NUR 101 : Exam 1

What is the bodys first line of defense against bacteria? 1) Intact skin 2) White blood cells 3) Lymph glands 4) Inflammatory response

ANS: 1) Intact skin Intact skin is the bodys first line of defense against bacteria. Once bacteria enter the body, the inflammatory response, white blood cells, and lymph glands play a role in fighting against the bacteria.

Which of the following protect(s) the body against infection? Select all that apply. 1) Eating a healthy, well-balanced diet 2) Being an older adult or an infant 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days a week

ANS: 1) Eating a healthy, well-balanced diet 3) Leisure activities three times a week 4) Exercising for 30 minutes 5 days a week Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. Illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle factors can make the body more susceptible to infection.

All of the following clinical signs may be present with hypoxia. However, only two are specific indicators of hypoxia (that is, if they are present, it means that the patient is probably hypoxic). Which ones are specific indicators of hypoxia? Choose all that apply. 1) Feelings of anxiety 2) Crackles in the lung bases 3) Increased heart rate 4) Improved breathing in upright position

ANS: 1) Feelings of anxiety 3) Increased heart rate Apprehension, confusion, dizziness, and an increased heart rate are all specific manifestations of hypoxia. Although they are not listed in this question, cyanosis of the tongue and oral mucosa are also good indicators of hypoxia because those areas are not affected by cold or reduced circulation as are the nails, lips, and skin. Crackles and orthopnea are abnormal respiratory findings, but they do not necessarily indicate poor oxygenation.

The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning? 1) I can contract the infection by walking barefoot in the gymnasiums showers. 2) The best way to avoid contracting the infection is to use good hand washing. 3) Wearing unventilated shoes prevents the fungus from gaining contact with my feet. 4) There is really no way to prevent its spread; its highly contagious.

ANS: 1) I can contract the infection by walking barefoot in the gymnasiums showers. One can contract the infection by walking barefoot in public showers, such as those in the schools gymnasium. Good hand washing does not prevent a person from contracting tinea pedis. Wearing unventilated shoes may actually aggravate the infection by allowing moisture to accumulate in the shoes. Although the infection is highly contagious, the spread of infection can be prevented by wearing special footwear in the shower.

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning)

ANS: 1) Risk for Falls Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers.

The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. The nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. The NAP: 1) uses a paper towel to turn off the faucet. 2) holds fingertips above the wrists while rinsing off the soap. 3) removes all rings and watch before washing hands. 4) cleans underneath each fingernail.

ANS: 1) uses a paper towel to turn off the faucet. 3) removes all rings and watch before washing hands. 4) cleans underneath each fingernail. Hand washing requires at least 15 seconds of washing, which includes lathering all surfaces of the hands and fingers to be effective. The fingers should be held lower than the wrists.

A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient? 1) Avoid giving the patient a complete bed bath. 2) Limit the amount of time spent with the patient. 3) Allow extra time for the patient to express feelings. 4) Do not allow anyone to visit the patient.

ANS: 2) Limit the amount of time spent with the patient. When caring for a patient with a radiation implant, the nurse should organize nursing care to limit the amount of time with the patient to limit radiation exposure. The nurse must meet the patients personal hygiene needs by bathing the patient, if necessary. The nurse should encourage the patient to express her feelings; however, she should limit her contact with the patient. Pregnant women should not visit the patient; however, others may visit as long as they uphold the principles of time, distance, and shielding.

Which is the most commonly reported incident in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays

ANS: 2) Patient falls Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as patient falls.

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patients room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patients door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.

ANS: 2) Place the tray in a special isolation bag held by a second healthcare worker at the patients door. Patients who require airborne isolation are served meals on disposable dishes and trays. To dispose of the tray, the nurse inside the room must wear protective garb and place the tray and its contents inside a special isolation bag that is held by a second healthcare worker at the patients door. The items must be placed on the inside of the bag without touching the outside of the bag.

A patient is admitted to the hospital for chemotherapy and has a low white blood cell count. Which precaution should the staff take with this patient? 1) Contact 2) Protective 3) Droplet 4) Airborne

ANS: 2) Protective Protective isolation is used to protect those patients who are unusually vulnerable to organisms brought in by healthcare workers. Such patients include those with low white blood cell counts, with burns, and undergoing chemotherapy. Some hospital units, such as neonatal intensive care units and labor and delivery suites, also use forms of protective isolation.

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1) Continue using the gloves inside the package because the package is intact. 2) Remove gloves from the sterile field and use a new pair of sterile gloves. 3) Throw all supplies away that were to be used and begin again. 4) Use the gloves and make sure the yellow edges of the package do not touch the client.

ANS: 2) Remove gloves from the sterile field and use a new pair of sterile gloves. The gloves should be discarded because the gloves are likely to be contaminated from an outside source. The supplies do not have to be thrown away because they have not been contaminated.

A patient tells the nurse, Im having a lot of pain in my hip. Which response by the nurse is open-ended and would stimulate the patient to provide the most complete data? Choose all that are correct. 1) Is your pain severe? 2) Tell me about your pain. 3) When did you first notice this pain? 4) How would you describe your pain?

ANS: 2) Tell me about your pain. 4) How would you describe your pain? The responses Tell me about your pain and How would you describe your pain? are open-ended responses that stimulate conversation. Although it is important information, the question Is your pain severe? prompts a yes or no response. When did you first notice this pain?also important informationis likely to stimulate a brief, factual answer. Such questions allow the nurse to control the patients response. Limiting the response might lead to an incomplete assessment.

A patient who has a temperature of 101F (38.3C) most likely requires: 1) acetaminophen (Tylenol). 2) increased fluids. 3) bedrest. 4) tepid bath.

ANS: 2) increased fluids. Fever, a common defense against infection, increases water loss; therefore, additional fluid is needed to supplement this loss. Acetaminophen and a tepid bath are not necessary for this low-grade fever because fever is beneficial in fighting infection. Adequate rest, not necessarily bedrest, is necessary with a fever.

Which blood pressure has a pulse pressure within normal limits? Choose all that apply. 1) 104/50 mm Hg 2) 120/62 mm Hg 3) 120/80 mm Hg 4) 130/86 mm Hg

ANS: 3) 120/80 mm Hg 4) 130/86 mm Hg The pulse pressure is the systolic blood pressure (BP) minus the diastolic BP. The pulse pressure is usually approximately one third of the systolic pressure. (120 80 = 40; 40 = 1/3 of 120) (130 86 = 44; 1/3 of 130 = 43.3)

For which range of time must a nurse wash her hands before working in the operating room? 1) 1 to 2 minutes 2) 2 to 4 minutes 3) 2 to 6 minutes 4) 6 to 10 minutes

ANS: 3) 2 to 6 minutes In a surgical setting, hands should be washed for 2 to 6 minutes, depending on the type of soap used.

Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? 1) It prevents microorganisms from adhering to the skin. 2) It facilitates the absorption of latex proteins through the skin. 3) It decreases the risk of latex allergies. 4) It prevents the skin from drying and chaffing.

ANS: 3) It decreases the risk of latex allergies Non-petroleum-based lotion is preferred because it prevents the absorption of latex proteins through the skin, which can cause latex allergy. Both types of lotion help prevent the skin from drying and becoming chafed. Neither prevents microorganisms from adhering to the skin.

A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse is(are) advisable? 1) Reassure the patient by entering the room alone. 2) Ask the patient if he is carrying any weapons. 3) Stay between the patient and the door; keep the door open. 4) Make eye contact while stating firmly I will not tolerate cursing and threats.

ANS: 3) Stay between the patient and the door; keep the door open. The nurse should keep the door open and position herself so that the patient cannot block her exit from the room (stay between the patient and the door). The nurse should not enter a room alone with an angry patient. The progression to physical violence is first anxiety, then verbal aggression, and finally physical aggression. The nurses first priority in this situation is her own safety and the safety of others in the environment. The object is to relieve the patients anxiety and not respond to anger with anger. Questioning about weapons, or being firm and defending against verbal aggression will likely provoke even more anger from the patient. The nurse must be calm and reassuring.

While assessing a patient, the nurse notes that the patients nails are excessively brittle. What does this finding suggest? 1) Inadequate dietary intake 2) Normal aging process 3) Fungal infection 4) Excessive use of silver salts

ANS: 1) Inadequate dietary intake Inadequate dietary intake or metabolic changes can cause the nails to become brittle. As a person ages, nails thicken, become ridged, and may yellow or become concave in shape. Brown or black discoloration of the nail plate may indicate a fungal infection. Bluish gray discoloration of the nail plate signals excessive intake of silver salts.

In which situation would using standard precautions be adequate? Select all that apply. 1) While interviewing a client with a productive cough 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter

ANS: 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter Standard precautions should be instituted with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions, secretions, mucous membranes, and breaks in the skin (e.g., while inserting a peripheral IV). When interviewing a client, if the disease is not spread by air or droplets, there is no likelihood of the nurses encountering body fluids. If the disease is spread by air or droplets, then droplet or airborne precautions would be needed in addition to standard precautions. If giving a complete bed bath or performing oral hygiene, the nurse would need to use standard precautions (gloves); if merely assisting a client to perform those ADLs, it is not necessary. No exposure to body fluids is likely when helping a client to ambulate after surgery.

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel? 1) Assessing the patients status 2) Determining the need for restraint 3) Evaluating the patients response to restraints 4) Applying and removing the restraints

ANS: 4) Applying and removing the restraints The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown. The nurse responsible for care of the patient must assess the patients need for restraint and the patients status and must evaluate the patients response to restraints.

Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning? 1) Store medications on countertops out of the childs reach. 2) Purchase medication in child-resistant containers 3) Take medications in front of the child, and explain that they are for adults only. 4) Never leave the child unattended around medications or cleaning solutions.

ANS: 4) Never leave the child unattended around medications or cleaning solutions. The nurse should instruct the mother to avoid leaving her child unattended around medications or cleaners even for a moment. Medications should never be stored on kitchen counters or bathroom surfaces because children love to explore and climb and can get into them. The nurse should explain that medications should not be taken in front of the child because children imitate adult behavior. The nurse should reinforce that although child-resistant containers are a deterrent, they are not foolproof because many toddlers and preschoolers can open them.

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? 1) When fingers feel sticky 2) After 5 to 10 seconds 3) When leaving the clients room 4) Once fingers and hands feel dry

ANS: 4) Once fingers and hands feel dry The nurse should rub the antiseptic hand solution over all surfaces of the hands until the solution dries, usually 10 to 15 seconds, to ensure effectiveness.

Rank the following leading causes of accidental death in the United States according to their frequency of occurrence. Rank as 1 the one that occurs most frequently; rank as 4 the one that occurs least frequently. A. Motor vehicle accidents B. Falls C. Suffocation D. Poisonings

ANS: A. Motor vehicle accidents D. Poisonings B. Falls C. Suffocation Motor vehicle accidents are the leading cause of accidental death in the United States, followed by poisonings, falls, and suffocation.

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patients door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure

ANS: 1) Closing the patients door to limit room traffic while preparing the sterile field To maintain sterile technique, the nurse should close the patients door and limit the number of persons entering and exiting the room because air currents can carry dust and microorganisms. Sterile gloves, not clean gloves, should be used to handle sterile equipment. Placing nonsterile syringes on the sterile field contaminates the field. One foot, not 6 inches, is required between people and the sterile field to prevent contamination.

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1) Encourage the child to continue coughing. 2) Deliver upward abdominal thrusts with a fisted hand. 3) Deliver five rapid back blows between the shoulder blades. 4) Perform a blind finger sweep of the childs mouth.

ANS: 1) Encourage the child to continue coughing. If the nurse suspects aspiration in a child who is coughing vigorously, the nurse should encourage the child to continue coughing. If coughing weakens, the nurse should perform the choking maneuver by administering five rapid back blows alternated with five upward thrusts to the upper abdomen with a fisted hand, just below the rib cage. A blind finger sweep should never be performed because it could push the foreign object into the airway.

A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed? 1) Endogenous nosocomial 2) Exogenous nosocomial 3) Latent 4) Primary

ANS: 1) Endogenous nosocomial Thrush in this patient is an example of an endogenous nosocomial infection. This type of infection arises from suppression of the patients normal floras as a result of some form of treatment, such as antibiotics. Normal floras usually keep yeast from growing in the mouth. In exogenous nosocomial infection, the pathogen arises from the healthcare environment. A latent infection causes no symptoms for long periods. An example of a latent infection is human immunodeficiency virus infection. A primary infection is the first infection that occurs in a patient.

Which item is best for providing mouth care for an unconscious patient? 1) Foam swabs 2) Lemon-glycerin swabs 3) Hydrogen peroxide 4) Cotton-tipped applicator soaked in mouthwash

ANS: 1) Foam swabs Commercially packaged applicators or foam swabs are typically used to provide mouth care. Lemon-glycerin swabs are not recommended because they are drying to the oral mucosa. Hydrogen peroxide should be avoided because it is irritating to oral mucosa and may alter the balance of normal floras that occur in the mouth. Mouthwash can be used by conscious patients as part of their routine mouth care. However, cotton-tipped applicators should not be soaked in it to perform mouth care.

Which action should the nurse take when preparing a patient for a bed bath? 1) Place the nurse call device within reach for safety. 2) Cover the patient with the top linens from the bed. 3) Have the patient completely bathe himself to promote independence. 4) Wash the patients body without assistance from the patient.

ANS: 1) Place the nurse call device within reach for safety. When preparing a patient for a bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), place a basin of warm water, bath linens, a clean gown, and other bathing supplies on the overbed table. Provide privacy, and place the nurse call device within reach. Remove the top linens from the bed, and cover the patient with a bath blanket. If the patient cannot bathe all areas of his body, complete the bath for him. The nurse performs at least part of a bed bath; if the patient bathes himself completely while remaining in bed, it is referred to as an assist bath.

Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. 1) Put an ice pack on the clients neck and axillae. 2) Provide the client a blanket when he is shivering. 3) Offer the client fluids to drink every 1 to 2 hours. 4) Take the temperature using a tympanic thermometer.

ANS: 1) Put an ice pack on the clients neck and axillae. 3) Offer the client fluids to drink every 1 to 2 hours. If ice packs are used, they are applied to the groin, neck, or axillae. A fever increases metabolic needs, so fluids are necessary to prevent dehydration. A blanket would help with heat retention. A tympanic thermometer is not appropriate when an accurate temperature is needed, as when a client has a fever.

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately.

ANS: 1) Remove the contaminated clothing immediately. The nurse should tell the mother to first remove the contaminated clothing as quickly as possible. Then, flood the contaminated area with lukewarm water. Next, gently wash the area with soap and water and rinse. Have someone call the poison control center. It does not need to be a local poison control center. Additionally, it is most important to remove contact between the skin and poison before doing anything.

A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct? 1) The virus mutates too rapidly to develop a vaccine. 2) Vaccines are developed only for very serious illnesses. 3) Researchers are focusing efforts on an HIV vaccine. 4) The virus for the common cold has not been identified.

ANS: 1) The virus mutates too rapidly to develop a vaccine. More than 200 viruses are known to cause the common cold. These viruses mutate too rapidly to develop a vaccine. Although some researchers are focusing efforts on a vaccine for HIV infection, others continue to research the common cold.

Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial spores 3) Yeast 4) Mold

ANS: 1) Virus 3) Yeast 4) Mold If there is potential for contact with bacterial spores, hands must be washed with soap and water; alcohol-based solutions are ineffective against bacterial spores.

Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown

ANS: 1) Washing hands Scrupulous hand washing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown may be needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-related infections are transmitted by lack of or ineffective hand washing.

The Joint Commissions national Speak Up campaign encourages patients to become active and informed participants on the healthcare team. The goal is to: 1) prevent healthcare errors. 2) help control the cost of healthcare. 3) reduce the number of automobile accidents. 4) provide a forum for people without health insurance.

ANS: 1) prevent healthcare errors. The Joint Commission, with the Centers for Medicare and Medicaid Services, urges patients to take a role in preventing healthcare errors by becoming active, involved, and informed participants on the healthcare team. A reduction in healthcare errors could indirectly reduce healthcare costs, but this is not the intent of the campaign. The campaign has nothing to do with automobile accidents, as might be deduced from the fact that the Joint Commission and Medicare/Medicaid regulate healthcare agencies. The campaign has little relationship to insurance, other than to encourage clients to speak up, ask questions, and know their rights.

The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patients care plan? Teach the patient to: 1) use an electric razor for shaving. 2) apply skin moisturizer. 3) use less soap when bathing. 4) floss teeth daily.

ANS: 1) use an electric razor for shaving. The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.

For which patient is it most important to provide frequent perineal care? The patient: 1) with active lower gastrointestinal bleeding. 2) after an episode of diabetic ketoacidosis. 3) who has a circumcised penis. 4) with a history of acute asthma.

ANS: 1) with active lower gastrointestinal bleeding. The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care.

As a general rule, how much liquid soap should the nurse use for effective hand washing? At least: 1) 2 mL 2) 3 mL 3) 6 mL 4) 7 mL

ANS: 2) 3 mL APIC guidelines dictate that 3 to 5 mL of liquid soap is necessary for effective hand washing.

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact

ANS: 2) Airborne transmission The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission.

A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? 1) Total Self-care Deficit 2) Bathing/Hygiene Self-care Deficit 3) Dressing/Grooming Self-care deficit 4) Activity Intolerance

ANS: 2) Bathing/Hygiene Self-care Deficit The nursing diagnosis Bathing/Hygiene Self-care Deficit is most appropriate for addressing the patients inability to get in and out of the bathtub independently. There are no data to suggest that the patient is completely unable to care for himself; therefore, Total Self-care Deficit is not appropriate. There is nothing to suggest that the patient is unable to dress or groom himself. Activity Intolerance is present when a patient exhibits extreme fatigue, which is not mentioned in this scenario.

The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering

ANS: 2) Gloves The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering.

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G? 1) Cell-mediated 2) Passive 3) Humoral 4) Active

ANS: 2) Passive Intravenous administration of immunoglobulin G provides the patient with passive immunity. Immunoglobulin G does not provide cell-mediated, humoral, or active immunity. Passive immunity occurs when antibodies are transferred from an immune host, such as from a placenta to a fetus. Passive immunity is short lived. Active immunity is longer lived and comes from the host. Humoral immunity occurs by secreted antibodies binding to antigens. Cell-mediated immunity does not involve antibodies but rather is a fight of infection from macrophages that kill pathogens.

A clients epidermis has insufficient melanin. Which nursing diagnosis is appropriate? 1) Risk for Infection 2) Risk for Impaired Skin Integrity 3) Risk for Deficient Fluid Volume 4) Impaired Skin Integrity

ANS: 2) Risk for Impaired Skin Integrity The epidermis contains melanin, a pigment that protects against the suns ultraviolet rays; therefore, a person with insufficient melanin is at Risk For Impaired Skin Integrity (sunburn). There are no symptoms to indicate that the client has a sunburn (actual Impaired Skin Integrity), only that a risk factor is present. The dermis contains blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands; melanin does not prevent fluid loss. Fibroblasts (not melanin), also found in the dermis, produce new cells and assist in wound healing, thereby helping to prevent infection.

When assessing the quality of a clients pedal pulses, what is the nurse assessing? Choose all that apply. 1) Rhythm of the pulses 2) Strength of the pulses 3) Bilateral equality of pulses 4) Rate compared with apical pulse

ANS: 2) Strength of the pulses 3) Bilateral equality of pulses The quality of a pulse refers to the pulse volume (strength) and bilateral equality of the pulses.

A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) The epidermal layer of skin was rubbed away. 4) A lesion caused by tissue compression was present.

ANS: 2) Superficial layers of skin were absent. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.

A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed? 1) Call for assistance to help the patient into the bathtub. 2) Wait for the patient to calm down, and then give him a towel bath. 3) Allow the patient to go without bathing for a day or two. 4) Ask another staff member to attempt the tub bath.

ANS: 2) Wait for the patient to calm down, and then give him a towel bath. Nurses need to individualize bathing to meet the needs of the patient. If the patient becomes belligerent, the nurse should wait until the patient calms down and then attempt a towel bath. Towel baths have been shown to reduce agitation significantly. The patient should not be forced into the tub. Having another staff member attempt the tub bath will most likely increase the patients agitation, as consistency of caregivers is important for patients with dementia.

Which of these steps in taking a blood pressure is correct? Choose all that apply. 1) Use a bladder that encircles 40% of the arm. 2) Wrap the cuff snugly around the clients arm. 3) Ask the client to hold the arm at heart level. 4) Have the client sit with feet flat on the floor.

ANS: 2) Wrap the cuff snugly around the clients arm. 4) Have the client sit with feet flat on the floor. The cuff should be wrapped snugly around the clients arm. Crossed legs or dangling legs can increase blood pressure, so feet should be flat on the floor. The bladder should encircle 80% of the arm. Holding the arm out can cause an erroneously higher blood pressure measurement; the arm should be supported.

After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as: 1) pediculosis. 2) alopecia. 3) dandruff. 4) hirsutism.

ANS: 2) alopecia. Alopecia is abnormal hair loss that can occur as a result of chemotherapy. Pediculosis is an infestation of head lice. Dandruff is a condition in which there is excessive shedding of the epidermal layer of the scalp. Hirsutism is the excessive growth of body hair in women.

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion

ANS: 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.

Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1) Blood pressure decreases less than heart rate and respiratory rate. 2) Respiratory rate remains fairly stable throughout a persons life. 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause.

ANS: 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause. Heart rate and respiratory rate tend to decrease as people age, whereas the blood pressure increases because of increased vascular resistance. Mens blood pressure tends to be higher than womens until after menopause, when womens blood pressure typically increases.

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodromal 3) Decline 4) Convalescence

ANS: 3) Decline The stage of decline occurs when the patients immune defenses, along with any medical therapies (in this case antibiotics), are successfully reducing the number of pathogenic microbes. As a result, the signs and symptoms of infection begin to fade. Incubation is the stage between the invasion by the organism and the onset of symptoms. During the incubation stage, the patient does not know he is infected and is capable of infecting others. The prodromal stage is characterized by the first appearance of vague symptoms. Convalescence is characterized by tissue repair and a return to healing as the organisms disappear.

What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members

ANS: 3) Hands of healthcare workers Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers.

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? 1) Phagocytosis 2) Complement cascade 3) Inflammation 4) Immunity

ANS: 3) Inflammation The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection.

While bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Pallor. 2) Erythema. 3) Jaundice. 4) Cyanosis.

ANS: 3) Jaundice. A yellow skin tone, known as jaundice, commonly occurs in patients with impaired liver function. Pallor is pale skin without underlying pink tones in the light-skinned person. Pallor occurs with anemia. Erythema, or redness of the skin, commonly occurs with inflammation or vasodilation. Cyanosis, a bluish coloring of the skin, is caused by poor peripheral circulation or decreased oxygen in the blood.

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply. 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport.

ANS: 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport. Transporting a patient who requires airborne precautions should be limited; however, when necessary the patient should wear a surgical mask (an N-95 respirator mask is not required) that covers the mouth and nose to prevent the spread of infection. Moreover, the department where the patient is being transported should be notified about the precautions before transport

The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient. 2) Use cool water for bathing. 3) Provide care in small intervals. 4) Rub briskly when towel drying.

ANS: 3) Provide care in small intervals. The nurse should provide care in small intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

. A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient? 1) Tub bath 2) Complete bed bath 3) Towel bath 4) Bed bath

ANS: 3) Towel bath A towel bath is a modification of the bed bath, in which a large towel and a bath blanket are placed in a plastic bag and saturated with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water. The bag and its contents are then placed in the microwave, and they are used to bathe the patient. This bathing method is preferred for patients who have Activity Intolerance. A tub bath, complete bed bath, and conventional bed bath may deplete this patients energy.

Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only when leaving each room. 4) uses cold water for medical asepsis.

ANS: 3) washes hands only when leaving each room. Patients acquire infection by contact with other patients, family members, and healthcare equipment. But most infection among patients is spread through the hands of healthcare workers. Hand washing interrupts the transmission and should be done before and after all contact with patients, regardless of the diagnosis. When the hands are soiled, healthcare staff should use antibacterial soap with warm water to remove dirt and debris from the skin surface. When no visible dirt is present, an alcohol-based rub should be applied and allowed to dry for 10 to 15 seconds.

Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin? 1) 99F (37.2C) 2) 102F (38.9C) 3) 103F (39.4C) 4) 105F (40.6C)

ANS: 4) 105F (40.6C) Bath water temperature should be 105F (40.6C) to prevent chilling, burning, and excess drying of the skin.

The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include? 1) Cleanse only those areas likely to cause odor. 2) Provide the patient with warm water for washing his perineum. 3) Wash the patients back, buttocks, and perineum first. 4) Bathe the patient from head-to-toe, cleanest areas first.

ANS: 4) Bathe the patient from head-to-toe, cleanest areas first. The nurse should instruct the NAP to give a complete bed bath (a bath for patients who must remain in bed but who are able to bathe themselves), in head-to-toe fashion, beginning with the cleanest part of the body and ending with the dirtiest. The NAP should provide the patient with a basin of warm water and allow him to wash his perineum when giving an assist bath or bed bath (this is a total bed bath). During a partial bath, the NAP should cleanse only the areas that may cause odor or discomfort. The NAP should never begin the bath with the back, buttocks, and perineum because this violates the principle of clean to dirty.

The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3) A small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair.

ANS: 4) Clearly label the pump and send it for repair. Whenever an electrical safety hazard is suspected or visible, the nurse should label the malfunctioning equipment and send it for repair or inspection. Continuing to use the IV infusion pump or any other equipment places the patient at risk for injury. Placing the pump back on the shelf places other healthcare team members at risk for electrical injury if they attempt to use the equipment.

A patient with a history of seizures who takes phenytoin is at risk for which oral problem? 1) Dryness of the mouth 2) Bitter taste 3) Demineralization of the tooth enamel 4) Gingival hyperplasia

ANS: 4) Gingival hyperplasia Phenytoin causes gingival hyperplasia. Medications, such as atropine, cause dry mouth. Bitter taste can result from drugs, such as docusate sodium, a stool softener. Phenytoin does not cause demineralization of the tooth enamel.

Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care 4) Hour of sleep care

ANS: 4) Hour of sleep care The nurse should offer a back massage during hour of sleep (HS) care to promote relaxation. During afternoon care the nurse should prepare the patient to receive visitors or for afternoon rest. Early morning care is provided after the patient awakens. It commonly prepares the patient for breakfast or procedures, such as diagnostic testing. Early morning care typically consists of assisting with toileting, face and hand washing, and mouth care. Morning care occurs after breakfast and commonly consists of toileting, bathing, and mouth, skin, and hair care. It may also include dressing and positioning or assisting the patient to the chair.

The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would most likely be found in a test of immunoglobin levels? 1) IgA 2) IgE 3) IgG 4) IgM

ANS: 4) IgM IgM are the first antibodies made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the body in fighting viral and bacterial infections, and appear later. IgG antibodies also appear laterperhaps up to 10 days later.

Wearing poorly fitting shoes may result in which condition? 1) Tinea pedis 2) Plantar wart 3) Excoriation 4) Ingrown toenail

ANS: 4) Ingrown toenail Wearing poorly fitting shoes and improperly trimming the toenails may cause an ingrown toenail. Tinea pedis occurs when moisture accumulates in unventilated shoes. Plantar wart is a painful growth that is caused by a virus. Excoriation occurs when digestive enzymes come in contact with skin.

The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care? 1) Supine 2) Prone 3) Semi-Fowlers 4) Side-lying

ANS: 4) Side-lying The nurse should position an unconscious patient in a side-lying position to provide mouth care to prevent aspiration. Supine, prone, and semi-Fowlers positions are unsafe positions for providing mouth care for the unconscious patient.

A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1) pathogen. 2) fomite. 3) vector. 4) carrier.

ANS: 4) carrier. Some people might harbor a pathogenic organism, such as the human immunodeficiency virus, within their bodies and yet do not acquire the disease/infection. These individuals, called carriers, have no outward sign of active disease, yet they can pass the infection to others. A pathogen is an organism capable of causing disease. A fomite is a contaminated object that transfers a pathogen, such as pens, stethoscopes, and contaminated needles. A vector is an organism that carries a pathogen to a susceptible host through a portal for entry into the body. An example of a vector is a mosquito or tick that bites or stings.

When the nurse walks into the patients room, she notices fire coming from the patients trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last. A. Activate the fire alarm. B. Move the patient out of the room. C. Close all doors and windows. D. Put out the fire using the proper extinguisher.

ANS: B. Move the patient out of the room. A. Activate the fire alarm. C. Close all doors and windows. D. Put out the fire using the proper extinguisher. The nurse should first move the patient out of the room, then activate the alarm, close all doors and windows and turn off oxygen valves, and use the proper extinguisher to put out the fire.

A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1) Chest pain, pneumonitis, and inflammation of the mouth 2) Intestinal obstruction and numbness of the hands 3) Hypotension, oliguria, and tingling of the feet 4) Tachycardia, hematuria, and diaphoresis

ANS: 1 1) Chest pain, pneumonitis, and inflammation of the mouth Acute adverse effects of mercury inhalation include chest pain, inflammation of mouth, pneumonitis, respiratory damage, wakefulness, muscle weakness, anorexia, headache, and ringing in the ears, Chronic effects include numbness or tingling of the hands, lips, and feet, and personality changes. Intestinal obstruction is an acute effect of mercury ingestion. Hypotension, oliguria, hematuria, and diaphoresis are not acute effects of mercury inhalation.

A clients average normal temperature is 98F. Which of the following temperatures would be expected during the night in this healthy young adult client who does not have a fever, inflammatory process, or underlying health problems? 1) 97.2F 2) 98.0F 3) 98.6F 4) 99.2F

ANS: 1) 97.2F The lowest temperature occurs during sleep (usually at night) when the metabolic rate is lowest. Temperature normally increases throughout the day until it peaks in the early evening.

At last measurement, the clients vital signs were as follows: oral temperature 98F (36.7C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2F (38.5C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurses first intervention at this time? 1) Ask the client if he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the clients temperature. 3) Ask the client if he is feeling chilled. 4) Take the temperature by a different route.

ANS: 1) Ask the client if he has had a warm drink in the last 30 minutes. With a fever, the heart rate and respiratory rate are usually elevated. In this case, they are within normal limits, so the nurse should wonder about the accuracy of the temperature reading and validate it in some way. Because having a hot drink is a common cause of false readings, the nurse should determine whether that has occurred before retaking or otherwise validating the reading.

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to 1) Ask the client to demonstrate the use of the blood pressure device 2) Explain the importance of frequent calibration of the device 3) Give the client a chart to record his blood pressure readings 4) Provide written instructions of the information taught

ANS: 1) Ask the client to demonstrate the use of the blood pressure device All are important things to include in client education, but self-monitoring of blood pressure is of little value unless it is done using proper technique. Requesting that the client demonstrate the procedure would allow the nurse to evaluate the clients technique.

The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to 1) Compare the left pedal pulse with the right pedal pulse 2) Count the clients respiratory rate for 1 full minute 3) Take the blood pressure in the arm without an IV 4) Take an oral temperature with an electronic thermometer

ANS: 1) Compare the left pedal pulse with the right pedal pulse For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This can be done only by comparing one leg with the other. The nurse would, of course, count the respiratory rate for 1 full minute and take the BP in the arm without the IV. Oral temperatures are commonly obtained using electronic thermometers.

Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? 1) Counting the rate for 1 full minute 2) Exposing only the left side of the chest 3) Determining why assessment of apical pulse is indicated 4) Using your ring finger to palpate the intercostal spaces

ANS: 1) Counting the rate for 1 full minute Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often they have irregular heartbeats or slow rates. A more accurate count is obtained when such heartbeats are counted for a full minute. Exposing the chest is, of course, necessary; exposing only the left side protects the patients privacy but does not improve the accuracy. The nurse should know why an apical pulse is indicated, but this would not affect the accuracy of the count. Which finger the nurse uses to palpate depends on which hand is used. Even if the nurse failed to use the index or ring finger, this would be unlikely to affect the accuracy of the counting.

The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? 1) I would have the client rate her pain on a scale of 0 to 10. 2) I would ask the client when she had her last bowel movement. 3) I would take the clients pulse oximetry reading. 4) I would interview the client about history of tobacco use.

ANS: 1) I would have the client rate her pain on a scale of 0 to 10. Pain is considered to be the fifth vital sign.

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg 2) Oral temperature is 97.9F in the morning and 99.8F in the evening 3) Heart rate was 76 beats/min before eating and 88 beats/min after eating 4) Respiratory rate is 16 breaths/min when standing and 18 when lying down

ANS: 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg Both the blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines. Body temperature normally increases during the course of a day. Heart rate increases for several hours after eating. Respiratory depth decreases when lying down, so it would be normal for the rate would increase; both rates are within normal limits.

The nurse assesses the following changes in a clients vital signs. Which client situation should be reported to the primary care provider? 1)Decreased blood pressure (BP) after standing up 2)Decreased temperature after a period of diaphoresis 3)Increased heart rate after walking down the hall 4)Increased respiratory rate when the heart rate increases

ANS: 1)Decreased blood pressure (BP) after standing up A drop in the clients blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in vital signs indicated in the other options are normal changes for the situations. PTS:1DIF:ModerateREF:p. 439 for hypotension information but should read content about all of the vital signs

During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurse intervene? 1) Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it. 2) Notify the hazardous material management team immediately. 3) Evacuate the area immediately. 4) After putting on a gown, gloves, and a mask, clean up the mercury. 5) Wash her hands well after removing the spill. 6) Ventilate the area well for several days.

ANS: 1, 5, 6 1) Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it. 5) Wash her hands well after removing the spill. 6) Ventilate the area well for several days. The nurse should put on gloves and use a paper towel to pick up the mercury. Then place the mercury, broken thermometer, and soiled paper towel into a plastic bag along with the gloves. Next, the nurse should dispose of the plastic bag, wash her hands, and ventilate the area well. It is not necessary to notify the hazardous material management team or evacuate the area for a spill this small, unless agency policy actually mandates that. The nurse does not need to put on a gown and mask to dispose of the mercury.

A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next? 1) Perform the Get Up and Go Test. 2) Ask the patient if he has fallen in the past year. 3) Refer the patient for a comprehensive fall evaluation. 4) Administer the Timed Up and Go Test.

ANS: 2 2) Ask the patient if he has fallen in the past year. If a patients gait or balance is unsteady, the nurse should question the patient for a history of falls. If the patient reports a single fall, the nurse should do the Get Up and Go Test. If the patient has difficulty with that test, or is unsteady with it, the nurse should perform a follow-up assessment of gait and balance by having the person close the eyes for a few seconds wile standing in place; stand with eyes closed while the nurse pushes gently on the sternum; walk, stop, turn around, return to the chair, and sit in the chair without using his arms for support. Physicians and advanced practitioners perform the Timed Up and Go Test; it is recommended annually for patients 65 years or older.

A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4F (37.4C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the clients respiratory rate to be 1)16 2)18 3)20 4)22

ANS: 2) 18 For every degree Fahrenheit (0.6C) the temperature falls, the respiratory rate may decrease up to 4 breaths per minute. The clients temperature has fallen 2 degrees; multiplied by 4, this is 8. It was 26 breaths/min: 26 8 = 18 breaths/min. Keep in mind, this is an estimate and would vary depending on the patients baseline health, current condition, age, and other factors.

The clients temperature is 101.1F. Which is the correct conversion to centigrade? 1)38.0C 2)38.4C 3)38.8C 4)39.2C

ANS: 2) 38.4C To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9.

Which of the following sets of vital signs are all within normal limits for patients at rest? 1) Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 3) Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 4) Older adult: T 98.6F (oral), HR 110, RR 28, BP 170/95

ANS: 2) Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 All of the adolescents vital signs are within normal parameters for the age. The infants temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age.

Which of the following pieces of information in the clients health history might indicate a risk for primary hypertension? 1) Consumes a high-protein diet 2) Drinks three to four beers every day 3) Has a family history of kidney disease 4) Does not engage in physical exercise

ANS: 2) Drinks three to four beers every day Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, family history of hypertension, and high cholesterol levels put a client at risk for primary hypertension. Kidney disease is a cause of secondary hypertension.

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has 1) Had surgery and is receiving a narcotic analgesic 2) Had surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Been exposed to the cold and is now hypothermic

ANS: 2) Had surgery and lost a unit of blood intraoperatively A reduction in hemoglobin from blood loss would increase the respiratory rate. Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes to higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or have no effect. Hypothermia decreases the metabolic rate, so the respiratory rate would likely decrease.

The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the clients blood pressure and apical pulse. 4) Count the clients respiratory rate for 1 minute.

ANS: 2) Request the client take a deep breath and cough. Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse and counting the respiratory rate are not effective for clearing rhonchi and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi.

Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1) Oral temperature 100F (37.8C) 2) Respiratory rate 26 breaths/min and shallow 3) Apical heart rate 56 beats/min 4) Blood pressure 124/82 mm Hg

ANS: 2) Respiratory rate 26 breaths/min and shallow Respiratory rate 26 breaths/min and shallow. Acute pain causes an increase in respiratory rate but a decrease in depth. Elevated temperature does not indicate pain. The apical pulse is lower than normal, but because the pulse increases with pain, a rate of 56 beats/min does not indicate pain. A blood pressure of 124/82 mm Hg is within normal limits. Blood pressure usually elevates temporarily with acute pain; it may decrease over time with unremitting chronic pain.

Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1) Make sure the child sleeps on his back at night. 2) Keep the telephone number of the poison control center accessible. 3) Use a front-facing car seat placed in the back seat of the car. 4) Keep syrup of ipecac on hand in case of accidental poisoning.

ANS: 2, 3 2) Keep the telephone number of the poison control center accessible. 3) Use a front-facing car seat placed in the back seat of the car. The nurse should teach the mother of a toddler to keep the telephone number of the poison control center accessible because toddlers are at risk for accidental poisonings. Toddlers should also have front-facing car seats. Syrup of ipecac is no longer recommended to induce emesis after poisonings. Infants, not toddlers, should sleep on their backs to prevent sudden infant death syndrome.

A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first? 1) Administer a dose of syrup of ipecac. 2) Administer activated charcoal immediately. 3) Give water to the child immediately. 4) Call the nearest poison control center.

ANS: 3 3) Give water to the child immediately. If the child is awake and able to swallow, and the child has swallowed a household chemical, give one-half glassful of water immediately. After giving the water, call the poison control center. The American Academy of Pediatrics does not advise giving syrup of ipecac. Emergency departments have stopped using ipecac in favor of activated charcoal, which binds to poison in the stomach and prevents it from entering the bloodstream. Continued vomiting caused by syrup of ipecac may later result in the child being unable to tolerate activated charcoal or other poison treatments. No one can tell how much a child vomits, and therefore, no one would know if all the poison was eliminated from the stomach. There is also potential for misuse by bulimics. The poison control center may recommend activated charcoal, depending upon the agent ingested.

A clients vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the clients oral temperature is 102.2F (39C). Based on the temperature change, the nurse should anticipate the clients heart rate would be how many beats/min? 1) 62 2) 82 3) 102 4) 122

ANS: 3) 102 Heart rate increases about 10 beats per minute for each degree of temperature to meet increased metabolic needs and compensate for peripheral dilation.

A nurse is splashed in the face by body fluid during a procedure. Prioritize the nurses actions, listing the most important one first. 1. Contact employee health 2. Complete an incident report 3. Wash the exposed area 4. Report to another nurse that she is leaving the immediate area. 1) 1, 2, 3, 4 2) 2, 3, 4, 1 3) 3, 4, 1, 2 4) 4, 1, 2, 3

ANS: 3) 3, 4, 1, 2 If a nurse becomes exposed to body fluid, she should first wash the area, tell another nurse she is leaving the area, contact the infection control or employee health nurse immediately, and complete an incident report. It is most important to remove the source of contamination (body fluid) as soon as possible after exposure to help prevent the nurse from becoming infected. The other activities can wait until that is done.

The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions? 1) I dont have to worry if my blood pressure is high once in a while. 2) I guess I will have to make sure I dont drink too much water. 3) I can lose some weight to help lower my blood pressure. 4) I will need to reduce the amount milk and other dairy products I use.

ANS: 3) I can lose some weight to help lower my blood pressure. A single lifestyle change, such as weight loss, can lower blood pressure (BP). Whenever the client has an elevated BP, the reading should be monitored even when it occurs just occasionally. Drinking too much alcohol is associated with hypertension, but water consumption is not unless accompanied by high sodium intake. A diet high in calcium is recommended to prevent and manage hypertension; therefore, it is not advisable to limit the intake of dietary calcium found in dairy products.

A clients axillary temperature is 100.8F. The nurse realizes this is outside normal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1F to 100.8F to obtain an oral equivalent. 2) Add 2F to 100.8F to obtain a rectal equivalent. 3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading.

ANS: 3) Obtain a rectal temperature reading. Body temperatures, from lowest to highest, are axillary, oral, rectal, and tympanic. For oral, axillary, and rectal temperatures, there is a 1F degree difference between each site and the next higher one. However, mathematical conversions between sites are not reliable and should be used only when a rough estimate is neededfor instance, to decide whether a reading needs to be validated by another site or another thermometer. Rectal temperatures are most reliable and most accurately reflect the core temperature. Tympanic membrane readings are considered by most to be the least accurate and least reliable.

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include? 1) Be sure to put mittens on the baby. 2) Layer the infants clothing. 3) Place a cap on the infants head. 4) Put warm booties on the baby.

ANS: 3) Place a cap on the infants head. All interventions are correct, but because of the many blood vessels close to the skin surface in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head.

A client who has been hospitalized for an infection states, The nursing assistant told me my vital signs are all within normal limits; that means Im cured. The nurses best response would be which of the following? 1) Your vital signs confirm that your infection is resolved; how do you feel? 2) Ill let your healthcare provider know so you can be discharged. 3) Your vital signs are stable, but there are other things to assess. 4) We still need to keep monitoring your temperature for a while.

ANS: 3) Your vital signs are stable, but there are other things to assess. Vital signs are one indicator of a clients physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. The healthcare providers decision regarding the clients readiness for discharge is not based exclusively on the vital signs but rather is based on a compilation of other sources of information, primarily the clients clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiologic evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be monitored; therefore, the statement We still need to keep monitoring your temperature . . . is incomplete and less useful than the statement that begins Your vital signs are stable, but . . .

Despite less-restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation? 1) Obtain a physicians order before applying restraints. 2) Monitor the patients status every 4 hours while restrained. 3) Release the restraints and check circulation every hour. 4) Continually reevaluate the patients need for restraint.

ANS: 4 4) Continually reevaluate the patients need for restraint. The patient must be continually monitored, and the need for restraint must be continually reevaluated. As a rule, a medical order should be obtained before applying restraints. However, in an emergency, the nurse is permitted to apply restraints for behavior management, but a physician or advanced practice nurse must then evaluate the patient within 1 hour of restraint application. The order for restraint must be renewed daily. The restraints must be released at least every 2 hours, and circulation must be checked.

For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who 1) Had abdominal surgery 2 hours ago 2) Suffered a fractured hip yesterday 3) Is dehydrated from vomiting 4) Has a heart or lung disease

ANS: 4) Has a heart or lung disease Conditions that require assessment of pulse deficit include digitalis therapy and blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status.

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1) Ask the client when in the day dizziness occurs. 2) Help the client to assume a recumbent position. 3) Measure both heart rate and blood pressure with the client standing. 4) Measure vital signs with the client supine, sitting, and standing.

ANS: 4) Measure vital signs with the client supine, sitting, and standing. Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting, and standing) to assess for orthostatic hypotension. The time of day is irrelevant to the diagnosis. If the nurse observes the patient become dizzy upon standing, the first action would be to help the client lie down and then obtain orthostatic vital signs; but this is not necessary when the symptom is not present. The nurse needs to measure both the heart rate and the blood pressure but not only in the standing position.

In evaluating a clients blood pressure for hypertension, it would be most important to 1) Use the same type of manometer each time 2) Auscultate all five Korotkoff sounds 3) Measure the blood pressure in both arms 4) Monitor the blood pressure for a pattern

ANS: 4) Monitor the blood pressure for a pattern Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. The type of manometer does not greatly influence the reliability of BP readings, although the mercury manometer is more accurate. Only the first and last Korotkoff sounds are necessary to determine a BP reading. The first time BP is assessed for a patient, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension.

The client has had a fever, ranging from 99.8F orally to 103F orally, over the last 24 hours. The clients fever would be classified as 1)Constant 2)Intermittent 3)Relapsing 4)Remittent

ANS: 4) Remittent Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above normal with only slight fluctuations. Intermittent fevers alternate between normal or subnormal temperatures with periods of fever. Relapsing fevers alternate between periods of fever and periods of normal temperature, each phase lasting 1 to 2 days.

In caring for a client who has a fever, it would be important for the nurse to monitor for increased 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate

ANS: 4) Respiratory rate The metabolic rate increases with a fever, increasing a persons respiratory rate. Urine output would more likely decrease, rather than increase, because of increased insensible loss and possible loss of intake because of loss of appetite. Change in pain sensation is not a symptom of a fever. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.

Indicate whether the statement is true or false. Bacteria are necessary for human health and well-being.

ANS: True Organisms that normally inhabit the body, called normal floras, are essential for human health and well-being. They keep pathogens in check. In the intestine, these floras function to aid digestion and promote the release of vitamin K, vitamin B12, thiamine, and riboflavin.