Quiz #1 Final Review 323

A nurse teaches a post-operative patient about atelectasis. Which statement by the patient indicates an understanding about atelectasis? A. "Atelectasis affects only those with chronic conditions such as emphysema." B. "It is important to do breathing exercises every hour to prevent atelectasis." C. "Hyperventilation will open up my alveoli, preventing atelectasis." D. "If I develop atelectasis, I will need a chest tube to drain excess fluid."

B. "It is important to do breathing exercises every hour to prevent atelectasis."

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. Restricts the client's ability to eat, speak, or drink. B. Delivers a high concentration of oxygen. C. Delivers a constant rate of a specific concentration of oxygen. D. Delivers a low concentration of oxygen.

D. Delivers a low concentration of oxygen. A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).

A nurse is teaching a newly licensed nurse about the risk factors for wound complications for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. obesity B. wound infection C. Altered mental status D. poor nutritional state E. pain medication administration

A, B, D A client who is obese is at risk for wound complications due to poor healing abilities of adipose tissue and the constant strain placed on the incision. A client who has a wound infection is at risk for wound complications due to delayed healing. A client who is in a poor nutritional state is at risk for wound complications due to impaired healing.

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.) A. Shave the client's hair in the direction of the hair growth. B. Place a clean gown on the strongest arm first. C. Keep the bath water temperature between 43.3° C (110° F) and 46.1° C (115° F). D. Wash the client's extremities from proximal to distal. E. Check for personal items when changing the bed linens.

A, C, E The nurse should shave the client's facial hair in the direction of hair growth to prevent discomfort and minor cuts. This temperature range is generally comfortable for the client and prevents burns and chilling.While changing bed sheets, the nurse can easily overlook small items the client was unable to retrieve from the linens.

A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? A. "As adults age, their ability to perceive pain decreases." B. "Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs." C. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." D. "Patients who have dementia probably experience pain, and their pain is not always well controlled."

A. "As adults age, their ability to perceive pain decreases."

A client states, "Why do I feel relief now that my dad is gone?" Which of the following responses should the nurse make? A. "Tell me what you are thinking." B. "Do you feel guilty?" C. "Your dad is not suffering anymore." D. "You are in denial about your dad's death."

A. "Tell me what you are thinking." This statement provides a general lead, a therapeutic communication technique that encourages the expression of ideas and feelings.

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching? A. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." B. "A patient's behavior is more reliable than the patient's report of pain." C. "Pain assessment scales determine the quality of a patient's pain." D. "When patients say they don't need pain medication, they aren't in pain."

A. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient."

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. hydrogen C. wet-to-dry gauze dressing D. Alginate dressing

A. Transparent dressing A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? A. full thickness skin loss B. exposed bone C. partial thickness skin loss D. serum filled blisters

A. full thickness skin loss

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 2 hrs. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

A: Frequent position changes are important for preventing skin breakdown, the nurse should reposition the client at least every 2 hr.

A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make? A. "Please explain what you mean by the word 'nervous.'" B. "What is making you feel nervous?" C. "Would a backrub ease your nervousness?" D. "You shouldn't feel nervous."

B. "What is making you feel nervous?" This question asks the client for an explanation and assumes there is a reason why the client is feeling this way.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Secure the oxygen tubing to the bed sheet near the client's head. B. Attach a humidifier bottle to the base of the flow meter. C. Remove the nasal cannula while the client eats. D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

B. Attach a humidifier bottle to the base of the flow meter. Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? A. Pulse rate B. BP C. Temp D. Respiratory Rate

B. BP A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? A. Placing a sterile dressing 5 cm (2 in) from the border of the sterile field. B. Opening a sterile package over the middle of the sterile field. C. Holding a sterile item at just above waist level. D. Opening the sterile tray by first unfolding the flap farthest from his body.

B. Opening a sterile package over the middle of the sterile field: Opening a sterile package over the middle of the sterile filed requires reaching into the field, which can result in contamination. The nurse should place the object on the field by approaching the field from an angle.

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? A. properly disposing of contaminated equipment B. Performing hand hygiene frequently and consistently C. changing soiled linens daily for clients who have drainage wounds D. discarding used syringes in appropriate containers

B. Performing hand hygiene frequently and consistently: The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Apply petroleum jelly to the client's lips after oral care. B. Turn the client on his side before starting oral care. C. Use the thumb and index finger to keep the client's mouth open. D. Use a stiff toothbrush to clean the client's teeth.

B. Turn the client on his side before starting oral care.

A nurse is assessing a client who has mild signs of hypoxia. Which of the following findings should the nurse expect? A. somnolence B. tachycardia C. cyanosis D. bradypnea

B. tachycardia (NOT c. b/c The nurse should expect the client to manifest cyanosis, a bluish discoloration of the skin and mucous membranes, with SEVERE hypoxia.)

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? A. Checks the instrument gauge to ensure the reading starts at zero. B. Centers the cuff bladder over the client's brachial artery. C. Wraps the blood pressure cuff snugly around the client's arm. D. Places the client's arm above the level of the client's heart.

D. Places the client's arm above the level of the client's heart. The partner should place the client's arm at heart level to ensure accurate blood pressure readings.

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove last? A. gown B. gloves C. face shield/goggles D. mask

D. mask

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI? A. the client has bipolar disease B. The client had an appendectomy 6 months ago C. the client is male D. the client is 71 yrs old

D. the client is 71 yrs old

The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? A. Place the patient in a room with negative airflow. B. Wear a gown, gloves, face mask, and goggles for interactions with the patient. C. Transport the patient safely and quickly when going to the radiology department. D. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

D: Dedicated assessment tools should be used and left in the room for patients on contact precautions.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? A. To eliminate the need for wound irrigations. B. To limit the amount of bleeding from the surgical site. C. To provide a means for medication administration. D. To prevent fluid from accumulating in the wound.

D: The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.