Prevention and Risk Management - NCLEX-PN
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A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
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The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should .
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should .
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Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse .
The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse .
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In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair.
In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair.
The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?
The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?
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There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.
There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.
The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?
The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?
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The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.
The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.
The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?
The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?
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The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above 
suggest hepatic damage.
The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above
The oncology nurse cares for a patient receiving morphine sulfate 
IV push q4h for pain. Which of the following most concerns the nurse?
The oncology nurse cares for a patient receiving morphine sulfate
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The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.
The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.
The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?
The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?
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The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.
The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.
The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?
The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?
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Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.
Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Tap to see back →
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should .
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should .
Tap to see back →
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse .
The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse .
Tap to see back →
In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair.
In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair.
The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?
The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?
Tap to see back →
There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.
There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.
The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?
The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?
Tap to see back →
The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.
The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.
The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?
The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?
Tap to see back →
The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above suggest hepatic damage.
The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above
The oncology nurse cares for a patient receiving morphine sulfate IV push q4h for pain. Which of the following most concerns the nurse?
The oncology nurse cares for a patient receiving morphine sulfate
Tap to see back →
The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.
The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.
The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?
The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?
Tap to see back →
The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.
The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.
The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?
The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?
Tap to see back →
Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.
Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Tap to see back →
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should .
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should .
Tap to see back →
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.