NURSING NCLEX Module 6 Exam Questions and Answers,100% CORRECT

NURSING NCLEX Module 6 Exam Questions and Answers Module 6 Exam Questions 1. 1.ID: Which of the following events would require a nurse to complete and file an incident report? A. A client has a seizure. B. The nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct Rationale: An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test­Taking Strategy: Use the process of elimination and read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337, 403). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report Correct D. Telling the nursing supervisor that the physician did not want an incident report completed and filed Rationale: Incident reports are an important part of a healthcare agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a healthcare unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the physician that the error warrants completion and follow­through with an incident report. Therefore, the other options are incorrect. Test­Taking Strategy: Focus on the subject of the question, the physician’s telling the nurse that an incident report is not needed. Eliminate the options that are comparable or alike in that they involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: Contact precautions are initiated for a client with methicillin­resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. Correct D. To wear a gown when caring for the client and remove the gown immediately after leaving the client’s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood or body fluids, secretions, or excretions. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test­Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed­ ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: A nurse hears someone calling, “Help! My bed is on fire!” On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take: Correct A. Removing the client from the room B. Pulling the nearest fire alarm C. Closing the door to the room D. Running to get the nearest fire extinguisher Rationale: A nurse who encounters a fire emergency should think of the mnemonic RACE. The first step is to remove the client from the room, after which the nurse should activate the fire alarm, contain the fire, and extinguish the fire. This is a universal standard that may be applied to any type of fire emergency. Removing the client from the room is the first step. Pulling the nearest fire alarm is the second step (alarm). Closing the door to the room to contain the fire is the third action. Obtaining the nearest fire extinguisher to put out the fire is the fourth action. Test­Taking Strategy: Focus on the subject, the steps to take in a fire emergency. With this in mind, sequence the actions, using the RACE mnemonic. Review fire safety if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 839, 840). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 2. 5.ID: The mother of a 3­year­old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center Correct B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department D. Leave a message at the physician answering service about the incident Awarded 1.0 points out of 1.0 possible points. B. 6.ID: A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan Correct B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm Awarded 1.0 points out of 1.0 possible points. C. 7.ID: A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. “I need to follow the oxygen prescription exactly.” Correct B. “I can use my electric razor while I’m using oxygen.” C. “I have to keep the oxygen concentrator out of direct sunlight.” Correct D. “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” E. “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Correct Awarded 1.0 points out of 1.0 possible points. D. 8.ID: A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: A. Every 2 hours Correct B. Every 3 hours C. Every 4 hours D. Every 30 minutes Awarded 1.0 points out of 1.0 possible points. E. 9.ID: A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity Correct Awarded 1.0 points out of 1.0 possible points. F. 10.ID: The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client’s record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 am. Correct C. Twice the amount of the prescribed ramipril was administered at 9 am. D. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. Rationale: After an incident, the nurse would document a concise and objective description of what occurred and any follow­up actions taken in the client’s record. The nurse would not document in the client’s record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given. Test­Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the options that are comparable or alike in that they indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. References: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 557, 558). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 704, 705). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. G. 11.ID: A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? A. The client’s bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed. Correct Awarded 1.0 points out of 1.0 possible points. H. 12.ID: A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. A. Skin Correct B. Lungs Correct C. Immune D. Urinary E. Lymphatic F. Gastrointestinal Correct Awarded 1.0 points out of 1.0 possible points. I. 13.ID: A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin’s disease. Which of the following precautions should the nurse take while working with this intravenous (IV) infusion? A. Wearing gloves and a mask Incorrect B. Wearing gloves and a gown C. Wearing gloves, a mask, and eye protectionCorrect D. Wearing gloves, a mask, and a head covering Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological hood is not available. Wearing gloves and a mask or gloves and a gown will not provide adequate protection. A head covering is not necessary. Test­Taking Strategy: Knowledge regarding the precautions for handling chemotherapeutic agents is necessary to answer this question. Think about the effects and cytotoxic nature of chemotherapy to answer the question. Select the option that will provide the greatest degree of protection to the nurse handling chemotherapeutic agents. If you had difficulty with this question, review the precautions for preparing a chemotherapy infusion. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 423). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 0.0 points out of 1.0 possible points. J. 14.ID: A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? A. Obtaining new IV tubing Correct B. Obtaining a new IV solution bag C. Scrubbing the tubing port with an alcohol swab D. Wiping the tubing port with povidone­iodine solution (Betadine) Rationale: If IV tubing becomes contaminated as a result of coming into contact with some nonsterile object, the nurse should obtain new IV tubing. Contaminated tubing could cause systemic infection in the client. The IV solution bag has not been contaminated and does not need replacement. Wiping the tubing port with Betadine or scrubbing it with alcohol is insufficient and would be contraindicated regardless, because the tubing will be attached directly to a catheter in the client’s vein. Test­Taking Strategy: Visualize the situation as you read the question. Use your knowledge of basic infection control measures and IV therapy to answer this question. Also, focus on the data in the question and note that the IV tubing has become contaminated. Review aseptic technique if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 179, 188). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. K. 15.ID: A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? A. Staying secluded in the bedroom B. Wearing an oxygen mask at all times C. Keeping the house closed up to minimize the spread of disease D. Disposing of contaminated tissues in a container with a leak­proof bag Correct Rationale: The client under respiratory precautions at home does not need to remain secluded; the client would not be at home if he or she were infectious. However, proper respiratory precautions are necessary. The house should be properly ventilated, and the windows should be opened as much as possible. Wearing an oxygen mask at all times is not a respiratory precaution, and there is no information in the question to indicate that oxygen is necessary. Contaminated tissues should be discarded in container with a leak­proof bag and then placed in an outdoor trash bin. Tissues should not be left lying around. Test­Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and the subject, respiratory precautions at home. Recalling the mode of transmission and home care measures for TB will direct you to the correct option. Also note the words “secluded,” “all times,” and “closed up” in the incorrect options. If you had difficulty answering this question, review the precautions that should be taken by the client with TB who has been discharged home. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 670). St. Louis: Saunders. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. L. 16.ID: A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. A. “I need to use night lights.” B. “I need to remove my wall­to­wall carpeting.”Correct C. “I need to get handrails put up in the bathroom.” D. “I need to use the staircase handrails when I go up the stairs.” E. “I should walk barefoot as much as possible so that I’ll know about any wet spots on the floor.”Correct Awarded 1.0 points out of 1.0 possible points. M. 17.ID: A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? A. Planning to have the nuclear scan performed at the bedside B. Asking the technicians in the nuclear scan department to wear masks C. Placing a surgical mask on the client for transport and for contact with other individualsCorrect D. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued Awarded 1.0 points out of 1.0 possible points. N. 18.ID: A nurse employed in a physician’s office hears a client in the waiting room call out, “Help! Fire!” The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately: A. Confines the fire B. Extinguishes the fire C. Activates the fire alarm D. Removes the clients from the waiting roomCorrect Awarded 1.0 points out of 1.0 possible points. O. 19.ID: A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? A. Confining the fire B. Extinguishing the fire C. Activating the fire alarm Correct D. Running for the fire extinguisher Awarded 1.0 points out of 1.0 possible points. P. 20.ID: The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first: A. Aiming at the base of the fire B. Pulling the pin on the fire extinguisher Correct C. Squeezing the handle of the extinguisher D. Sweeping from the top to the bottom of the fire with the extinguisher Awarded 1.0 points out of 1.0 possible points. Q. 21.ID: A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? A. The assistant applies a tie knot in the restraint strap. B. The assistant attaches the restraint straps securely to the siderails. C. The assistant applies the restraint so that the strap does not tighten when force is applied against it. Correct D. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client’s skin. Awarded 1.0 points out of 1.0 possible points. R. 22.ID: A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply. A. The assistant leans forward when turning a client in bed. B. The assistant positions a box that is to be lifted between his knees. Correct C. The assistant turns his back to change position while moving a client. D. The assistant keeps the object to be moved as close to his body as possible. Correct E. The assistant helps a client requiring total care into a chair without additional assistance. Awarded 1.0 points out of 1.0 possible points. S. 23.ID: A home care nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? A. “A space heater should never be used in an apartment.” B. “A space heater can be used as long as it is kept at a low setting at all times.” C. “A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs.” D. “A space heater can be used as long as it’s placed at least 3 feet from anything that may ignite.”Correct Awarded 1.0 points out of 1.0 possible points. T. 24.ID: A nurse is preparing to initiate a continuous tube feeding, using a tube­feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What should the nurse do? A. Plug in the pump cord into an available plug above the sink B. Ask the physician to change the prescription to intermittent feedings C. Determine the need for the appliances now plugged into the needed wall socket Correct D. Use a regular extension cord to allow the use of more than one electrical appliance Rationale: It is most appropriate for the nurse to assess the situation and determine the need for the appliances already plugged into the needed wall socket. The use of electrical appliances near a sink presents a hazard. It is not appropriate (and is premature) to ask the physician to change the prescription, because the prescription is based on the client’s needs. A regular extension cord should not be used, because it poses a risk of fire. Test­Taking Strategy: Use the process of elimination and the steps of the nursing process to answer the question. The only option that addresses assessment is the one that involves determining the need for the appliances currently plugged into the needed wall socket. Review electrical safety procedures if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 323). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. U. 25.ID: View video. A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. A. Holding the pair of sterile forceps below waist level area B. Positioning the sterile field so that it remains in full view Correct C. Reaching across the sterile field to pick up a sterile gauze D. Leaving the room to obtain a bottle of sterile normal saline solution E. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Correct F. Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves Correct Rationale: View video. The principles of surgical asepsis must be followed in the preparation of a sterile field. Among these principles: A sterile object remains sterile only when touched by other sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of the range of vision or an object held below the nurse’s waist is to be considered contaminated; a sterile object or field becomes contaminated with prolonged exposure to air; when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by way of capillary action; fluid flows in the direction of gravity; a 1­inch edge of a sterile field or container is to be considered contaminated. Test­Taking Strategy: Focus on the subject, use of the principles of aseptic technique. Reading each option carefully and recalling the principles of aseptic technique will direct you to the correct options. Review aseptic technique and the procedure for preparing a sterile field if you had difficulty with this question. References: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp. 670­672). St. Louis: Mosby. Video/animation: Preparing a sterile field: L001_preparing_a_sterile_ Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. V. 26.ID: A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately: A. Asks the LPN to complete and file an incident report Correct B. Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided C. Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route D. Instructs the LPN to write “pr” (per rectum) on the medication record next to the time at which the medication was administered Rationale: If a medication is prescribed to be administered by way of the oral route, the nurse may not use an alternate route to administer the medication unless the change is prescribed by the physician. The nurse would ask the LPN to complete and file an incident report because the LPN, legally speaking, made a medication error. Telling the LPN that she made a sound judgment in administering the medication by way of the rectal route is incorrect. Although the client must be reassessed and the LPN would document administration of the medication by way of the rectal route in the client’s record, the most appropriate option given is having the LPN complete and file an incident report. Test­Taking Strategy: Use the process of elimination and note the strategic words “most appropriately.” Focusing on the data indicates that the LPN made a medication error. This will direct you to the correct option. Review the appropriate actions in the event of a medication error if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 403, 704, 705). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. W. 27.ID: A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client’s plan of care? A. Wearing gloves when emptying the client’s bedpan Correct B. Allowing the client to ambulate in the hall only once a day C. Placing the client in a semiprivate room at the end of a hallway D. Placing used linen in double bags and sending a bag to the laundry room every evening Rationale: A primary goal of care for the client with an internal radiation implant is to prevent exposure of others to radiation. Therefore, a client with an internal radiation implant is required to remain in a private room to prevent accidental exposure of other clients, staff, and visitors to radiation. For this reason, a private room with a private bath is essential. All client linens should be kept in the client’s room until the implant is removed. Wearing gloves when emptying the client’s bedpan is the only appropriate intervention, of those provided, for a client with an internal radiation implant. Test­Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed­ ended word “only.” Also eliminate the option involving the use of a semiprivate room. To select from the remaining options, use your knowledge of standard precautions and precautions for a client with an internal radiation implant. This will direct you to the correct option. Review radiation safety principles if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 420). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. X. 28.ID: A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which of the following observations by the instructor indicates a need for further teaching? A. The nursing student changes gloves between tasks and procedures. B. The nursing student washes hands before making contact with the client. C. The nursing student wears a gown to change the bed of an incontinent client. D. The nursing student washes her hands before glove removal after emptying a Foley bag. Correct Rationale: Standard precautions require that gloves be removed promptly after use and before the wearer touches noncontaminated surfaces or other clients. Gloves are not washed before removal, because splashing of contaminated material may result. Changing gloves between tasks and procedures, washing the hands before making contact with the client, and wearing a gown to change the bed of an incontinent client reflect correct understanding of the principles of standard precautions. Test­Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect action. Use the process of elimination, visualizing each of the procedures described in the options. Thinking about the principles of standard precautions will direct you to the correct option. Review the principles associated with standard precautions if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 178, 179). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. Y. 29.ID: A physician writes a prescription for the application of a heating pad to a client’s back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply. A. Placing the heating pad under the client B. Adjusting the heating pad to the high setting C. Frequently assessing the client’s skin for signs of burns Correct D. Assessing the client’s medical history and risk factors for burns Correct E. Assessing the heating pad periodically for proper electrical function Correct Rationale: The nurse should first assess the client’s medical history, including risk factors for burns. The heating pad should never be placed under a client; instead, it should be placed lightly against or on top of the involved area. Burns may result when a client lies on a heating pad. The heating pad is adjusted to the low setting; the high setting can cause burns. Assessing the client for altered skin integrity and checking for proper electrical function are appropriate measures for the use of a heating pad. Test­Taking Strategy: Focus on the subject, the correct use of a heating pad for a client. Thinking about the hazards or risks to the client will assist you in selecting the correct options. Placing the heating pad under the client or adjusting the heating pad to the high setting could result in a burn. If you had difficulty with this question, review the principles of safe use of a heating pad. References: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., pp. 1047, 1048). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. Z. 30.ID: A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to: A. Place the ice pack directly on the eye B. Avoid the use of commercially prepared ice bags C. Keep the ice pack on the eye continuously for 24 hours D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye Correct Awarded 1.0 points out of 1.0 possible points. AA. 31.ID: A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line–related sepsis is diagnosed. The nurse interprets this finding as meaning that this infection is: A. An iatrogenic infection B. A result of bacterial colonization C. A community­acquired infection D. A healthcare­associated infection Correct Awarded 1.0 points out of 1.0 possible points. AB. 32.ID: A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. A. The use of latex gloves B. The use of shielded needles Correct C. The use of recessed needles Correct D. The use of needleless devices Correct E. Disposal of needles in special puncture­resistant containers Correct Awarded 1.0 points out of 1.0 possible points. AC.33.ID: A nurse is preparing to clean up a blood spill on the client’s bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. A. Using tongs to collect any broken glassCorrect B. Wearing gloves for the cleanup procedureCorrect C. Placing the pieces of broken glass in a plastic bag D. Blotting up the spill with a face cloth or cloth towel E. Disinfecting the area of the blood spill with a dilute bleach solution Correct Awarded 1.0 points out of 1.0 possible points. AD.34.ID: The unit supervisor of an emergency department (ED) is called at home and told by an emergency department nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the unit supervisor be? A. “Has the disaster plan been activated?”Correct B. “Call as many nursing staff as you can to come in to work.” C. “Make sure all of the rooms are well stocked with supplies.” D. “Be sure that the nursing staff finds as many stretchers as they can.” Awarded 1.0 points out of 1.0 possible points. AE. 35.ID: A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to: A. Induce vomiting B. Call an ambulance C. Call the poison control center Correct D. Bring the child to the emergency department (ED) Awarded 1.0 points out of 1.0 possible points. AF. 36.ID: A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low­bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. A. Fresh apple B. Raw celery C. Italian bread Correct D. Tossed salad E. Baked chicken Correct F. Well­cooked cheeseburger Correct Awarded 1.0 points out of 1.0 possible points. AG. 37.ID: Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. A. Saving vomitus for laboratory analysis Correct B. Placing the client in the supine position C. Determining the type and amount of substance ingested Correct D. Removing any visible materials from the nose and mouth Correct E. Inducing vomiting if a household cleaner has been ingested F. Assessing the client’s airway patency, breathing, and circulation Correct Rationale: In the event of accidental poisoning, the poison center is called before any attempt at interventions is made. Additional interventions in an accidental poisoning include assessing the client’s airway patency, breathing, and circulation; removing any visible materials from the nose and mouth to terminate exposure; determining the type and amount of substance ingested, if possible, to identify an antidote; saving vomitus for laboratory analysis, which may aid further treatment; and positioning the victim with the head to the side to prevent aspiration of vomitus and help keep the airway open. Because of the risk of aspiration, vomiting is never induced in an unconscious client or in a client who is experiencing seizures. Additionally, vomiting is not induced if lye, a household cleaner, a hair care product, grease, a petroleum product, or furniture polish has been ingested, because of the risk of internal burns. Test­Taking Strategy: Focus on the subject, interventions in the event of accidental poisoning. Visualize each of the interventions and how they might be helpful in treating the poisoning. Use of the ABCs (airway, breathing, and circulation) will also help you determine the correct interventions. Remember, too, that caustic substances may cause further injury to the client if vomiting is induced. If you had difficulty with this question, review the interventions for a victim of accidental poisoning. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 840­842). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Awarded 1.0 points out of 1.0 possible points. AH.38.ID: A nurse is assigned to care for a client with an infection caused by methicillin­ resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client’s room, which necessary protective items does the nurse obtain? Select all that apply. A. Mask Incorrect B. Gown Correct C. Gloves Correct D. Face shield Correct E. Shoe protectors Rationale: Infection caused by MRSA necessitates contact precautions. The care of this client requires the use of gown, gloves, and a face shield. The face shield is worn to protect the face and the mucous membranes of the mouth, nose, and eyes during interventions that could produce splashes of blood, body fluids, secretions, and excretions (e.g., wound irrigation and suctioning). Contact precautions also require the use of gloves and a gown if direct client contact is anticipated. A mask does not provide adequate protection. Shoe protectors are not necessary. Test­Taking Strategy: Focus on the data in the question and think about the events that might occur during a wound irrigation and suctioning. This will help you determine the necessary items for the care of this client. If you had difficulty with this question, review standard and contact precautions. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 655, 663). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 0.0 points out of 1.0 possible points. AI. 39.ID: A nurse is assisting with disaster relief after a tornado. The nurse’s goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? A. Initial B. Primary C. Tertiary Correct D. Secondary Awarded 1.0 points out of 1.0 possible points. AJ. 40.ID: A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? A. Airway patency Correct B. Active bowel sounds C. Adequate urine output D. Orientation to surroundings Awarded 1.0 points out of 1.0 possible points. AK. 41.ID: A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client’s physician does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is appropriate? A. Asking a family member to sit with the client B. Asking a nursing assistant to monitor the client C. Staying with the client and consulting with the nurse manager about the situation Correct D. Telling the family that the application of wrist restraints is critical in preventing injury to the client Awarded 1.0 points out of 1.0 possible points. AL. 42.ID: A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10­car wreck on the interstate will be brought to the ED. The nurse manager initially manages this situation by: A. Telling EMS to take the victims to another hospital B. Closing the emergency department temporarily to incoming clients C. Calling the nursing supervisor to discuss activation of the disaster plan Correct D. Demanding that the nurses from the night shift stay until all of the victims have been treated Awarded 1.0 points out of 1.0 possible points. AM. 43.ID: A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first? A. A victim who has died of multiple serious injuries B. A hysterical victim who has sustained a head injury C. An alert victim who has numerous bruises on the arms and legs D. A victim with a partial amputation of a leg who is bleeding profusely Correct Awarded 1.0 points out of 1.0 possible points. AN.44.ID: A nurse giving a client a bed bath drops the towel on the floor. The nurse should: A. Use a bath blanket as a towel B. Borrow a towel from the client’s roommate C. Wash her hands, pick up the towel, and shake the towel out D. Wash her hands and go to the linen room to obtain another towel Correct Rationale: To avoid spreading the client’s germs, the nurse must wash her hands before leaving the client’s room. Therefore the nurse should cover the client and ensure that the client is safe, wash her hands, and go to the linen room to obtain another towel. It is not appropriate to use a bath blanket as a towel. It is never appropriate to borrow other clients’ supplies, because this is inconsistent with the principles of infection control. The nurse would never use linen that had been dropped on the floor. Also, shaking linen spreads germs. Test­Taking Strategy: Focus on the data in the question and note that the nurse has dropped the towel on the floor. Read each option carefully and use your knowledge of infection control and the principles of bathing a client to direct you to the correct option. Review the principles of infection control if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 874­877). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. AO. 45.ID: A nurse is attending an inservice program on disaster preparedness. Which of the following events is described as an example of a natural disaster? A. Drought Correct B. Bus accident C. Terrorist attack D. Toxic waste spill Awarded 1.0 points out of 1.0 possible points. AP. 46.ID: A nurse manager tells the nursing staff that the agency’s disaster preparedness plan will be distributed to all employees for review. The nurse manager states that the plan is an important component of disaster readiness because it primarily: A. Identifies the location of healthcare supplies B. Identifies the types of disasters that may occur C. Aids determination of how victims will be triaged D. Describes a formal plan of action for the coordination of a response Correct Awarded 1.0 points out of 1.0 possible points. AQ. 47.ID: A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? A. Declaring a disaster B. Providing disaster relief Correct C. Activating disaster medical assistant teams D. Developing a federal disaster response plan Awarded 1.0 points out of 1.0 possible points. AR.48.ID: A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. A. Anthrax is never fatal. B. No vaccine to prevent anthrax is available. C. Anthrax can be transmitted from person to person. D. A blood test is available for the detection of anthrax. Correct E. One way that anthrax can be contracted is through the skin. Correct Awarded 1.0 points out of 1.0 possible points. AS. 49.ID: Acccording to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, in which phase are the available resources for the care of infants, older clients, the disabled, and people with chronic health problems addressed? A. Response B. Recovery C. Mitigation Correct D. Preparedness Rationale: The mitigation phase consists of actions or measures that can either prevent the occurrence of a disaster or reduce a disaster’s damaging effects. The task of determining the resources available for the care of infants, older clients, the disabled, and people with chronic health problems is addressed in this phase. The preparedness phase involves actions that plan for rescue, evacuation, and care of disaster victims. The response phase involves putting disaster­planning services into action and enumerating the actions needed to save lives and prevent further damage. The recovery phase includes actions taken to return to normal after the disaster. Test­Taking Strategy: Focus on the subject, available resources. Think about the definition of each item in the options. This will help you determine the correct phase. Review the phases of disaster management if you had difficulty with this question. Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for families and populations (4th ed., pp. 566, 567). Philadelphia: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Biological/Chemical Warfare Awarded 1.0 points out of 1.0 possible points. AT. 50.ID: An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. A. Keep visitors to a minimum B. Acknowledge the client’s feelings Correct C. Provide information about hospital routinesCorrect D. Put the client in a room far from the nurses’ station E. Keep the door open and the room lights on at all times F. Allow the client to have as many choices regarding his care as possible Correct Rationale: Several general interventions can be used to minimize stress in the hospitalized client. These include acknowledging the client’s feelings, providing information, providing social support, and giving the client control, when possible, over choices related to care. Admitting the client to a room far from the nurses’ station and limiting visitors would both serve to increase the client’s anxiety. Keeping the door open and the room lights on at all times could cause further disruption in the client’s sleep pattern in addition to the disruption created by the hospitalization. Test­Taking Strategy: The strategic words are “safe” and “minimize the stress.” This tells you that the correct option(s) allay(s) the client’s fears and anxiety after sudden placement in a foreign environment. Use your knowledge of the principles of safety and stress reduction to answer the question and review these principles if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., pp. 17, 18). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. AU.51.ID: A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. A. Have a first aid kit available. Correct B. Have a firearm or other weapon available. C. Plan a meeting place for family members.Correct D. Obtain a 1­day supply of water (1 gallon per person). E. Have an adequate supply of prescription medications. Correct F. Have a battery­operated radio and a flashlight and batteries available. Correct Awarded 1.0 points out of 1.0 possible points. AV. 52.ID: A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. A. A victim with respiratory distress Correct B. A victim with a fractured humerus C. A victim with partial amputation of the footCorrect D. A victim with a forehead laceration that is not bleeding E. A victim with multiple nonbleeding bruises of the arms and legs Rationale: One rating system commonly used in the ED consists of three tiers — emergent, urgent, and nonurgent — with the categories sometimes identified with color coding or numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life­threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a. yellow or priority 2) classification is given to clients whose injuries and complications are not life threatening (here, the client with the fractured humerus), provided that they are treated within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients with the forehead laceration and bruises of the arms and legs) who do not have immediate complications and can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Test­Taking Strategy: Use the ABCs — airway, breathing, and circulation — which will easily direct you to the correct options. Respiratory distress involves the airway, and the victim with amputation is at risk for bleeding (i.e., circulation). Review the triage system and priorities of care if you had difficulty with this question. References: Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health for families and populations (4th ed., p. 567). Philadelphia: Saunders. McEwen, M., & Pullis, B. (2009). Community­based nursing: An introduction (3rd ed., p. 157). Philadelphia: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Awarded 1.0 points out of 1.0 possible points. AW. 53.ID: A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply. A. Untacked rugs on the stairs Correct B. Small rugs in the living room Correct C. Carpet on stairs secured with tacks D. Clothes hamper at the end of the hallway E. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator Correct Rationale: Area rugs and runners should not be used on or near stairs. Injuries in the home are frequently the result of loose objects, including small rugs on the stairs or floor, wet spots on the floor, or clutter on bedside tables, closet shelves, the top of the refrigerator, and bookshelves. Care should also be taken to ensure that end tables are secure and have stable straight legs. Nonessential items should be placed in drawers to eliminate clutter. If the stairs must be carpeted, carpeting should be secured with the use of tacks. Test­Taking Strategy: Note the strategic words “requires instruction.” These words indicate a negative event query and the need to identify safety hazards in the environment. Reading each option carefully will assist you in answering correctly. Review safety hazards in the home if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 1062). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Awarded 1.0 points out of 1.0 possible points. AX. 54.ID: A home health nurse is performing an assessment of a client’s skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client? A. Putting on a pair of gloves B. Donning a mask and gloves C. Putting on a gown and gloves Correct D. Avoiding sitting on the client’s furniture Awarded 1.0 points out of 1.0 possible points. AY. 55.ID: An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? A. An open ulcer B. An itchy bump Correct C. A weeping blister D. A black skin area of skin Awarded 1.0 points out of 1.0 possible points. AZ. 56.ID: A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of inhalation anthrax is: A. Hemorrhage B. Signs of shock C. Flulike symptoms Correct D. Respiratory distress Rationale: Inhalation anthrax is caused by the inhalation of spores from Bacillus anthracis, which multiply in the alveoli. This form of anthrax begins with the same symptoms as the flu, including fever, muscle aches, and fatigue. Symptoms suddenly become more severe with the development of breathing problems and shock. Toxins from the anthrax spores cause hemorrhage and destruction of lung tissue. Test­Taking Strategy: Focus on the data in the question and note the strategic word “inhalation.” This will assist you in eliminating the options that indicate hemorrhage and signs of shock. To select from the remaining options, note the word “early,” which will direct you to the correct option. Review the signs of inhalation anthrax if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., pp. 672, 673). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/Chemical Warfare Awarded 1.0 points out of 1.0 possible points. BA. 57.ID: A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse? A. “You really need to ask your doctor about that.” B. “That’s hard to say. We won’t know for a week or two.” C. “Antibiotic therapy is usually prescribed and will cure the infection.” Correct D. “It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly.” Rationale: Skin anthrax starts with an itchy bump (papule) that looks like a mosquito bite. It progresses to a small fluid­filled sac that becomes a painless ulcer with an area of dead black tissue in the middle. (Toxins from the anthrax spores destroy surrounding tissue.) Antibiotic treatment cures this infection, but untreated skin anthrax can result in overwhelming septicemia and death. Replying, “You really need to ask your physician about that” or “That’s hard to say. We won’t know for a week or two” is nontherapeutic and places the client’s question on hold. Stating, “It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly” is incorrect. Test­Taking Strategy: Use your knowledge of therapeutic communication techniques to eliminate the options that place the client’s question on hold. To select from the remaining options, note that the correct option is the only one that directly addresses the client’s question. Review skin anthrax and therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient–centered collaborative care (6th ed., pp. 166, 167). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Biological/chemical warfare Awarded 1.0 points out of 1.0 possible points. BB. 58.ID: The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? A. Enteric B. Inhalation Correct C. Gastrointestinal D. Through open wounds Rationale: Smallpox, transmitted in air droplets and in the handling of contaminated materials, is highly contagious. Symptoms include fever, back pain, vomiting, malaise, and headache, followed 2 days later by the appearance of papules that progress to pustular vesicles, which are initially abundant on the face and extremities. Enteric, gastrointestinal, and open wounds are not routes of smallpox transmission. Test­Taking Strategy: Specific knowledge regarding the route of transmission of smallpox is necessary to answer this question. Remember that smallpox is transmitted in air droplets and through the handling of contaminated materials. Review the characteristics of smallpox if you had difficulty with this question. References: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., p. 338). St. Louis: Saunders. McEwen, M., & Pullis, B. (2009). Community­based nursing: An introduction (3rd ed., pp. 411, 412). Philadelphia: Saunders. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Infection Control Awarded 1.0 points out of 1.0 possible points. BC.59.ID: A client with paraplegia has spasticity of the leg muscles. Which interventions should be included in the plan of care for this client? Select all that apply. A. The use of restraints to immobilize the limbs B. Range­of­motion exercises of the affected limbsCorrect C. An as­needed prescription for a muscle relaxantCorrect D. Removal of potentially harmful objects near the client Correct E. The use of padding against the client’s legs when the client is sitting in a wheelchair Correct Awarded 1.0 points out of 1.0 possible points. BD.60.ID: A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet? A. Soak the scab that forms with warm water every day. B. Keep the vaccination site open to air as much as possible. C. Apply an antihistamine ointment to the scab to prevent itching. D. Avoid sharing towels or other items that have come in contact with the vaccination site. Correct Awarded 1.0 points out of 1.0 possible points. BE. 61.ID: An older client in a long­term care facility is at risk for injury because of confusion. Which of the following devices would be the best choice to help prevent injury while the client is in bed? A. B. C.