Which biological practices are federally regulated for healthcare workers? (Select all that ap-
ply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - ANSWER 3. Blood-borne patho-
gen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and Health Ad-
ministration (OSHA), include standard precautions, droplet precautions using N-95 respira-
tory particulate masks when caring for a client who is positive for tuberculosis, and required
annual updates for healthcare workers about blood-borne pathogen transmission, methods
of minimizing exposure, and employee rights. Other options [BPEL and ALARA ] are not fed-
erally regulated.
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not
been sleeping well lately and is experiencing labored breathing. List the client's problems in
order of priority for the nurse. (Rank in the priority order from highest to lowest.)
1.
Airway and breathing.
2.
1
,Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - ANSWER Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this sce-
nario, airway and breathing are the first priority, followed by pain management, Maslow's
hierarchy of basic needs for rest and sleep, and then definitive drug therapies.
A client with severe depression tells the nurse, "I do not know why you bother with me or
give me pills. I am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad any-
more."
3. "I have known many clients with depression who have felt better after several weeks of
treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you
recover." - ANSWER 3. "I have known many clients with depression who have felt better
after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a person to
stop negtive thinking is ineffective because the client must be taught cognitive strategies to
stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs
and attempting to tell him how to feel, both of which are not therapeutic responses. Bring
up pessimistic feelings interprets the client's feelings and does not provide the same degree
of hope.
2
,The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inade-
quate primary defenses as evidenced by surgical incision and IV access." What nursing inter-
vention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. - AN-
SWER 3. Assess and document skin condition around the incision and IV site at each shift.
Early identification of infection leads to prompt treatment and decreased nosocomial trans-
mission to others, so the condition of any invasive lines or breaks in the skin should be as-
sessed and documented during each shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J
pouch). As part of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - ANSWER 4. Stool is eventually ex-
pelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal
reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of
stool through the rectum is the eventual result. To promote healing of the anastomosed
parts of the colon, a temporary loop ostomy is created, not a permanent one. Although ap-
pliances that are easy to use are advantageous, the ostomy is reversed after healing takes
place. Stool drains into the reservoir, so daily irrigation is not usually indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client
who is breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
3
, 2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - ANSWER 4.
Inject air until no air is auscultated over the larynx during a deep breath.
To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall,
inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over
the larynx (over the cuff) during inhalation. At the point when sounds of air movement
cease, inflation is stopped, indicating that the cuff is sealed against the tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night
sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test.
Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - ANSWER 1. Refer for further diag-
nostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis in-
fection (LTBI), which this client is in a high-risk category for exposure in a homeless environ-
ment. Although productive prolonged cough, fever, and night sweats are common early
symptoms, persons suspected of LTBI should not begin treatment until active TB disease has
been excluded. Further diagnostic evaluation should be implemented. A dormant form that
neither causes disease nor is communicable.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates
a disturbance in electrical conduction in the ventricles?
1. T wave of 0.16 second.
2. PR interval of 0.18 second.
3. QT interval of 0.34 second.
4. QRS interval of 0.14 second. - ANSWER 4. QRS interval of 0.14 second.
4
ply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - ANSWER 3. Blood-borne patho-
gen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and Health Ad-
ministration (OSHA), include standard precautions, droplet precautions using N-95 respira-
tory particulate masks when caring for a client who is positive for tuberculosis, and required
annual updates for healthcare workers about blood-borne pathogen transmission, methods
of minimizing exposure, and employee rights. Other options [BPEL and ALARA ] are not fed-
erally regulated.
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not
been sleeping well lately and is experiencing labored breathing. List the client's problems in
order of priority for the nurse. (Rank in the priority order from highest to lowest.)
1.
Airway and breathing.
2.
1
,Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - ANSWER Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this sce-
nario, airway and breathing are the first priority, followed by pain management, Maslow's
hierarchy of basic needs for rest and sleep, and then definitive drug therapies.
A client with severe depression tells the nurse, "I do not know why you bother with me or
give me pills. I am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad any-
more."
3. "I have known many clients with depression who have felt better after several weeks of
treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you
recover." - ANSWER 3. "I have known many clients with depression who have felt better
after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a person to
stop negtive thinking is ineffective because the client must be taught cognitive strategies to
stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs
and attempting to tell him how to feel, both of which are not therapeutic responses. Bring
up pessimistic feelings interprets the client's feelings and does not provide the same degree
of hope.
2
,The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inade-
quate primary defenses as evidenced by surgical incision and IV access." What nursing inter-
vention should the nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. - AN-
SWER 3. Assess and document skin condition around the incision and IV site at each shift.
Early identification of infection leads to prompt treatment and decreased nosocomial trans-
mission to others, so the condition of any invasive lines or breaks in the skin should be as-
sessed and documented during each shift.
A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J
pouch). As part of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - ANSWER 4. Stool is eventually ex-
pelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal
reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of
stool through the rectum is the eventual result. To promote healing of the anastomosed
parts of the colon, a temporary loop ostomy is created, not a permanent one. Although ap-
pliances that are easy to use are advantageous, the ostomy is reversed after healing takes
place. Stool drains into the reservoir, so daily irrigation is not usually indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client
who is breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
3
, 2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - ANSWER 4.
Inject air until no air is auscultated over the larynx during a deep breath.
To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall,
inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over
the larynx (over the cuff) during inhalation. At the point when sounds of air movement
cease, inflation is stopped, indicating that the cuff is sealed against the tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night
sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test.
Which action should the nurse implement?
1. Refer for further diagnostic evaluation.
2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - ANSWER 1. Refer for further diag-
nostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis in-
fection (LTBI), which this client is in a high-risk category for exposure in a homeless environ-
ment. Although productive prolonged cough, fever, and night sweats are common early
symptoms, persons suspected of LTBI should not begin treatment until active TB disease has
been excluded. Further diagnostic evaluation should be implemented. A dormant form that
neither causes disease nor is communicable.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates
a disturbance in electrical conduction in the ventricles?
1. T wave of 0.16 second.
2. PR interval of 0.18 second.
3. QT interval of 0.34 second.
4. QRS interval of 0.14 second. - ANSWER 4. QRS interval of 0.14 second.
4
