff 4\. all of the above

The incident report itself includes all of the following information except: 1\. staff person responsible for the incident. 2\. who the incident involved. 3\. a description of the incident. 4\. a signature of who prepared the report

As the charge nurse, you reviewed an incident report written on the last shift. It contained the following note: “Mrs. C was found lying on the bathroom floor, complaining of pain and a bump on the head. No injuries noted. Dr. notified.” The significant details missing from the documentation include: 1\. How was she lying on the floor? Description of pain? What were the immediate interventions when she was found? 2\. How did she get to the bathroom? Had she been incontinent? 3\. Was her call bell in reach? Has she fallen before? 4\. How steady was her gait? Has she recently been medicated?

Typical areas of high risk for employees related to their job requirements within a healthcare facility include all of the following except: 1\. food served in the cafeteria. 2\. employee prevention of back strain. 3\. stress injuries for example carpal tunnel. 4\. employee stress in high acuity areas (for example, critical care).

High risk aspects of care that have been high volume over the last decade or so include all of the following except: 1\. needlestick injuries. 2\. falls. 3\. restraints. 4\. meals.

The public’s sources for accessing information regarding incidents that occur in a healthcare facility are: 1\. the facility itself. 2\. the American Hospital Association. 3\. the Web site for the Department of Health and the Agency for Health Care Administration. 4\. information is not accessible.