Safety And Infection Conttrol Report

Student Exam Results

Student Information lazaro Last Name: briselda First Name: Exam:

Reference:

RN Lesson 2 Posttest

Reference: Exam Name: Objective:

Total Attempts: 2

Total Submitted Attempts : 2

Mark: 100 %

RN Lesson 2 Posttest RN Lesson 2 Posttest - Safe and Effective Care Environment: Safety and Infection Student Control Mark for this Objective: 47%

Correct Responses: 9 / 19

Correct (Ref: )Which of these actions is the primary nursing intervention designed to limit transmission of a client's Salmonella infection? Learner Response:

A) Wash hands thoroughly before and after client contact

Correct Response:

A) Wash hands thoroughly before and after client contact

Feedback:

Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Two million new cases appear each year. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are appropriate activities, but handwashing is primary. Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of nursing. Upper Saddle River, N.J.: Pearson Prentice Hall. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements? Learner Response: A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." Correct Response: A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." Feedback: The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters of fluid a day for the initial 48 hours to help remove the (131I) from the body. Staff should limit contact with hospitalized clients to 30 minutes per day per person. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier.

Correct (Ref: )The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these interventions would be a priority for the nurse to implement? D) Place client in a negative pressure private room and have all who enter the room use masks with shields Learner Response: D) Place client in a negative pressure private room and have all who enter the room use masks with shields Correct Response:

Feedback:

A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries, transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier.

Incorrect (Ref: )A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance? D) "Has the child had vomiting, diarrhea or stomach cramps?" Learner Response:

Correct Response:

A) "Ask the child if the mouth is burning or throat pain is present."

Feedback:

Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child's overall condition, however the question concerns evaluation for ingesting a caustic substance. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Incorrect (Ref: )The parents of a toddler who is being treated for pesticide poisoning ask: "Why is activated charcoal used? What does it do?" What is the nurse's best response? D) "The action may bind or inactivate the toxins or irritants that are ingested by children and adults." Learner Response: B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." Correct Response:

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Student Exam Results

Feedback:

All of the options are correct responses. However, option B is most accurate information to answer the parents' questions about the use and action of activated charcoal. The language is appropriate for a parent's understanding. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Incorrect (Ref: )Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls? Learner Response:

A) Sensory perceptual alterations related to decreased vision

Correct Response:

D) Altered patterns of urinary elimination related to nocturia

Feedback:

Nocturia is especially problematic because many elders fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling, and then they may fall over furniture or carpets. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier.

Correct (Ref: )Which approach is the best way to prevent infections when providing care to clients in the home setting? Learner Response:

A) Handwashing before and after examination of clients

Correct Response:

A) Handwashing before and after examination of clients

Feedback:

Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag. All of the options are correct, and the sequence of priorities would be options A, C, B, and D. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, is which of these? D) Have gloves on while handling bedpans with feces Learner Response: D) Have gloves on while handling bedpans with feces Correct Response:

Feedback:

The specific measure to prevent the spread of hepatitis A is careful handling and protection while working with fecal material. All of the other actions are correct but not the most significant specific approach used with hepatitis A. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Correct (Ref: )Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions? Learner Response:

B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray

Correct Response:

B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray

Feedback:

The client who must be placed in airborne precautions is the client with these findings that suggest a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When signs and symptoms do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? A) Institute seizure precautions Learner Response: C) Place in respiratory/secretion precautions Correct Response:

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Student Exam Results

Feedback:

Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes respiratory/secretions precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs, instituting seizure precautions and lastly maintaining optimum hydration. The first action for nurses to take is initiate any necessary precautions to protect themselves and others from possible infection. Viral meningitis usually does not require protective measures of isolation. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Incorrect (Ref: )A school nurse has a 10 year-old child with a history of epilepsy with tonic-clonic seizures attending classes regularly. The school nurse should inform the teacher that if the child experiences a seizure in the classroom, the most important action to take during the seizure would be to A) move any chairs or desks at least 3 feet away from the child Learner Response: D) place the hands or a folded blanket under the head of the child Correct Response:

Feedback:

The priority during seizure activity is to protect the person from physical injury. Place a pillow, folded blanket or your hands under the child's head to prevent concussion or other head trauma. The other body parts are at less risk for injury, consequently the prioritized sequence of the actions above would be options D, A, B, and C. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus Humanus Capitis) in the school. The information that would be most important to include is reflected in which of these statements? C) "Children should not share hats, scarves and combs." Learner Response: C) "Children should not share hats, scarves and combs." Correct Response:

Feedback:

Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. All of the options are correct statements, however they do not best answer the question of how to prevent the spread of lice in a school setting. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Incorrect (Ref: )Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours? Learner Response:

A) An infant with a positive culture of stool for Shigella

Correct Response:

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

Feedback:

Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time. Options A and D may need contact isolation precautions. Option C -- findings may indicate the initial stage of autoimmune deficiency syndrome (AIDS). Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Incorrect (Ref: )A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation? Learner Response:

B) A toddler who has eaten a number of ibuprofen tablets

Correct Response:

A) An infant who has been identified as suffering from botulism

Feedback:

C. botulinum forms a toxin in improperly processed foods in anaerobic conditions. It is a neurotoxin that impairs autonomic and voluntary neurotransmission and causes muscular paralysis. Findings appear within 36 hours of ingestion. The nurse should be aware that all of these clients may be candidates for gastric lavage or for activated charcoal administration. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client? D) Contact Learner Response: D) Contact Correct Response:

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Student Exam Results

Feedback:

Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient's sputum is expected. A private room and contact precautions , along with good hand washing techniques, are the best defenses against the spread of MRSA pneumonia. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. Which lunch selection suggests the client has learned about necessary dietary changes? C) peanut butter sandwich, banana, and iced tea Learner Response: B) roast beef, mashed potatoes, and green beans Correct Response:

Feedback:

The client has correctly selected an appropriate lunch and appears to know the dietary restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. Options A, C and D do not demonstrate learning, as raw fruits, vegetables, and milk are to be avoided. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier. Altman, G. (2004). Delmar’s fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar.

Incorrect (Ref: )The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice? Learner Response: D) Verify the client's allergies on the admission sheet and order. Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?" Correct Response: B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. Feedback: A dual check is always done for a client's name. This would involve verbal and visual checks. Since this is a new medication an allergy check is appropriate. Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility? Learner Response:

D) A young adult in the second day of treatment for an overdose of acetometaphen

Correct Response:

D) A young adult in the second day of treatment for an overdose of acetometaphen

Feedback:

An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time . A strong risk of liver failure exists immediately following Tylenol overdose. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )After an explosion at a factory one of the employees approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers? A) Get temperatures Learner Response:

Correct Response:

C) Palpate pulses

Feedback:

The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first. Delaune, S. & Lander, P. (2002). Fundamentals in nursing: standards and practice. (2nd ed). Clinton Park, New York: Delmar. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Objective:

RN Lesson 2 Posttest - Safe and Effective Care Environment: Safety and Infection Student Control Mark for this Objective: 100%

Correct (Ref: )Which of these actions is the primary nursing intervention designed to limit transmission of a client's Salmonella infection? Learner Response:

A) Wash hands thoroughly before and after client contact

Correct Response:

A) Wash hands thoroughly before and after client contact

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Correct Responses: 19 / 19

Student Exam Results

Feedback:

Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Two million new cases appear each year. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are appropriate activities, but handwashing is primary. Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of nursing. Upper Saddle River, N.J.: Pearson Prentice Hall. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements? Learner Response: A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." Correct Response: A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." Feedback: The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters of fluid a day for the initial 48 hours to help remove the (131I) from the body. Staff should limit contact with hospitalized clients to 30 minutes per day per person. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier.

Correct (Ref: )The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these interventions would be a priority for the nurse to implement? D) Place client in a negative pressure private room and have all who enter the room use masks with shields Learner Response: D) Place client in a negative pressure private room and have all who enter the room use masks with shields Correct Response:

Feedback:

A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. Tuberculosis (TB) is caused by spore-forming mycobacteria, more often Mycobacterium tuberculosis. In developed countries the infection is airborne and is spread by inhalation of infected droplets. In underdeveloped countries, transmission also occurs by ingestion or by skin invasion, particularly when bovine TB is poorly controlled. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier.

Correct (Ref: )A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance? A) "Ask the child if the mouth is burning or throat pain is present." Learner Response:

Correct Response:

A) "Ask the child if the mouth is burning or throat pain is present."

Feedback:

Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child's overall condition, however the question concerns evaluation for ingesting a caustic substance. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )The parents of a toddler who is being treated for pesticide poisoning ask: "Why is activated charcoal used? What does it do?" What is the nurse's best response? B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." Learner Response: B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." Correct Response:

Feedback:

All of the options are correct responses. However, option B is most accurate information to answer the parents' questions about the use and action of activated charcoal. The language is appropriate for a parent's understanding. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls? Learner Response:

D) Altered patterns of urinary elimination related to nocturia

Correct Response:

D) Altered patterns of urinary elimination related to nocturia

10 July 2007 6:21:01PM

Page 5 of 9

Student Exam Results

Feedback:

Nocturia is especially problematic because many elders fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling, and then they may fall over furniture or carpets. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier.

Correct (Ref: )Which approach is the best way to prevent infections when providing care to clients in the home setting? Learner Response:

A) Handwashing before and after examination of clients

Correct Response:

A) Handwashing before and after examination of clients

Feedback:

Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag. All of the options are correct, and the sequence of priorities would be options A, C, B, and D. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to handwashing, is which of these? D) Have gloves on while handling bedpans with feces Learner Response: D) Have gloves on while handling bedpans with feces Correct Response:

Feedback:

The specific measure to prevent the spread of hepatitis A is careful handling and protection while working with fecal material. All of the other actions are correct but not the most significant specific approach used with hepatitis A. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Correct (Ref: )Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions? Learner Response:

B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray

Correct Response:

B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray

Feedback:

The client who must be placed in airborne precautions is the client with these findings that suggest a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When signs and symptoms do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Correct (Ref: )A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? C) Place in respiratory/secretion precautions Learner Response: C) Place in respiratory/secretion precautions Correct Response:

Feedback:

Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes respiratory/secretions precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs, instituting seizure precautions and lastly maintaining optimum hydration. The first action for nurses to take is initiate any necessary precautions to protect themselves and others from possible infection. Viral meningitis usually does not require protective measures of isolation. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )A school nurse has a 10 year-old child with a history of epilepsy with tonic-clonic seizures attending classes regularly. The school nurse should inform the teacher that if the child experiences a seizure in the classroom, the most important action to take during the seizure would be to D) place the hands or a folded blanket under the head of the child Learner Response:

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Student Exam Results

Correct Response:

D) place the hands or a folded blanket under the head of the child

Feedback:

The priority during seizure activity is to protect the person from physical injury. Place a pillow, folded blanket or your hands under the child's head to prevent concussion or other head trauma. The other body parts are at less risk for injury, consequently the prioritized sequence of the actions above would be options D, A, B, and C. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus Humanus Capitis) in the school. The information that would be most important to include is reflected in which of these statements? C) "Children should not share hats, scarves and combs." Learner Response:

Correct Response:

C) "Children should not share hats, scarves and combs."

Feedback:

Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. All of the options are correct statements, however they do not best answer the question of how to prevent the spread of lice in a school setting. Ball, J., & Bindler, R. (2003). Pediatric nursing. Upper Saddle River, N.J.: Pearson Education. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours? Learner Response:

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

Correct Response:

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

Feedback:

Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time. Options A and D may need contact isolation precautions. Option C -- findings may indicate the initial stage of autoimmune deficiency syndrome (AIDS). Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation? Learner Response:

A) An infant who has been identified as suffering from botulism

Correct Response:

A) An infant who has been identified as suffering from botulism

Feedback:

C. botulinum forms a toxin in improperly processed foods in anaerobic conditions. It is a neurotoxin that impairs autonomic and voluntary neurotransmission and causes muscular paralysis. Findings appear within 36 hours of ingestion. The nurse should be aware that all of these clients may be candidates for gastric lavage or for activated charcoal administration. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong's nursing care of infants and children.(7th ed). St. Louis: Elsevier.

Correct (Ref: )A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client? D) Contact Learner Response: D) Contact Correct Response:

Feedback:

Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient's sputum is expected. A private room and contact precautions , along with good hand washing techniques, are the best defenses against the spread of MRSA pneumonia. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Correct (Ref: )A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. Which lunch selection suggests the client has learned about necessary dietary changes?

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Learner Response:

B) roast beef, mashed potatoes, and green beans

Correct Response:

B) roast beef, mashed potatoes, and green beans

Feedback:

The client has correctly selected an appropriate lunch and appears to know the dietary restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. Options A, C and D do not demonstrate learning, as raw fruits, vegetables, and milk are to be avoided. Swearingen, P. (2004). All-in-one care planning resource: medical-surgical, pediatric, maternity, and psychiatric nursing care plans. St. Louis: Elsevier. Altman, G. (2004). Delmar’s fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar.

Correct (Ref: )The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice? Learner Response: B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. Correct Response: B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. Feedback: A dual check is always done for a client's name. This would involve verbal and visual checks. Since this is a new medication an allergy check is appropriate. Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility? Learner Response:

D) A young adult in the second day of treatment for an overdose of acetometaphen

Correct Response:

D) A young adult in the second day of treatment for an overdose of acetometaphen

Feedback:

An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time . A strong risk of liver failure exists immediately following Tylenol overdose. Phipps, W., Monahan, F., Sands, J., Marke, J., & Neighbors, N. (2003). Medical-surgical nursing: health and illness perspectives. (7th ed.). St. Louis: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Correct (Ref: )After an explosion at a factory one of the employees approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers? C) Palpate pulses Learner Response:

Correct Response:

C) Palpate pulses

Feedback:

The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first. Delaune, S. & Lander, P. (2002). Fundamentals in nursing: standards and practice. (2nd ed). Clinton Park, New York: Delmar. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

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