Foundations test #1

What is the cycle of infection?

-Pathogen -Source of reservoir of infection -Portal of Exit -Means of transmission -Portal of entry -Susceptible host

Children under the age of 9 you assess the need for restraints how often?

1 hour

anuria is defined as

<50mL urine in 24 hrs

A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? A saline osmotic laxative A bulk-forming laxative Methylcellulose A stool softener

A saline osmotic laxative

What vitamin is in need of those that drink alcohol?

B

What are the main signs of infection?

High white blood cells High ESR erythrocyte sedimentation rate

how often do you assess the need for restraints on 9-17 years of age

Q2H

how often do you reassess the need for restraints on 18 years or older

Q4H

What two things are used for venous thrombosis prevention?

TED SCD's

A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime.

a

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? a. Decreased and highly concentrated b. Decreased and highly dilute c. Increased and concentrated d. Increased and dilute

a

muscle shortening and active movement a. isotonic b. isometric c. isokinetic

a

standard precautions apply to which items? a. mucus membranes b. blood c. nonintact skin d. intact skin e. sweat f. body fluid secretions

a b c f

What can a person do to care for their parents with Alzheimer's? select all a. ensure parents engage in regular exercise b. provide frequent reorientation c. ensure the parent to take naps frequently d. increase parents social interaction e. ensure that the parents routine changes frequently

a b d

Which common complications should the nurse observe for after removal of indwelling catheter SELECT all that apply a. urinary retention b. difficulty voiding c. urinary incontinence d. burning/irritation when voiding e. urinary frequency

a b d

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select all that apply. a. Keep extra batteries on hand. b. Do not get hair spray or other chemicals on the hearing aid. c. Store the hearing aid in a very warm environment so that it will not crack. d. Use a small knife to remove cerumen that becomes embedded in the earpiece. e. Carefully wipe the outer surface of the hearing aid to maintain cleanliness.

a b e

A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who is comatose and needs long-term nutritional support e. A patient who has anorexia and refuses to take foods via the oral route f. A patient with burns who has not been able to eat adequately for 5 days

a b f

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a. A patient diagnosed with peritonitis b. A patient who is on prolonged bedrest c. A patient who has diarrhea d. A patient who has gastroenteritis e. A patient who has an early bowel obstruction f. A patient who has paralytic ileus caused by surgery

a b f

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. a. A patient diagnosed with rubella b. A patient diagnosed with diphtheria c. A patient diagnosed with varicella d. A patient diagnosed with tuberculosis e. A patient diagnosed with MRSA f. An infant diagnosed with adenovirus infection

a b f

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a. Providing a bed bath for a patient b. Visibly soiled hands after changing the bedding of a patient c. Removing gloves when patient care is completed d. Inserting a urinary catheter for a female patient e. Assisting with a surgical placement of a cardiac stent f. removing old magazines from a patients table

a c d f

What needs to be included in the documentation of a nurse assessing a clients fecal device a. clients reaction to the procedure b. color and consistency of stool c. appearance of perianal area d. amount of stool in bag e. date and time fecal device is to be removed f. date and time fecal device was applied

a c d f

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a. A 78-year-old male patient diagnosed with an enlarged prostate b. An 83-year-old female patient who is on bedrest c. A 75-year-old female patient who is diagnosed with vaginal prolapse d. An 89-year-old male patient who has dementia e. A 73-year-old female patient who is taking antihistamines to treat allergies f. A 90-year-old male patient who has difficulty walking to the bathroom

a c e

A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. a. Measure the patient's fluid intake and output. b. Keep the skin around the stoma moist. c. Empty the appliance frequently. d. Report any mucus in the urine to the primary care provider. e. Encourage the patient to look away when changing the appliance. f. Monitor the return of intestinal function and peristalsis.

a c f

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Reevaluate the nursing care plan. d. Move to the patient's other side to perform exercises. e. Encourage the patient to finish the exercises and then rest. f. Assess the patient for other symptoms.

a c f

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a. Compare bilateral parts for symmetry. b. Proceed in a toe-to-head systematic manner. c. Use standard terminology to report and record findings. d. Do not allow data from the nursing history to direct the assessment. e. Document only skin abnormalities on the patient record. f. Perform the appropriate skin assessment when risk factors are identified.

a c f

A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore with the patient why she does not want to eat her food. d. Offer high-calorie snacks such as pudding and ice cream.

a- first step is always remove the food first

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual? a. Once per shift b. Every 4 to 6 hours c. Immediately after each flush that is administered d. Every 4 hours for the first 24 hours after tube placement and every 24 hours thereafter

b

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? a. When the patient had his or her most recent bath b. The patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is convenient for the patient care assistant

b

A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient? a. Administering pain medication after meals. b. Encouraging food from home when possible. c. Scheduling his respiratory therapy before each meal. d. Reinforcing the importance of his eating exactly what is delivered to him.

b

the nurse has just confirmed proper placement of the NG tube, what is the next step? a. measure the exposed end of the tube b. apply skin barrier to the tip and end of the nose c. secure the tube using tape d. lubricate the lips

b

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed?

b a d c

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. a. Do full-body pushups in bed six to eight times daily. b. Breathe in and out smoothly during quadriceps drills. c. Place the bed in the lowest position or use a footstool for dangling. d. Dangle on the side of the bed for 30 to 60 minutes. e. Allow the nurse to bathe the patient completely to prevent fatigue. f. Perform quadriceps two to three times per hour, four to six times a day.

b c f

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 50 b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year-old patient who is transferred to long-term care

b d f

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a. A patient who is taking narcotics for pain b. A patient who is taking metformin for type 2 diabetes mellitus c. A patient who is taking diuretics d. A patient who is dehydrated e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids

b e f

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? a. a verbal prescription of the restraints renewed every 48 hr b. the alternative measures attempted before applying the restraints c. the type of PPE used before applying restraints d. a detailed description of the restraint process.

b- ALWAY attempt ALTERNATIVE measures

antidepressants cause the urine to be what color?

blue green

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? a. Elevate the head of the bed 30 degrees and reposition the rectal tube. b. Place the patient in a supine position and modify the amount of solution. c. Lower the solution container and check the temperature and flow rate. d. Remove the rectal tube and notify the primary care provider.

c

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a. Reassure the patient that this is a normal finding with a new ostomy. b. Notify the primary care provider that the stoma is prolapsed. c. Have the patient rest for 30 minutes to see if the prolapse resolves. d. Remove the appliance and redo the procedure using a larger appliance

c

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? a. Shift the focus of the interaction to the "process of bathing." b. Wash the face and hair at the beginning of the bath. c. Consider using music to soothe anxiety and agitation. d. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. Have the patient extend his arms outward and cross his legs on top of a pillow. b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. c. Have the patient cross his arms on his chest and place a pillow between his knees. d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

c

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. Lateral position c. Fowler's position d. Sims' position

c

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? a. Teach the patient that incontinence is a normal occurrence with aging. b. Ask the patient's family to purchase incontinence pads for the patient. c. Teach the patient to perform PFMT exercises at regular intervals daily. d. Insert an indwelling catheter to prevent skin breakdown.

c

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

c

A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? a. The nurse administers a large volume of solution (500 to 1,000 mL) b. The nurse mixes milk and molasses in equal parts for an enema c. The nurse instructs the patient to retain the enema for at least 30 minutes d. The nurse administers the enema while the patient is sitting on the toilet

c

The nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection? a. A 60-year-old patient who smokes two packs of cigarettes daily b. A 40-year-old patient who has a white blood cell count of 6,000/mm3 c. A 65-year-old patient who has an indwelling urinary catheter in place d. A 60-year-old patient who is a vegetarian and slightly underweight

c

The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment? a. "Do you dribble urine throughout the day?" b. "Do you lose control of your urine all day?" c. "Do you have the sensation to urinate?" d. "Do you leak urine with strain or coughing?"

c

The nurse is teaching a class about caloric intake. Which statement should the nurse use to describe why weight loss may occur when a client has an infection? a. Infection can lead to diarrhea and loss of fluids from the body and a lack of nutrient absorption. b. Infection causes the body to perspire and burn more calories. c. Infection increases the basal metabolic rate and causes more calories to be utilized. d. Infection increases the respiratory rate and causes more calories to be utilized.

c

a nurse is assisting an older, continent client with dry skin. Which approach should the nurse take when bathing? a. provide a full bed bath w/ soap and water b. provide a tub bath with bath oil every day c. alternate between a full bed bath and on one day and use of skin lotion or bath oil the next. d. use lotion daily and avoid bed baths

c

contraction with resistance a. isotonic b. isometric c. isokinetic

c

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. Sixty percent of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Fire-related injury and death have declined due to the availability and use of smoke alarms. e. Fires are more likely to occur in homes without electricity or gas. f. Fires are less likely to spread if bedroom doors are kept open when sleeping.

c d e

What is the priority assessment when assisting a patient using a walker? a. allergies b. muscle strength c. cognitive function d. vital signs

c- a patient has to be able to understand and follow directions for proper use

What kind of meds lead to contraction of detrusor muscles?

cholinergic

A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a. Feed the patient solids first and then liquids last. b. Place the head of the bed at a 30-degree angle during feeding. c. Puree all foods to a liquid consistency. d. Provide a 30-minute rest period prior to mealtime.

d

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? a. Checking to make sure fire alarms are working properly. b. Preventing exposure to temperature extremes. c. Screening for partner or elder abuse. d. Making sure patient rooms are decluttered.

d

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure? a. Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. b. Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. c. Provide a light meal before the test and administer two Fleet enemas. d. Ensure that the client fasts 6 to 12 hours before the test as per policy.

d

after caring for a client with transmission based precautions, which action is correct? a. remove goggles before any other equipment b. remove respirator at the doorway c. slide one gloved hand under the other to remove d. touch the inside of the gown and pull it away from the torso

d

what liquid is considered clear liquid diet a. tomato soup b. orange juice c. milk d. cranberry juice

d

what outcome of providing oral care is the priority to the client? a. promoting client sense of well being b. preventing dental caries c. preventing deterioration of the oral cavity d. decrease the incidence of hospital- acquired pneumonia

d

A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a. "When you inspect the stoma, it should be dark purple-blue." b. "The size of the stoma will stabilize within 2 weeks." c. "Keep the skin around the stoma site clean and moist." d. "The stool from an ileostomy is normally liquid." e. "You should eat dark-green vegetables to control the odor of the stool." f. "You may have a tendency to develop food blockages."

d e f

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? reddish-brown, clear clear, light yellow dark brown, cloudy aromatic, green

dark brown, cloudy

What are ways that can lead to acute kidney injury/failure

dehydration, anaphylactic shock, sepsis, obstruction, medication

creatinine tests for what?

dehydration, total muscle mass, sever malnutrition

During urination, ___________ muscles contract and ___________muscles relax

detrusor , sphincter

What position do you place the foot in to prevent a foot drop?

dorsiflexion?

What are part of transmission based precautions? select all droplet microbial body fluids respiratory airborne contact

droplet, airborne, contact

How often do you remove restraints?

every 2 hours

glycosuria

glucose in the urine

the KATS index assess what?

independent functions the client can perform on their own daily living

Oliguria means

less than 400 ml in 24 hr

Function of the proprioceptor or Kinesthetic sense

locates the limbs/body part

serum albumin tests for what?

malnutrition and malabsorption

PPE for standard precautions involves what?

mask gloves eye protection fluid repellent gown

Epistaxis occurs during removal of the NG tube. What should the nurse do during this occurrence?

occlude both nares until bleeding stops

Phenazopyridine cause the urine to be what color?

orange/red

Dysuria means

painful or difficult urination

diuretics cause the urine to be what color?

pale yellow

anticoagulants cause the urine to be what color?

pink/red

What is the major factor that contributes to fall in hospitals?

polypharmacy

At what stage of infection is a person the most infectious and shows NON specific signs?

prodromal

What position do you avoid when a client has a spinal injury?

prone

Pyuria means:

pus in the urine

An older adult woman tells the nurse that she has trouble controlling her urine. She states, "The urine starts dripping even before I feel like I have to go." The nurse interprets this as: urge incontinence. stress incontinence. functional incontinence. reflex incontinence.

reflex incontinence

What is the function of the labyrinthine sense?

sensory organ in inner ear, orientation movement/position

A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? urge total reflex stress

stress

Who might be at risk for dysphagia

stroke dementia

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? The stoma is hard and dry. The stoma is a pale pink color. The stoma is swollen. The stoma is a purple-blue color.

the stoma is purple blue color

The school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced? total urge reflex stress

total