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21.A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the AP's indicates a need for further teaching?

"As long as I change gloves between clients, it is not necessary to wash my hands." Rationale: While the use of gloves does reduce contamination, it is still necessary to perform hand hygiene between clients. This statement by one of the AP's indicates a need for further teaching.

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." Rationale: The staff should rub the product over all aspects of the hands and fingers until they are dry, which generally takes 20 to 30 seconds.

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

"The client was lying on the floor next to his bed." Rationale:In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?

"The provider was notified." Rationale: Nursing interventions that support factual information should be documented in the health record.

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne Rationale: The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time. Rationale: The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects.

A nurse is preparing to remove staples from a client's surgical incision. Which of the following actions should the nurse take? (Select all that apply.)

Clean the surgical site. Examine the incision. Verify the prescription for staple removal.

A nurse in a provider's office is caring for a client who reports pruritus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders?

Contact dermatitis Rationale: These findings are consistent with contact dermatitis, which is skin inflammation that results from direct skin contact with chemicals or causative agents.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice Rationale: Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

A nurse is caring for a client who requires removal of surgical sutures. Which of the following actions should the nurse take?

Cut the suture as close to the skin as possible. Rationale: The nurse should grasp the surgical knot with tweezers and gently lift while cutting below the suture knot. To avoid contamination, the nurse should never pull the visible portion of a suture through underlying tissue. The part of the sutures that is exposed on the skin surface harbours micro-organisms and debris and pulling the contaminated portion of the suture through the tissue can lead to infection.

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?

Delivers a low concentration of oxygen Rationale:A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene?

Washes and rinses her hands for 10 seconds Rationale: The nurse should intervene because the AP should wash her hands for at least 20 seconds.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion Rationale:Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion.

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?

Report of exposure to a skin irritant Rationale: The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is a component of treatment.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Laceration Rationale:Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound.

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Mask Rationale: The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.

A nurse is measuring a client for knee-high anti embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space. Rationale:If the stocking is too short, if could impair circulation at its upper end. If it is too long, it can bunch together, which would cause pressure and irritate the skin. Measuring the length from the feet to the popliteal space helps the nurse identify the right size stockings for the client's legs.

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Performing hand hygiene before, during, and after direct contact with the client Rationale: The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures.

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Remove the gloves. Remove the eyewear. Remove the gown. Remove the face mask. Perform hand hygiene.

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Reposition the client at least every 2 hr. Rationale: The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

8.A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie. Rationale: The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care. Rationale:Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.

Cut the suture as close to the skin as possible. Rationale: The nurse should grasp the surgical knot with tweezers and gently lift while cutting below the suture knot. To avoid contamination, the nurse should never pull the visible portion of a suture through underlying tissue. The part of the sutures that is exposed on the skin surface harbours micro-organisms and debris and pulling the contaminated portion of the suture through the tissue can lead to infection.

Urine output of 175 mL in the past 8 hr Rationale: The nurse should notify the provider if the client's urinary output is less than 30 mL/hr. This finding indicates a fluid imbalance, decreased circulating fluid volume, and possibly inadequate renal perfusion.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Use soap and water to wash the catheter after each use. Rationale: The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

Withdraw 3 to 5 mL of urine from the port. Rationale: The nurse should withdraw the required amount of urine which would be approximately 3 to 5mL for a urine culture or 30 mL for a routine urinalysis.