NCLEX PRACTICE QUESTIONS BASED ON PROVISION OF A SAFE ENVIRONMENT Part-6

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Priority concepts are infection and safety

  • FIRE SAFETY: Priority nursing actions in case of FIRE including
    • RACE means
      • Rescue clients who are in immediate danger
      • Activate the fire alarm
      • Confine the fire
      • Extinguish the fire
    • PASS means Obtain the fire extinguisher
      • Pull the pin on the4 fire extinguisher
      • Aim at the base of the fire
      • Squeeze the extinguisher handle
      • Sweep the extinguisher from side to side to coat the area of the fire evenly
  • What are the types of fire extinguisher?
    • Type A including Wood, cloth, upholstery, paper, rubbish, plastic
    • Type B including Flammable liquids or gases, grease, tar, oil-based
    • Type C including Electrical equipment

Remember the mnemonic RACE (Rescue clients, Activate the fire alarm, Confine the fire, Extinguish the fire) to set priorities in the event of a fire and the mnemonic PASS (Pull the pin. Aim at the base of the fire, Squeeze the extinguisher handle, Sweep the extinguisher from side to side) to use a fire extinguisher.

  • Any electrical equipment that the client brings into the health care facility must be inspected for safety before use.
  • Sharps Needles should not be recapped, bent, or broken because of the risk of accidently injury (needle stick)
  • An PHCP’s prescription for use of a safety device (restraint) is needed. Alternative measures for safety devices should always be used first.
  • The Poison Control Center should be called first before attempting an intervention.
  • Handle all blood and body fluids from all clients as if they were contaminated.
  • In the event of a disaster, the emergency response plan is activated immediately.
  • Anthrax is transmitted by the direct contact with bacteria and spores and can be contracted through the digestive system, abrasions in the skin, or inhalation through the lungs.
  • SARIN is a highly toxic nerve gas that can cause death within minutes of exposure.
  • PHOSGENE is a colorless gas normally used in the chemical manufacturing that if inhaled at high concentrations for a long enough period will lead to severe respiratory distress, pulmonary edema and even death.
  • BOTULISM is serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium botulinum (death can occur within 24 hours)
  • PLAGUE is caused by the Yersinia pestis, a bacteria found in rodents and fleas

PRACTICE QUESTIONS:

  1. The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which actions?
    1. Intimate the IV line without the use of a pump
    2. Contact the electrical maintenance department for assistance
    3. Plug in the pump cord in the available plug above the room sink.
    4. Use an extension cord from the nurse’s lounge for the pump plug
  2. The nurse obtains a prescription from a primary health care provider to restrain a client and instructs assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?
    1. Placing a safety knot in the safety device straps
    2. Safely securing the safety device straps to the side rails
    3. Applying safety device straps that do not tighten when force is applied against them
    4. Securing so that 2 fingers can slide easily between the safety device and the client’s skin.
  3. The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.
    1. Bites from ticks or deer flies
    2. Inhalation of bacterial spores
    3. Through a cut or abrasion in the skin
    4. Direct contact with an infected individual
    5. Sexual contact with an infected individual
    6. Ingestion of contaminated undercooked meat
  4. The nurse is giving report to assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?
    1. Every 2 hours
    2. Every 3 hours
    3. Every 4 hours
    4. Every 30 minutes
  5. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?
    1. Wearing gloves when emptying the client’s bedpan
    2. Keeping all linens in the room until the implant is removed
    3. Wearing a lead apron when providing direct care to the client
    4. Placing the client in a semiprivate room at the end of the hallway
  6. Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by the methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?
    1. Gloves and gown
    2. Gloves and goggles
    3. Gloves, gown, and shoe protectors
    4. Gloves, gown, goggles, and a mask or face shield
  7. The nurse enters a client’s room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?
    1. Call for help
    2. Extinguish the fire
    3. Activate the fire alarm
    4. Confine the fire by closing the room door.
  8. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?
    1. Induce Vomiting
    2. Call an ambulance
    3. Call the Poison Control center
    4. Bring the child to the emergency department
  9. The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous causalities have occurred. The victims will be brought to the ED. The nurse should take which initial action?
    1. Prepare the triage rooms
    2. Activate the emergency response plan specific to the facility
    3. Obtain additional supplies from the central supply department
    4. Obtain additional nursing staff to assist in treating the causalities
  10. The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?
    1. Private room or cohort client
    2. Personal respiratory protection device
    3. Private room with negative airflow pressure
    4. Mask worn by staff when the client needs to leave the room
  11. The nurse working in the emergency department is assessing a client who is recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?
    1. Check the client’s temperature
    2. Isolate the client in a private room
    3. Check a complete set of vital signs
    4. Contact the primary health care provider

ANSWERS:

  1. 2
  2. 2
  3. 2,3,6
  4. 4
  5. 4
  6. 4
  7. 3
  8. 3
  9. 2
  10. 1
  11. 2

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