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Client Need 1:

Safe and Effective Care Environment

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

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Other PracticeQs:

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