Safe and Effective Care Environment

1. A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia. She is admitted to the hospital for treatment. The nurse should assign the patient

(A) to a private room so she will not infect other patients and health care workers.
(B) to a private room so she will not be infected by other patients and health care workers.
(C) to a semiprivate room so she will have stimulation during her hospitalization.
(D) to a semiprivate room so she will have the opportunity to express her feelings about her illness.

2. The nurse teaches a group of mothers of toddlers how to prevent accidental poisoning. Which of the following suggestions should the nurse give regarding medications?

(A) Lock all medications in a cabinet.
(B) Child proof all the caps to medication bottles.
(C) Store medications on the highest shelf in a cupboard.
(D) Place medications in different containers.

3. While inserting a nasogastric tube, the nurse should use which of the following protective measures?

(A) Gloves, gown, goggles, and surgical cap.
(B) Sterile gloves, mask, plastic bags, and gown.
(C) Gloves, gown, mask, and goggles.
(D) Double gloves, goggles, mask, and surgical cap.

4. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions?

(A) Sims’.
(B) Side-lying.
(C) Supine.
(D) Prone.

5. A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN?

(A) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer.
(B) A 42-year-old patient with cancer of the bone complaining of pain.
(C) A 55-year-old patient with terminal cancer being transferred to hospice home care.
(D) A 23-year-old patient with a fracture of the right leg who asks to use the urinal.

ANSWERS AND RATIONALE

1. The correct answer is B.

Question: What are the needs of the patient with acute lymphocytic leukemia and thrombocytopenia?

Needed Info: Lymphocytic leukemia, disease characterized by proliferation of immature WBCs. Immature cells unable to fight infection as competently as mature white cells. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegs, small frequent meals, O₂, good skin care.

(A) to a private room so she will not infect other patients and health care workers — poses little or no threat
(B) to a private room so she will not be infected by other patients and health care workers — CORRECT: protects patient from exogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection
(C) to a semiprivate room so she will have stimulation during her hospitalization — should be placed in a room alone
(D) to a semiprivate room so she will have the opportunity to express her feelings about her illness — ensure that patient is provided with opportunities to express feelings about illness

2. The correct answer is A.

Question: What is the BEST way to prevent accidental poisoning in children?

Strategy: Picture toddlers at play.

(A) Lock all medications in a cabinet — CORRECT: improper storage most common cause of poisoning; highest incidence in two-year-olds
(B) Child proof all the caps to medication bottles — children can open
(C) Store medications on the highest shelf in a cupboard — toddlers climb
(D) Place medications in different containers — keep in original container

3. The correct answer is C.

Question: What is the correct universal precaution?

Strategy: Think about each answer choice. How is each measure protecting the nurse?

Needed Info: Mask, eye protection, face shield protect mucous membrane exposure; used if activities are likely to generate splash or sprays. Gowns used if activities are likely to generate splashes or sprays.

(A) Gloves, gown, goggles, and surgical cap — surgical caps offer protection to hair but aren’t required.
(B) Sterile gloves, mask, plastic bags, and gown — plastic bags provide no direct protection and aren’t part of universal precautions
(C) Gloves, gown, mask, and goggles — CORRECT: must use universal precautions on ALL patients; prevent skin and mucous membrane exposure when contact with blood or other body fluids is anticipated
(D) Double gloves, goggles, mask, and surgical cap — surgical cap not required; unnecessary to double glove

4. The correct answer is B.

Question: What is the best position after tonsillectomy to help with drainage of oral secretions?

Strategy: Picture the patient as described.

(A) Sims’ — on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination
(B) Side-lying — CORRECT: most effective to facilitate drainage of secretions from the mouth and pharynx; reduces possibility of airway obstruction.
(C) Supine — increased risk for aspiration, would not facilitate drainage of oral secretions
(D) Prone — risk for airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing

5. The correct answer is A.

Question: Which patient is an appropriate assignment for the LPN/LVN?

Strategy: Think about the skill level involved in each patient’s care.

Needed Info: LPN/LVN: assists with implementation of care; performs procedures; differentiates normal from abnormal; cares for stable patients with predictable conditions; has knowledge of asepsis and dressing changes; administers medications (varies with educational background and state nurse practice act).

(A) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer — CORRECT: stable patient with an expected outcome
(B) A 42-year-old patient with cancer of the bone complaining of pain — requires assessment; RN is the appropriate caregiver
(C) A 55-year-old patient with terminal cancer being transferred to hospice home care — requires nursing judgement; RN is the appropriate caregiver
(D) A 23-year-old patient with a fracture of the right leg who asks to use the urinal — standard unchanging procedure; assign to the nursing assistant

source: http://www.kaptest.com

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