Exam 1 prep u practice questions (24, 25, 31)

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond? "It is possible that you are not washing your hands well enough." "You will have to limit who comes to visit since they may be exposing you." "As we age, our immune system does not function as well." "There are a lot of infectious processes around and there is nothing that can be done."

"As we age, our immune system does not function as well."

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? "My personal belongings should remain in the room until I am discharged." "I can leave my room any time I want as long as I wear a mask." "I will tell my visitors to keep their distance from me." "Any staff who enters my room will be wearing personal protective equipment (PPE)."

"I can leave my room any time I want as long as I wear a mask."

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction? "I should install grab bars in the shower or tub at arm level of my loved one." "I should check the bath water temperature before allowing my loved one to bathe." "I should provide soap for daily bathing to remove debris and keep my loved one's skin moist." "I should obtain a tub or shower seat because my loved one has mobility issues."

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate? -"You will need to remain NPO until I notify your health care provider about your increased temperature." -"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." -"Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." -"I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly."

"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

A nurse is educating a postoperative adult client about taking daily temperatures. What statement by the client best indicates understanding of education? "I will use an ear thermometer because it is most accurate in postoperative clients." "If my temperature is above 99.6°F( 38.3°C) I should call the health care provider." "It is okay to take my temperature by mouth right after eating or drinking as long as it is not coffee." "I will use my axillary thermometer because it is convenient and accurate postoperatively."

"If my temperature is above 99.6F (38.3C) I should call the health care provider."

A client with a localized inflammatory response asks the nurse why the area is reddened. Which response by the nurse would be most appropriate? "There is pressure on, and injury to, the local nerves." "It's due to the fluid accumulating in the area." "There is bleeding into the interstitial space in the area." "It is the result of blood accumulating in the dilated vessels."

"It is the result of blood accumulating in the dilated vessels."

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? "You should not visit your friend if you have an infection of any kind because your friend may also get sick." "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others." "As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." "If you wash your hands before coming in contact with your friend you will prevent infection during your visit."

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

A client who has been reluctant to have the hair shampooed for 1 week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." What response by the nurse is appropriate? "Tell me about what you do to take care of your hair." "Please tell me what products you use for washing your hair." "Tell me why you do not want me to wash your hair." "How often do you wash your hair?"

"Tell me about what you do to take care of your hair."

The acute care nurse is talking with an older client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath and the person who bathed me today didn't even use soap and water, and barely rubbed my skin to dry it." Which response by the nurse is most appropriate? -"Can you tell me the name of the person who bathed you this morning? I will review proper bathing procedures with this person." -"When you feel well enough to bathe yourself, we can give you your favorite soap and a big, thick towel." -"It sounds like you are not happy with the care you are receiving. Would you like me to bathe you again?" -"That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact."

"That person probably used special bathing products and deliberately avoided scrubbing to help keep your skin intact."

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? "Using either side of the drape is okay, as long as you do not contaminate the sterile supplies on the field." "The way you are doing it helps to minimize contamination of the non-waterproof side." "I use my whole hand to touch the non-waterproof surface before placing the sterile equipment on it." "It is okay to turn the drape on the other side."

"The way that you are doing it helps to minimize contamination of the non-waterproof side."

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement? "Those spots are benign and are known as seborrheic keratoses." "Older people often have splotchy skin due to seborrheic keratoses." "Those spots are senile lentigines and may be cancerous." "Those are senile lentigines and are common in older adults."

"Those are senile lentigines and are common in older adults."

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement? "Those spots are senile lentigines and may be cancerous." "Those are senile lentigines and are common in older adults." "Older people often have splotchy skin due to seborrheic keratoses." "Those spots are benign and are known as seborrheic keratoses."

"Those are senile lentigines and are common in older adults."

A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask? "What are your expectations about bathing at this time?" "What kind of soap do you like to use?" "Are you not able to bathe yourself?" "Do you want to bathe regularly?"

"What are your expectations about bathing at this time?" If you want to assess her normal hygiene habits you need to assess what her expectations are.

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. The client has a temperature of 101.8°F (38.8°C) The client has a blood pressure of 122/70 mm Hg The client just finished ambulating with physical therapy The client has reports of pain of 8 on a scale of 0 to 10 The client has been drinking water

-The client has a temperature of 101.8F (38.8C) -The client just finished ambulating with physical therapy -The client has reports of pain of 8 on a scale of 0 to 10.

A female client with a Foley catheter requires perineal care. Which intervention(s) does the nurse use to prevent a health care-acquired infection? Select all that apply. Use front-to-back cleaning technique. Spread labia majora and wipe down the center, working from inner to outer areas. With each draining of the collection bag, also cleanse perineal areas with premoistened, rinse-free, disposable washcloths. If the catheter is soiled, clean with soap and water using proximal-to-distal technique. Turn folded washcloth over to new area each time a section of perineal area is cleaned.

-Use front-to-back cleaning technique -Spread labia majora and wipe down the center, working from inner to outer areas -If the catheter is soiled, clean with soap and water using proximal-to-distal technique -Turn folded washcloth over to a new area each time a section of perineal area is cleaned

When creating the teaching plan for a client who will be monitoring his or her pulse at home, which factors should the nurse teach the client that may influence the pulse rate by causing an increase in pulse? Select all that apply. Male gender Exercise Stress Aging Fever

-exercise -fever -stress

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? 0300 1500 1700 1100

1700 (5:00PM)

When assessing an infant's axillary temperature, it will be: the same as the tympanic temperature. 1°F (0.5°C) lower than an oral temperature. 1°F (0.5°C) higher than a rectal temperature. 1°F (0.5°C) higher than an oral temperature.

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

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur. 1Full stage of illness 2Prodromal stage 3Incubation period 4Convalescent period

3Incubation period 2Prodromal stage 1Full stage of illness 4Convalescent period

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

5, 7, 2, 1, 3, 4, 6

The nurse is caring for four clients. For which client is a sitz bath most appropriate? 51-year old with hemorrhoids 60-year old who is 1-day postop from a knee replacement 42-year old recovering from a C-section delivery 73-year old with pneumonia who can get up to bedside commode

51-year old with hemorroids

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into? R= Recommendation S= Situation B= Background A= Assessment

A = Assessment

Which client would the nurse consider at risk for low blood pressure? a client with a strong pumping action of blood into the arteries a client with low blood volume a client with high blood viscosity a client with decreased elasticity of walls of arterioles

A client with low blood volume

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments? When a sterile item touches something that is not sterile, it may not be contaminated. Any partially uncovered sterile package need not be considered contaminated. Sterility may not be preserved even when one sterile item touches another sterile item. A commercially packaged surgical item is not considered sterile if past expiration date.

A commercially packaged surgical item is not considered sterile if past the expiration date.

After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter? Soap and water hand washing technique Mixture of soap and alcohol-based hand rub techniques Scrubbing hands with soap, water, and brush Alcohol-based hand rub

Alcohol-based hand rub

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client? Use skin lotion daily and avoid giving bed baths. Provide a tub bath with bath oil every day. Provide a full bed bath with soap and water every day Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client? Provide a tub bath with bath oil every day. Provide a full bed bath with soap and water every day Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next. Use skin lotion daily and avoid giving bed baths.

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? ask the client to demonstrate self-blood pressure assessment report readings to primary care provider recommend lower sodium in the client's diet provide the client with a larger blood pressure cuff

Ask the client to demonstrate self-blood pressure assessment

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment? auscultate the client's brachial artery auscultate the client's apical pulse palpate the client's apical pulse arrange for cardiac monitoring

Auscultate the client's apical pulse

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. Take the measurement with the client in a standing position with the appropriate limb exposed. Monitor for serial readings and check the cuffed limb frequently for inadequate arterial perfusion and venous drainage. If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level.

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. Take the measurement with the client in a standing position with the appropriate limb exposed. Monitor for serial readings and check the cuffed limb frequently for inadequate arterial perfusion and venous drainage. Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? wearing clean unsterile gloves when changing the dressing isolating the client's belongings changing the soiled dressing applying a face mask with shield

Changing the soiled dressing

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? Client in the ICU for one day Client receiving chemotherapy Client on a short course of vancomycin Client with a history of eczema

Client receiving chemotherapy

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? Client with a urinary catheter Client with an intravenous catheter Client with a surgical wound Client with a diabetic foot ulcer

Client with a urinary catheter

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply. contagious disease noncommunicable disease health care-associated infection (HAI) infectious disease communicable disease

Contagious disease Infectious disease Communicable disease

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention? Do not use over-the-counter products on unknown rashes. Use a tepid bath to relieve inflammation and itching. Use a moisturizing lotion on a wet rash to prevent itching. Avoid washing the area because cleansing agents will only make the rash worse.

Use a tepid bath to relieve inflammation and itching.

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. Do not wash hands; apply clean gloves. Wash hands with soap and hot water. Wash hands with soap and water, followed by an alcohol-based hand rub.

Decontaminate hands using an alcohol-based hand rub.

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority? Promoting the client's sense of well-being Preventing dental caries Preventing deterioration of the oral cavity Decreasing the incidence of hospital-acquired pneumonia

Decreasing the incidence of hospital-aquired pneumonia

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention? Evaluate blood pressure Evaluate pulse rate quality Determine cause Assess for history of heart disease

Determine cause

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation? conduction diaphoresis radiation convection

Diaphoresis (sweating)

Which statement describes diastolic blood pressure? The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. To assess diastolic pressure, the blood pressure measured during ventricular contraction. During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels

Which statement describes diastolic blood pressure? During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. To assess diastolic pressure, the blood pressure measured during ventricular contraction. The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries.

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

The nurse is educating a client about ways to increase their cardiac output. Which topic does the nurse include in the teaching? decrease in blood pressure dehydration exercise sleep

Exercise

The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention? Soap should be used sparingly so the client's skin does not become overly dry. Use bath oil in the tub to decrease dry skin. Obtain a tub or shower seat if the client has mobility issues. Grab bars should be placed in the shower or tub at arm level.

Use bath oil in the tub to decrease dry skin

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? fold soiled side to the outside and roll with outer surface exposed fold soiled side to the inside and roll with inner surface exposed fold soiled side to the outside and roll with inner surface exposed fold soiled side to the inside and roll with outer surface exposed

Fold the soiled side to the inside and roll with inner surface exposed

An older adult client is reporting dry, itching skin. The nurse should assess: when the severe itching occurs. how often the client is bathing. when the client's last tub bath was. what linens they are using.

How often a client is bathing

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next? Encourage the client to brush his teeth 3 times a day. Inform the physician about this finding. Assess for the expiration dates of the antibiotics being administered. Inform the client that the antibiotics will resolve this problem.

Inform the physician about this finding

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make? with another client with a draining wound with a client with a myocardial infarction into a private room with a client with pneumonia

Into a private room

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client? This is unusual and he should be seen by the physician as soon as possible. This has no impact on BP readings and he should continue doing what he has been doing. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results.

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. Keep hands lower than elbows to allow water to flow toward fingertips. Remove all jewelry, including wedding bands, before hand washing. Use an alcohol-based hand rub to decontaminate the hands.

Keeps hands lower than elbows to allow water to flow toward the fingertips

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? Compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns. Encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands. Grasp the client's inner wrist with the nondominant thumb positioned over the radial artery. Lightly compress the client's radial artery using the first, second, and third fingers.

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

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? medications listed on the client's medication administration record (MAR) client's allergies to soap since shaving cream is contraindicated in the hospital cultural views and attitudes toward facial hair and grooming the last time shaving was performed because clients can only shave twice weekly in the hospital

Medications listed on the client's medication administration record (MAR)

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer? Ability to read gauge from any direction. Need for readjustment is eliminated. Inexpensive depending on quality. No stethoscope is required.

No stethoscope is required

A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client? obtaining rectal temperatures providing gentle oral care encourage wearing a mask when out of the room avoiding razors with blades

Obtaining rectal temperatures

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? Measure the rate for 30 seconds and multiply by 2. Measure the rate for 1 full minute. Palpate both arteries at the same time. Palpate one artery at a time.

Palpate one artery at a time

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? The client should remain in an upright position to avoid the tongue blocking the airway. The client should be placed in a position of comfort. The client should be placed in a side-lying position to prevent aspiration. The client should be placed in the lithotomy position.

Patients should be placed in a side-lying position to prevent aspiration.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? Perform hand hygiene Wrap all used materials together and discard in biohazard container Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps Don a new pair of gloves to dispose of materials

Perform hand hygiene

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? pulmonary embolism chronic obstructive pulmonary disease (COPD) peripheral vascular disease coronary artery disease

Peripheral vascular disease A pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated, a finding that is congruent with peripheral vascular disease. It does not signal a lack of circulation to the heart muscle (coronary artery disease), a pulmonary embolism, or COPD.

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the: convalescent period acute period incubation period prodromal period

Prodromal period

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? applying direct pressure to an area that is bleeding pulling the razor against the direction of hair growth rinsing the razor after each stroke of the razor washing the skin with soap and water prior to shaving

Pulling the razor against the direction of hair growth

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor? placing the client's arm in a comfortable resting position placing the ear tips of the stethoscope forward into the ear using light pressure over the anatomic site for assessment pumping the blood pressure cuff up to 200 mm Hg routinely

Pumping the blood pressure cuff up to 200 mm Hg routinely

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? Place a protective pad under the client's head and shoulders. Close curtains around the bed and close the door to the room, if possible. Place a drain container underneath the drain of the shampoo board. Raise the bed to elbow height.

Raise the bed to elbow height

The nurse has delegated an unlicensed assistive personnel (UAP) to obtain a temperature reading for a client who has neutropenia. Which route used by the UAP requires immediate intervention? axillae tympanic rectal oral

Rectal

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? Shaving the face of a resident who has worn a beard for several years Providing a tub bath to a resident who is unable to mobilize independently Using a tool to remove a contact lens that has adhered to the resident's eye Providing oral care to a client who has cognitive deficits and a decreased level of consciousness

Using a tool to remove a contact lens that has adhered to the resident's eye

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? She has hot water to bathe in. She has good mobility around her home. She has motivation to participate in self-care. She has family and friends who help her with self-care.

She has the motivation to participate in self-care

A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client? sit-down shower chair sitz bath partial bath at a wash basin bag bath

Sitz bath

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? the ability of the arteries to stretch the thickness of circulating blood the volume of air entering the lungs the oxygen levels in the blood

The abilities of the arteries to stretch

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this? The client is covered with a couple of thick blankets. A rectal thermometer must be used. The thermometer is broken. The client is showing initial signs of infection.

The client is covered with a couple of thick blankets.

The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change? the client who is to be discharged home on hospice the client who has been given 3 units of whole blood the client who has unresolved pain issues the client who has had persistent diarrhea

The client who has had persistent diarrhea

The nurse is removing gloves after performing care for a client on droplet precautions. What action best adheres to principles of infection control?

The image in which the nurse already has one glove off and if touching the inside of the glove with her hand that no longer has a glove on it. NOT the image in which the nurse is not touching the glove with her bare hand, and or pulling at the gloves so bacteria flings everywhere.

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits? the importance of completely finishing the prescribed treatment the fact that the health problem is self-limiting the need to destroy all clothing and bedding that the child has used the importance of teaching their children adequate personal hygiene habits

The importance of finishing the prescribed treatment

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure? The nurse rinses thoroughly with water flowing away from the fingertips. The nurse uses about 2 tsp (10 ml) of liquid soap to wash hands. The nurse uses soap and cold water to wash hands. The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.

The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? The carotid pulse is bounding. The blood pressure is elevated. A baseline pulse rate is needed. The radial pulse is difficult to obtain.

The radial pulse is too difficult to obtain

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? traditional bed bath with linen change tub bath bag bath shower with assist

Traditional bed bath with linen change

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? Wear gloves whenever entering the client's room. Place the client in a private room that has monitored negative air pressure. Keep visitors 3 feet (1 m) from the client. Use respiratory protection when entering the room.

Wear gloves whenever entering the client's room

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? wearing a particulate respirator for all care and interaction with this client wearing protective eye wear for contact with this client wearing a face mask when entering and staying at a distance from the client placing the client in a regular, private room

Wearing a particular respirator for all care and interaction with this client.

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client? No, knee-high hose are more comfortable. Yes, these are a safety hazard and should not be worn. No, the indentations will go away. Yes, these can obstruct lower extremity circulation.

Yes, these can obstruct lower extremity circulation

The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?

You would want to put on gown and gloves*****

Which client would the nurse consider at risk for low blood pressure? a client with a strong pumping action of blood into the arteries a client with high blood viscosity a client with low blood volume a client with decreased elasticity of walls of arterioles

a client with low blood volume

The nurse is admitting a client who has a draining wound that is contaminated with Staphylococcus aureus. What type of precautions should the nurse initiate for this client? contact precautions neutropenic precautions airborne precautions droplet precautions

contact precautions

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? droplet contact none airborne

droplet

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts? exit route infectious microorganism susceptible host vehicle of transmission

exit route

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? hand washing sterile technique putting on gloves signs of healing

hand washing

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? the cell-mediated immune response early intervention with antibiotics low levels of flora intact skin and mucous membranes staying home when sick

intact skin and mucous membranes

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? signs and symptoms of infection vital sign monitoring intravenous antibiotic administration hand hygiene measures

intravenous antibiotic administration

Which term indicates a potentially serious client condition? pulse pressure afebrile eupnea pyrexia

pyrexia

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature? mouth ear axilla rectum

rectum

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. Swelling Redness Pain Coolness Exudate

swelling redness pain excudate

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse? bounding pulse rapid pulse thready pulse strong pulse

thready