exam 1 refresher
During measurement of a rectal temperature, the thermometer probe should be inserted about how many inches (centimeters) into the anus in an infant? 0.5 in (1.25 cm) 1 in (2.5 cm)
1 in (2.5 cm) Insert the thermometer probe into the anus about 1.5 inches (3.75 cm) in an adult or no more than 1 inch (2.5 cm) in an infant.
Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply. 1-Nurses limit the spread of microorganisms by directing the chain of infection. 2-Nurses practice asepsis, which encompasses all activities to prevent infection. 3-Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. 4-Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. 5-Nurses use personal protective equipment (PPE), which is the most effective way to help prevent the spread of organisms. 6-Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.
2-Nurses practice asepsis, which encompasses all activities to prevent infection. 3-Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. 4-Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. 6-Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection. Limiting the spread of microorganisms is accomplished by breaking the chain of infection, not by directing the chain. The practice of asepsis includes all activities to prevent infection or break the chain of infection. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Surgical asepsis, or sterile technique, includes practices used to render and keep objects and areas free from microorganisms. Hand hygiene is the most effective way to help prevent the spread of organisms. The use of Standard and Transmission-Based Precautions is an important part of preventing infection.
A nurse is providing care to several clients. The nurse performs handwashing with soap and water instead of an alcohol-based hand sanitizer for a client infected with which pathogen? Select all that apply. Clostridium difficile Norovirus Staphylococcus aureas Candida albicans E. coli
Clostridium difficile Norovirus Alcohol-based products are not effective against Clostridium difficile or Norovirus. Therefore, handwashing with soap and water is required for any contact with a client who has diarrhea. Use of alcohol-based products are appropriate for clients with infections involving Staphylococcus aureas, candida, and E. coli.
A nurse caring for a client in a long-term health care facility measures the client's intake and output and weighs the client to assess water balance. These actions help to meet which type of need in Maslow's hierarchy of needs? Safety and security Physiologic
Physiologic A balance between the intake and elimination of fluids is essential to life and is, therefore, a physiologic need, according to Maslow's hierarchy of needs. Measuring intake and output and weighing the client help the nurse assess water balance. Safety needs in Maslow's hierarchy refer to the need for security and protection. The third stage in Maslow's hierarchy of needs is the social stage (also known as the love and belonging stage), which includes the need for interpersonal relationships. Self-actualization represents growth of an individual toward fulfillment of the highest needs; those for meaning in life.
When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? Physiologic Safety and security
Safety and security Physiologic needs are the physical requirements for human survival. Physiologic needs include breathing, water, food, sleep, clothing, shelter, and sex. Once a person's physiologic needs are relatively satisfied, the person's safety needs take precedence and dominate behavior. Safety and security needs include personal security, emotional security, financial security, health and well-being, and safety against accidents or illness and their adverse impacts. After physiologic and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of love and belonging. These include relationships with friends, intimacy, and family. Self-esteem needs are ego needs or status needs, such as for getting recognition, status, importance, and respect from others. All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Self-actualization is what a person's full potential is and the realization of that potential.
The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position? Sims Dorsal recumbent supine semi-Fowler position
Sims The Sims, or side-lying, position is especially used for clients who have limited hip mobility because it permits excellent visualization of the urinary meatus. Usually, female clients are placed in a dorsal recumbent position for catheterization, and male clients are put in a supine or semi-Fowler position.
A client who has undergone resection of the intestine is NPO with a nasogastric (NG) tube in place. A food tray with regular food comes to the room, and the client insists that the health care provider be called. The nurse insists that it is okay and encourages the client eat the food. The client complies and later develops complications that require another operation. Which action constitutes the primary breach of duty in this situation? The nurse encouraged the client to eat. The nurse did not realize the importance and purpose of the NG tube
The nurse did not realize the importance and purpose of the NG tube. Negligence is defined as harm that occurs because the person did not act reasonably. Establishing liability for negligence requires four elements: duty, breach of duty, causation, and damages. In this case, the primary breach of duty is that the nurse did not realize that the client was on an NG tube and should consequently have been on liquid feeds after intestinal surgery; as a result, the client at the food and developed complications. The acts of not calling the physician and insisting the client have food are not the primary breach of duty, as they are logical based on the assumption that the client could take food by mouth. The dietary department sending the wrong food is unrelated to the nurse.
A nurse is explaining the process of infection to a nursing student. Place the process in the most appropriate order. susceptible host transmission mode infectious agent entry portal a reservoir an exit route
infectious agent a reservoir an exit route transmission mode entry portal susceptible host The infectious process begins with an infectious agent. Then the infection needs a reservoir or place to grow. Once it grows, it needs a way out so that it can be transmitted. With transmission (e.g., sneezing), it needs an entry portal into a susceptible host.
When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: standard precautions contact precautions
standard precautions Standard or universal precautions relate to blood and certain body fluids to protect health care workers from clients possibly carrying HIV, hepatitis B virus, or other bloodborne pathogens.
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? condom catheter straight catheter retention catheter A urinary bag
straight catheter The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.
When collecting data on a client, the nurse implements which nonverbal communication form as one of the most effective to express feelings? eye contact touch Body posture gait
touch Touch, despite its individual variability, is viewed as one of the most effective nonverbal communication methods to express feelings. Not all cultures use direct eye contact; it may be considered disrespectful. Posture and gait are used to express feelings, but they are not as effective as touch.