Exam 1

A nurse is believed to have become infected by inhaling the spores of a bacterium. What precaution should have been applied when the nurse was working with the client who had this illness?

mask

Which of the following phrases is characteristic of case management as a method of healthcare delivery?

maximize positive outcomes and contain costs

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

"I've set up this sterile field for your procedure, so please do not touch anything around the tray."

The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate?

"If my pulse is higher than 100 beats/min at rest, that is considered abnormal."

The nurse is providing prenatal counseling for a pregnant client regarding the prevention of congenital disorders during pregnancy. Which statement made by the client indicates that the education provided was effective?

"My baby is most vulnerable if I take anything in the first 3 months of pregnancy."

The nurse is reviewing discharge instructions for a client who was prescribed amoxicillin to be taken twice a day. Which statement by the client would require further teaching?

"Once I start feeling better, I should stop taking the antibiotic."

A nurse is providing care to several clients at the clinic. When reviewing the clients' medical records, which client would the nurse identify as meeting the criteria for Medicare reimbursement? Select all that apply.

- 66-year-old male with heart failure - 45-year-old male with a permanent disability receiving social security benefits

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

managed care

A health care system whose goals are to provide cost effective quality care.

The nurse is providing care to several clients. For which client should the nurse include secondary care in the nursing plan of care?

A middle-aged client who presents with new-onset angina

Health

A state of complete physical, mental/emotional, and social well-being

Managed Care Organization (MCO)

A type of medical plan that pays for and manages the medical care a patient receives.

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care?

An older adult client who fell at home and required a hip replacement

A nurse is caring for an elderly client who has a history of postprandial hypotension. Which nursing intervention should be implemented?

Plan frequent, small meals throughout the day.

When pouring a sterile solution, what care should the nurse take to avoid contamination of the solution?

Pour and discard a small amount of the solution before each use

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

Apply a nonparticulate (N-95) respirator when entering the room.

Which nursing intervention is an example of tertiary preventive care?

Assisting with speech therapy a client with a traumatic brain injury

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?

Bradypnea is a response to IICP.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

The growth in home health care is largely attributed to which factor?

Early discharge of clients from the hospital setting

A nurse cares for clients with diabetes. Which is a characteristic of diabetes being a chronic illness?

Educate client and rehabilitation

Wellness

Full and balanced integration of all the aspects of health

The infection control nurse will be educating the clinical staff about a new infection control initiative that is being introduced at the health care facility. The initiative will further emphasize the need for hand hygiene. What information is important for the infection control nurse to include when educating the clinical staff?

Full compliance with hand hygiene is difficult to achieve.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

Provide privacy for the client.

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area?

Health promotion is the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

Hold sterile objects above waist level to prevent inadvertent contamination.

Values

Ideas that a person feels important ( knowledge, wealth, security, health )

The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?

Immediately assist the client back to bed.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers.

Nursing students are learning about common causes of congenital illnesses. Which would they correctly identify as potential causes? (Select all that apply.)

Rubella Alcohol Thalidomide

The nurse understands that a diagnostic-related group is one of the reimbursement strategies in a prospective payment system. The diagnostic-related group is a part of which health care system?

Medicare

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what?

Pathogenic

The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?

Teaching about adhering to a low-sodium diet

A nurse is assessing the blood pressure on a client with a BMI of 32. What error might occur if the cuff used is too narrow?

The reading will be erroneously high.

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?

Use a sterile intravenous catheter.

A nurse is teaching a client how to monitor the radial pulse after discharge from the hospital. Which instruction by the nurse is most appropriate?

Use the fingertips of your second and third fingers.

When providing care to a client, what perspective is followed by the nurse?

Viewing client's health as a balance of body, mind, and spirit

Surgical asepsis is defined as:

absence of all microorganisms

Nursing students are reviewing information about the changes in the health care industry and the effects on the scope of nursing practice. The students demonstrate understanding of this information when they identify what as having significantly affected the delivery of home health care?

advances in technology

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

The emergency department nurse is preparing a care plan for a young child who has suffered a fractured arm after a bicycle accident. Which factor should the nurse consider including in the care plan for this child to best address this issue?

applying for Children's Health Insurance Program (CHIP)

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

A preferred provider organization is described as a:

business arrangement between community health care providers and an insurance company.

A nurse is evaluating clients in an outpatient clinic. Which client requires the nurse to include a secondary illness in the care plan?

client with a history of chronic obstructive pulmonary disease (COPD) now has symptoms of right side heart failure

Beliefs

concepts that a person holds to be true

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which precautions are implemented by the nurse to prevent the spread of infection?

contact precautions

The nurse instructor has completed a session detailing major factors differentiating exacerbations from remissions. The instructor determines the session is successful when the students point out which factor(s) can contribute to exacerbations? Select all that apply.

immune system is functioning poorly sleep has been disrupted due to family issues client is facing a potential eviction

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

deep in the posterior sublingual pocket

A client is diagnosed with bradycardia. For which symptom should the nurse assess first?

dizziness

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

dysrhythmia

A client is in the terminal stage of leukemia. The client is discharged from the hospital and a licensed practical nurse is assigned for the nursing care of the client at home. This is an example of:

extended care

A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction?

facing away from the body

Preferred Provider Organization (PPO)

group of healthcare providers that provide services to a specific group, often at a reduced rate

What is the primary focus of health care today?

health promotion

A nurse has provided hygiene to an elderly client who has Clostridium difficile-related diarrhea. The nurse has been careful to wear a gown and gloves while providing care and has performed a thorough hand washing afterward. These precautions address what component of the chain of infection?

means of transmission

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50 mmHg. What is the name for this condition?

orthostatic hypotension

A nursing student has learned that an increasing number of individuals now live with one or more chronic illness. What health condition is an example of a chronic illness?

osteoarthritis

A client reports that she is in an abusive relationship and does not know how to break it off. Which of Maslow's hierarchy of needs does the nurse need to prioritize most for this client?

safety; security

Holism

sum of physical, emotional, social, and spiritual health

What is one way in which nurses can help shape health care reform?

support legislation to improve care

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

surgical asepsis

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent?

systolic pressure

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?

tertiary prevention

A pulse deficit is the difference between:

the apical pulse and the radial pulse rate Explanation: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

the client who is 48-hours postsurgical procedure

The nurse is educating a client about ways to increase their cardiac output. Which topic does the nurse include in the teaching?

to exercise