NUR 204 week 1-2
Which item in the plan of care for a client with paraplegia would the nurse question: -Change the client's bed position hourly. -Use supportive devices to maintain body alignment. -Instruct the client to do active leg exercises. -Perform passive leg exercises several times daily.
Answer: Instruct the client to do active leg exercises.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to? -Primary -Secondary -Superinfection -Nosocomial
Answer: Nosocomial
Which type of immunity would a 4-year-old child develop during the course of an infection with varicella? -Active natural immunity -Active artificial immunity -Passive natural immunity -Passive artificial immunity
Answer: Active natural immunity
Which type of immunity will clients acquire through immunizations with live or killed vaccines? -Natural active immunity -Artificial active immunity -Natural passive immunity -Artificial passive immunity
Answer: Artificial active immunity
The nurse is assessing four clients. Whic client would benefit most from reality orientation? Client A Dementia Client B Artificial Limb Client C Lacks self-esteem Client D Uses analgesics and sedatives
Answer: Client D
Which nursing intervention would the nurse classify as the highestpriority for a client with delirium? -Providing a body massage -Arranging for music therapy - Teaching relaxation techniques -Creating a calm and safe environment
Answer: Creating a calm and safe environment
The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment (PPE) would the nurse wear? -Mask -Clean gloves -Sterile gloves -Shoe covers
Answer: Clean gloves
The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? -Hand washing before and after providing client care -Cleaning all equipment with an approved disinfectant after use -Wearing personal protective equipment (PPE) when providing client care -Using medical and surgical aseptic techniques at all times
Answer: Hand washing before and after providing client care
Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries? -Incontinence; inability to move independently -Periodic diaphoresis; occasional sliding down in bed -Minimal reaction to painful stimuli; receiving tube feedings -Spending extensive time in a chair; body mass index (BMI) of 23
Answer: Incontinence; inability to move independently
Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis? -Place the client on airborne precautions. -Notify the client's health care provider. -Auscultate the client's breath sounds. -Notify the public health department.
Answer: Place the client on airborne precautions
The nurse changed a dressing on a client's wound with vancomycin-resistant enterococci (VRE). Which step would the nurse take to ensure proper disposal of the soiled dressing? -Place the dressing in the bedside trash can. -Place the dressing in a red bag/hazardous materials bag. -Contact environmental services personnel to pick up the dressing. -Transport the dressing to the laboratory to be placed in the incinerator.
Answer: Place the dressing in a red bag/hazardous materials bag
The nurse assists a client who had bariatric surgery to become more mobile. Which complication is the nurse attempting to prevent? -Incisional pain -Wound dehiscence -Anastomosis leakage -Pulmonary embolism
Answer: Pulmonary embolism
Which nursing intervention prevents footdrop in a client with osteomyelitis? -Elevating the foot with the use of pillows -Consistently flexing the affected extremity -Encouraging the client to change positions -Neutral positioning of the foot with the use of a splint
Answer: -Neutral positioning of the foot with the use of a splint
Which amount of time is the maximum amount the nurse would permit an older adult with a cerebrovascular accident (CVA) to remain in one position? - I to 2 hours -3 to 4 hours -15 to 20 minutes -30 to 40 minutes
Answer: 1 to 2 hours
Which statement made by the nurse will be most significant when teaching strategies to reduce the risk for developing antibiotic-resistant infections? "Wash your hands frequently with warm soapy water." "Do not skip any prescribed doses of your antibiotics. "Do not save unfinished antibiotics for later use. "Do not stop taking the antibiotics when you feel better"
Answer: Do not skip any prescribed doses of your antibiotics
Which nursing action is most appropriate to help reduce the likelihood of an older adult client falling during the night? -Moving the client's bedside table closer to the bed -Encouraging the client to take an available sedative -Instructing the client to call the nurse before going to the bathroom -Assisting the client to telephone home to say goodnight to the spouse
Answer: Instructing the client to call the nurse before going to the bathroom
Which room assignment would the nurse select for a child hospitalized with newly diagnosed tuberculosis? • Private room • isolation room • Four-bed room • Semiprivate room
Answer: Isolation room
Which action would the nurse encourage a client with obsessive-compulsive disorder who has red, raw, slightly bleeding hands from washing them 70 to 80 times a day to do? -Understand that the hands are not dirty. -Gain insight into the emotional problems. -Stop washing the hands so the skin will heal. -Limit the number of times hand washing occurs.
Answer: Limit the number of times hand washing occurs
Which action would the nurse teach an older adult to take to prevent frequent colds (viral rhinitis)? -Taking antihistamines as soon as symptoms begin -Spending more time indoors during the cold season -Wearing extra layers whenever going outside in winter -Washing hands before putting them near the nose or mouth
Answer: Washing hands before putting them near the nose or mouth
The registered nurse (RN) is caring for a client with peptic ulcers and dysphagia. Which task would the RN exclude when delegating this client's care to unlicensed assistive personnel (UAP)? -Assisting the client with feeding -Assisting the client with bathing -Assisting the client in oral hygiene -Assisting the client in administering medications
Answer: Assisting the client in administering medications
Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? -Pouring warm water over the perineum -Ensuring the patency of the catheter - Removing the catheter within 24 hours - Cleaning the catheter insertion site
Answer: Removing the catheter within 24 hours
When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give? "You developed an infection that requires antibiotics." "This is a highly contagious infection requiring isolation." "An infection you had before beginning treatment has flared up." "Your infection occurred because of exposure to a health care facility.
Answer: Your infection occurred because of exposure to a health care facility
Which nursing intervention would the nurse implement for a client with active tuberculosis who is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions? -Ensure regular visits by staff members to meet the client needs. -Explore what the airborne precautions mean to the client. - Report the situation to the infection control nurse immediately. -Reteach the concepts of airborne precautions to the client.
Answer: Explore what the airborne precautions mean to the client.
Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. One, some, or all responses may be correct. "Use a cane for support when walking. "Hold on to handrails while ambulating. "Look where your feet are placed while walking." "Wear shoes that give good support while walking." "If you are unable to change your position frequently, request assistance."
Answers: "Hold on to handrails while ambulating. I"Look where your feet are placed while walking." "Wear shoes that give good support while walking." "If you are unable to change your position frequently, request assistance."
Which action would be included in an organization's policy for hand hygiene? Select all that apply. One, some, or all responses may be correct. -Wash hands before applying sterile gloves. -Wash hands before touching any of the client's personal items. -Wash with either soap and water or alcohol-based hand rub (ABHR) before client contact. -Wash with soap and water when hands are visibly soiled with blood. -Wash with ABHR if hands are not visibly soiled. -Wash hands, between fingers, and under nails for 60 seconds.
Answers: -Wash hands before applying sterile gloves. -Wash with either soap and water or alcohol-based hand rub (ABHR) before client contact. -Wash with soap and water when hands are visibly soiled with blood. -Wash with ABHR if hands are not visibly soiled.
Which nursing interventions require the nurse to wear gloves? Select all that apply. One, some, or all responses may be correct. -Giving a back rub -Cleaning a newborn immediately after delivery -Emptying a portable wound drainage system -Interviewing a client in the emergency department -Obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)
Answers: Cleaning a newborn immediately after delivery Emptying a portable wound drainage system
Which strategies will promote safety and quality of client care on the unit? Select all that apply. One, some, or all responses may be correct. -Communicate with clarity and precision when designing multidisciplinary plans of care. -Create a safety huddle so all health care professionals are aware of the clinical objectives. -Emphasize electronic communication is quick and most effective means of sharing information in all situations. -Conduct communication simulations to increase knowledge about expertise of other health care disciplines. -Explain effective communication will take more time and effort compared with ineffective communication.
Answers: Communicate with clarity and precision when designing multidisciplinary plans of care. Create a safety huddle so all health care professionals are aware of the clinical objectives. Conduct communication simulations to increase knowledge about expertise of other health care disciplines.
Which actions by a client who lives with family and has an upper respiratory infection indicate that the home health nurse's teaching about infection control has been effective? Select all that apply. One, some, or all responses may be correct. -Covering mouth with a forearm when coughing or sneezing -Putting tissues in a plastic bag after using them to cough -Avoiding talking or spending time with family members -Asking the health care provider for an antibiotic prescription -Using an alcohol-based hand sanitizer to wash the hands
Answers: Covering mouth with a forearm when coughing or sneezing Putting tissues in a plastic bag after using them to cough Using an alcohol-based hand sanitizer to wash the hands
The nurse is caring for a client who underwent a hysterectomy and is admitted to a general medical-surgical unit. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. One, some, or all responses may be correct. -Oral hygiene -Assistance with bathing -Oral medication administration -Intravenous fluid administration -Providing treatments with supervision
Answers: Oral hygiene Assistance with bathing
The nurse manager appointed a registered nurse (RN) to provide hospice care for a client and explained the tasks to be performed. Which tasks has the nurse manager delegated to the RN? Select all that apply. One, some, or all answers may be correct. -Providing total client care -Performing all the hygiene tasks -Teaching the client and family members -Teaching the client about personal hygiene -Assisting the client in performing daily activities
Answers: Providing total client care Teaching the client and family members Teaching the client about personal hygiene
Which factors are unique to delirium when distinguishing between dementia and delirium? Select all that apply. One, some, or all responses may be correct. -Slurred speech -Lability of mood -Long-term memory loss -Visual or tactile hallucinations -Insidious deterioration of cognition -A fluctuating level of consciousness
Answers: Slurred speech Visual or tactile hallucinations A fluctuating level of consciousness
Which statement indicates the need for further learning after the nurse teaches a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA)? Select all that apply. One, some, or all responses may be correct. 'I can share athletic equipment." "I can participate in contact sports." "I should sit on upholstered furniture." " should use antibacterial soaps for bathing." "I should wash all infected skin areas before covering those areas.
Answers: 'I can share athletic equipment." "I can participate in contact sports." "I should sit on upholstered furniture."
The nurse is providing colostomy care to a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment (PPE) would the nurse use? Select all that apply. One, some, or all responses may be correct. Gloves Gown Mask Goggles Shoe covers Hair bonnet
Answers: Gloves Gown Goggles
Which statement made by the client indicates understanding after teaching about measures to decrease the risk for antibiotic-resistant infections? Select all that apply. One, some, or all responses may be correct. "I should wash my hands frequently." "| should skip doses when I am completely well." "I should avoid taking antibiotics to treat the common cold." "I should save unfinished antibiotics for later emergency use. "I should avoid taking antibiotics without asking the primary health care provider."
Answers: -I should wash my hands frequently -I should avoid taking antibiotics to treat the common cold -I should avoid taking antibiotics without asking the primary health care provider
Which complication would the nurse monitor for in a client on strict bed rest for 3 days? Select all that apply. One, some, or all responses may be correct. -Atelectasis -Hypotension -Constipation -Pressure injuries -Urinary tract infection
Answers: Atelectasis Hypotension Constipation Pressure injuries Urinary tract infection
Which intervention will be beneficial for the safe and effective care of a hospitalized immunosuppressed client? Select all that apply. One, some, or all responses may be correct. -Advise the client to eat raw fruits daily. -Avoid using supplies from common areas. -Encourage activity at an appropriate level. -I Use alcohol-based hand rubs before touching the client. -Change gauze-containing wound dressing on alternate days.
Answers: Avoid using supplies from common areas Encourage activity at an appropriate level Use alcohol-based hand rubs before touching the client
Which expected sensory loss associated with aging would a nurse recall when designing a plan of care for an 85-year-old client admitted to a nursing home? Select all that apply. One, some, or all responses may be correct. -Difficulty in swallowing -Diminished sensation of pain -Heightened response to stimuli -Impaired hearing of high frequency sounds -Increased ability to tolerate environmental heat
Answers: Diminished sensation of pain Impaired hearing of high frequency sounds
Which needs would the nurse address using Maslow's hierarchy of needs when caring for an emancipated minor reporting improper nutrition? -Physiological -Self-actualization -Safety and security -Love and belonging
Answers: Physiological
Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct. -Providing a cold bath to reduce the client's body temperature -Positioning the bed in a low position and keeping the side rails up -Monitoring vital signs, such as blood pressure to decrease the risk of falls -Observing a client who has suicidal tendencies to prevent adverse incidents -Collaborating with family members to provide emotional support for the client post-surgery
Answers: Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents
The nurse manager appointed a registered nurse (RN) to provide hospice care for a client and explained the tasks to be performed. Which tasks has the nurse manager delegated to the RN? Select all that apply. One, some, or all answers may be correct. -Providing total client care -Performing all the hygiene tasks -Teaching the client and family members -Teaching the client about personal hygiene -Assisting the client in performing daily activities
Answers: Providing total client care Teaching the client and family members Teaching the client about personal hygiene