Fundamentals review exam part 2

An older adult patient has been lying in the supine position for three hours and tells the nurse that she is too uncomfortable to move right now. What is the best response by the nurse?

The nurse should assess the patient as needed for pain medication before helping her change positions

The nurse is assigned to care for a Muslim patient. When the nurse enters the room, he realizes that the patient is praying. What action by the nurse is most appropriate?

The nurse should quietly leave the room and give the patient privacy to pray.

The nurse is reviewing the teaching plans of several patients on a medical unit. Which patient does the nearest correctly in a fight as most at risk for development of complications of the fee?

A 60-year-old patient with diabetes Mellitus

When assessing a patient's knowledge of the fire safety precautions, which action indicates the need for further fire safety instructions?

A heating pad card is taped when a frayed area is noted

The nurse is assigned to care for 82-year-old patient who weighs 252 pounds and has undergone a bilateral below the knee amputation. Which transfer method is the safest for the patient and the nurse?

A mechanical lift with a sling

When caring for a patient who speaks foreign language, the nursing diagnosis impaired verbal communication would be inappropriate for what reason?

An inability to understand each other is the problem, not impaired verbal communication.

The nurse works in a community with many Mexican-American families. What is the best method for the nurse to learn about the Mexican-American culture?

Conduct a library study or Internet search of information on the culture.

The nurse is receiving a report on a patient. The nurse giving the report states that the patient has foot drop. The nurse receiving the report knows that which is the correct terminology for foot drop?

plantar flexion of foot

Define spore

reproductive cell

When the patient, a native of Mexico, comes to the clinic, she asks the nurse to allow her 10-year-old daughter to remain with her in the examining room. What action by the nurse is most appropriate?

Consider that the child may be there to serve as an interpreter for her mother.

Hey 72 little patient with the stroke has led to the foot of the bed. With use of appropriate body mechanics, the nurse maintains a wide base of support and faces the patient in the direction of movement. What are these actions allow the nurse to do?

Exert less physical effort

A patient isolated for pulmonary tuberculosis seems to be angry. The nurse recognizes this is a normal response to isolation. What action by the nurse is most appropriate?

Explain isolation procedures and provide meaningful stimulation

The nurse and the UAP are to move it depended patient from the supine to the lateral position. Which action should be performed for first?

Explain to the patient what actions the nurse and UAP are going to perform.

The nurse caring for the patient in isolation where is late text gloves. Which is an important consideration?

First assess the patient for potential latex allergy

The patient explains to the nurse that he became ill because the natural balance in his body was upset when he moved into a new apartment. He has been taking herbs and rearranging objects to change the environment. The patient is most demonstrating what health belief system?

Folk

The nurse is reviewing documentations from the previous shift. The nurse is correct when determining the patient has a stage III pressure ulcer based on which note?

Full sickness tissue loss extending through subcutaneous tissue

The nurses working in a clinical medical area with their senses of 15. Each patient has a different illness. When planning care, the nurse recognizes which of the following is the most important action to provide protection to each patient from healthcare associated infections with?

Handwashing

A 45-year-old man is admitted to the hospital with cellulitis of the right foot. Three days later, he develops bacterial pneumonia. How is this type of infection classified?

Health care associated

The nurse is providing home poison control instructions to the parent of it to real boy. Which statement by the parent indicates the need for further teaching?

I will give my child syrup of ipecac If he can just a poisonous substance that is not caustic

A 72 year old African American woman from Mississippi has been diagnosed with type 2 diabetes and hypertension. The student nurse tells the patient that her vegetables should be steamed and served plain. The patient responds, " I always cook my green beans with ham and salt and pepper. How can I eat them plain?" Which response by the nurse is most culturally sensitive?

"Why don't you try cooking the beans with half as much ham and not add salt?"

What is the necessary safety precaution the one helping a patient who has an unsteady gait to ambulate?

1. Have patience where well fitting nonskid shoes or slippers 2.Have at least two people present to assist the patient 3. Use a gait belt when assisting the patient to stand and to ambulate

Although surgical asepsis is practiced in the operating room and other specialty areas, the nurse at times also use a surgical aseptic technique at the patient's bedside. For which procedures does the nurse use surgical asepsis?

1. Inserting an IV line 2. Inserting an indwelling catheter

And hygiene is the single most?

Important and basic preventative technique that healthcare workers can use to interrupt the infectious process

Before I go in Tatian of any newly prescribed procedure, and there's notices that the family up an older adult patient always consult stay out of the sun. What is the social organization of this family?

1. Patriarchal 2. Male dominated

The nurse is observing the UAP who is assisting a resident in a long-term care facility ambulate with a gait belt. Which action by the UAP indicates to the nurse that further instructions is necessary?

1. The UAP Loosely fastens the gate now around the patient's waist 2. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair

The nurse is supervising a new UAP providing hygiene care to a patient. Which action but the UAP requires the nearest provide additional instructions regarding hygiene care?

1. The UAP holds the clean linens against the uniform 2. The UAP places soiled lines on the floor.

A patient becomes Faint while sitting on the side of the bed. To prevent injury to the patient and nurse, which action should the nurse take?

1. The nurse should call for assistance 2. The nurse should lay the patient straight back and support the head

When caring for the patient who requires the use of an SRD, what should be included in the patient's plan of care?

1.Monitor at the scan for signs of impairment 2.Remove the SRD once every two hours 3.Re-evaluate the need for the SRD frequently

What is a major benefit of active ROM exercises?

1.Preventing contractures 2.Maintaining joint movement and mobility 3.Preventing atrophy of muscles near the joint 4.Increasing the patients self-esteem and motivation

The student nurse has completed her educational instructions on the correct procedures for bread making. Which intervention is correct for bed making?

1.Washing hands thoroughly after handling soiled linen 2.Folding and reusing the patients bedspread if it is not soiled

Which patient is at greater risk for skin impairment?

A 60-year-old patient in a body cast

The patient with severe crippling rheumatoid arthritis is confined to bed for extended periods. An erythematous Area over the coccyx that has the potential to become an open lesion is noted. The nurse is correct and reporting this area to the healthcare provider As having the potential to become what?

A pressure ulcer

During the 7 AM to 3 PM shift on the adult surgical unit, the code is an ounce for an external disaster emergency. Which event best represents this type of situation?

A school bus accident

The LPN/LVN is reviewing the care plan of the patient who has an SRD applied to his personal safety. Which is the best goal for this patient?

Patient will remain free of injury

In which position is the patient lying facedown or chest down?

Prone

The nurse is preparing to open the outer sterile wrap of a Foley tray. Which flap of the wrap should be opened first?

The flap that opens away from the nurse

The nurse is performing a surgical hand scrub. During a surgical hand scrub, how are the hands to be held?

Above the elbows

The student is reviewing sterile technique. When using the technique, the student nurse is reminded to hold sterile objects in which position?

Above the waist

The home health nurse is visiting an older adult patient and her husband. What safety concern is of the highest priority when the nurse is assessing the patient's home environment?

Accidental falls.

To practice Street surgical a sepsis, the nurse:

Adhere's to principles of sterile technique

The nurse is speaking with the patient about the need to prevent infection. The nurse recognizes that the patient understands proper hand hygiene when she makes a Watch statement?

After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water.

The nurse is assigned to represent the unit on the infection prevention and control committee. The committee is discussing the CDC's hand hygiene recommendations for implementation in the hospital. Which statement demonstrates an understanding of the CDC's recommendations?

Alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids

The Nurse is caring for a patient on a ventilator and read the order "restrain PRN." The nurse considers which factor when caring for this patient?

Allow as much freedom of movement as possible when applying SRD's

The patient is admitted to the hospital with reports of diffuse symptoms such as nausea, vomiting, weight loss, headaches insomnia, and chest pain, which she describes by saying, " my heart aches." Which intervention is appropriate for this patient, whose cultural beliefs may differ from the nurses beliefs about physical illness?

Contact an adviser who is familiar with the cultural beliefs of the patient.

The patient has been changing a dressing on a pressure ulcer for several days and is now being seen in the physicians office. The patient states, "there is a lot of pink tissue at the base of the ulcer." The nurse explains to the patient that this is a result of what process?

The normal process of healing with healthy granulation tissue.

Muslim patient visiting the health care provider's office was told she had to remove her clothes and put on an examination gown. The patient became upset and refused to do so. Why should the nurse allow the patient to remain in her clothes?

As a Muslim, the patient must keep as much of her body covered as possible.

If it's real patient is in her second postoperative day after an abdominal hysterectomy. The nurse plans to give the patient a bed bath. Which action is most appropriate when caring for the patients face?

Ask the patient her preference.

A 63-year-old patient is brought to the emergency department for treatment of an unintentional poisoning. What is the nurses first action in caring for this patient?

Assess the patient

If 56-year-old patient has an open cholecystectomy, the nurse is going to assist the patient with dangling on the side of the bed before ambulation. After sitting him on the edge of the bed, which nursing intervention should the nurse performed before proceeding with ambulation?

Assessment of his pulse and respiration.

The patient accidentally knocks the emesis basin to the floor. I'm picking up the Amazon basin, which movement demonstrates proper body mechanics by the nurse?

The nurse lowers the body by flexing the knees and bending the hips.

The nurse is planning to do a cultural assessment of a Chinese American patient. What position of the nurse is most therapeutic?

The nurse positions the chair so that the nurse sits at a right angle to the patient.

chain of infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

An 82 year old patient is in his first postoperative day. As part of his morning care, the nurse removes and cleanses his dentures. Which of the following Techniques is correct?

Brush dentures with a soft toothbrush

A 50 year old patient was discharged home with a fully catheter. The student nurse instructs the patient and the proper procedure for cleansing the female perineal area. What teaching points Should the nurse include in discharge instructions?

Cleanse from pubis toward the rectum

Hey 72-year-old patient has diffuse pancreatitis. The nearest cleanse is her ears while giving her a soothing bed bath. Which intervention for cleansing her ears is correct for this bath?

Cleansing outter ear with a washcloth during the bath

________ Means the nurse is aware of his or her own cultural believes in boxes and how they relate to those of others.

Cultural competence

What three forms does anthrax occur in?

Cutaneous, inhalation, and gastrointestinal

And it's real patient has had cerebral vascular accident that affects her right side. The nurse re-position the patient to her left side, placing a pillow between her legs and another to her back. What is the primary purpose of this intervention?

Ensuring the patients proper body alignment

The student nurse tells the instructor that she does not understand why a Chinese American family is not grieving for their dying father. What behaviors are being demonstrated by the student nurse?

Ethnocentric

Define surgical asepsis

Every microorganism is destroyed before an invasive procedure

The nursing instructor is discussing the chain of infection to a group of student nurses. What is the most important information about identifying the chain of infection for the healthcare provider?

Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection.

The home health nurse is assessing a child for the risk of injury. Which factor place is a child at greatest risk for a specific types of injuries?

Developmental level

It is the patients first night after an of Domino hysterectomy. She has not voided for nine hours, and the nurse is to insert a 16 Fr. Fully catheter into her bladder. What patient positioned best allows insertion of the catheter ?

Dorsal recumbent

Define compartment syndrome

Edema or hemorrhage causes swelling inside a muscle compartment. Rising pressure in the fascial compartment can result in permanent nerve damage and muscle necrosis.

The nurse explained to the patient that the logrolling technique will be used to help the patient change position. Patient asked why this is necessary. Which response is accurate?

It is important to keep your neck and spine and straight alignment while we help you move onto your side

The patient has nearest her that his skin will be sterilized before his surgery. What is the best response by the nurse?

It is not possible to sterilize skin but we will use an antimicrobial solution to illuminate most microorganisms

A Mexican American is pregnant with her second child. When the nurse is reviewing her diet, the patient states that she never drinks mild. What culturally related factor may explain this?

Lactose intolerance occurs often among Mexican Americans.

When using a lift sheet to assist in moving a patient up in bed, what should the nurse asked the patient to do?

Maintain a straight body position

The student nurse demonstrated principles of good body mechanics with which activity?

Maintaining a wide base of support and bending at the knees

What are CPM machine is used for?

Mobilization of the joint prevent complications, such as joint contracture, HOV of surrounding muscles, and thromboembolism

The nurse is this sign to care for a 64-year-old patient who was admitted for exacerbation of chronic obstructive pulmonary disease and ammonia. He has dyspnea and is unable to rest in the supine position. The nurse elevate the head of the bed to 90°, places a pillow on the over bed table, and assist the patient to lean forward, placing his head on the pillow. What positions of the nurse document the patient has being in?

Orthopenic

The nurse is assisting the physician with an irrigation of a draining abdominal wound by preparing the sterile tray. Sterility of the tray must be maintained at all times. During the process, which action by the nurse is most correct?

Put on sterile gloves to handle the contents of the tray

The nurse has completed a sterile procedure and is preparing to remove the soiled gloves. To remove the gloves, what action is required of the nurse?

Remove one glove, then use the bare fingers to push the remaining glove off from inside the cuff.

The nurse discover smoke in a soiled utility room across the hall from a patient's room. What should the nurses initial action be?

Remove the patient from area

And 80-year-old young circumcise man it's in the first postoperative day after a transurethral prostatectomy. When Administering perineal care, which action by the nurse is correct?

Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion.

The patient has been immobilized for five days because of extensive abdominal surgery. When this patient has helped out of bed for the first time, which nursing diagnosis related to safety applies to this patient?

Risk for activity intolerance

A patient in isolation is experiencing signs of social deprivation. Which intervention by the nurse is appropriate?

Set specific times when the nurse overturned to the patient's room.

The nurse is providing oral care to an 82-year-old patient who is unconscious. The optimal position for providing oral hygiene to this patient is________ To prevent choking.

Side lying with head facing to the side

The nurse came for a Chinese American woman after an Appendectomy can anticipate which intervention?

Sitting side-by-side to communicate

What term describes a nurse who is aware of her or his own cultural believes, the believes and practices of other cultures, and has ability to interact effectively with people from other cultures?

Stereotyping

Which is a principle of surgical asepsis?

Sterile fields and sterilized items are no longer sterile if they contact a clean surface.

The nurse helps ambulate and 84-year-old female patient who has peripheral vascular disease that caused a severe stasis ulcer. The patient becomes very weak, reports feeling faint, and begins to fall. What is the most appropriate action to prevent entry to the patient?

Support her while she is falling and allow her to sit on the floor.

During the bedbath, the nurse covers a patient with a path blanket. The patient asked what the bath blanket is for. What is the nurses best response?

The Bath blanket helps prevent chilling.

An 11 month old infant is admitted with its in panic temperature of 105°F. The physician orders a tempered sponge bath. The infants mother ass, "what is the purpose of this bath?" Which is the best response by the nurse?

The bath helps reduce your baby's body's temperature

A female nurse who is black is assigned to care for a new 86-year-old resident in a long-term care facility. When she enters his room, he makes several racially offensive remarks. What is an appropriate response?

The nurse should understand that he is possibly less tolerant of other races because of his own cultural experiences or he perhaps has disturbed cognitive functions.

The LPN/LVN as reviewing the admission information of a patient. Which information is of most concern to the nurse that this patient is at high risk for falling?

The patient becomes disoriented in the evening hours

A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond?

The patient is a Muslim, so only women should be assigned to care for her

The nurse is documenting on a patient with an SRD. What information was a nurse include in this documentation?

The specific type of SRD used

The nurse is providing instructions to the UAP who is assisting with caring for an Immobile patient who requires turning every two hours. The UAP asks the nurse why it is best to place the patient in the 30° lateral position. Which response by the nurse is correct?

This position helps prevent pressure ulcers on the greater trochanter's

A 24 year old is admitted to a medical unit with the diagnosis of hepatitis A and placed in contact precautions. What is the primary goal of this action?

To prevent transmission Of infectious Microorganisms

The student nurse is preparing to Dan sterile gloves. What action indicates understanding of the needed procedure?

Touch on the inside service of the first club while pulling out onto the hand

Which assistive device allows patients to pull with upper extremity's to raise their trunk of the bed, to assist in Transfer from the bed to wheelchair, and to perform upper arm exercises?

Trapeze bar

A 64-year-old patient with terminal cancer is too weak to perform her own perineal care. The student nurse include a bathing which areas as part of perineal care?

Upper thighs, genitalia, and anal area

The nurse is teaching the patient Barbara Jean measures. What should the nurse include one teaching the patient about Eye care?

Use a different section of washcloth for Each eye.

Define vector

a carrier, usually an arthropod, which transmits an infective agent from one host to another

Define contracture

a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.

Define asepsis

absence of pathogenic microorganisms

Define medical asepsis

clean technique

A type C fire extinguisher is required for which type of fire?

electrical

Four stages of infectious process

incubation period, prodromal stage, illness stage, convalescence