test 5 - practice questions + rationales

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate? a. "Dehiscence is not anything that you need to worry about." b. "Dehiscence is when a wound has partial or total separation of the wound layers." c. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." d. "Dehiscence is the softening of tissue due to excessive moisture."

"Dehiscence is when a wound has partial or total separation of the wound layers." Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound.

The nurse is teaching a community group about transmission of HIV. Which client statement by a community member demonstrates that further teaching is needed? a. "I can catch HIV by swimming in pools." b. "HIV is transmitted through sexual contact." c. "I should not share razors or toothbrushes with others." d. "Someone can be exposed to this virus by sharing needles."

"I can catch HIV by swimming in pools." HIV is not transmitted through swimming pools; further teaching is needed to clarify this point. The other client statements appropriately reflect how HIV is transmitted and do not require further teaching.

The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states which of the following? a. "I do not need to wash my hands if I am using gloves." b. "I should wash my hands before touching a client." c. "I should wash my hands before a clean procedure." d. "I should wash my hands after touching the client?s surroundings."

"I do not need to wash my hands if I am using gloves." The World Health Organization clearly defines the "Five Moments for Hand Hygiene." These include before touching a client, before a clean or sterile procedure, after a body fluid exposure risk, after touching a client, and after touching a client's surroundings. The Joint Commission cites that one of the factors that contributes to poor compliance with hand hygiene practices is the belief that hand hygiene is not required when gloves are worn.

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is a. "I really have limited time. Let me give you your bath right now." b. "I will set up your bath for you. I will come back and help you with your back." c. "You will need to sit up for your bath, and then I will change your bed." d. "You will be able to take your bath by yourself tomorrow when you can get up."

"I will set up your bath for you. I will come back and help you with your back." The nurse must value and support the client becoming independent in care.

A school nurse is conducting a safety seminar with 6th-grade students. Which of the following teaching points is most important? a. "Make sure that you have smoke detectors in your house and that they're in working order." b. "If your clothes should catch on fire, go to an open area as quickly as possible." c. "Make sure that your family's microwave oven was made after 1999, otherwise it may be a fire risk." d. "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary."

"Make sure that you have smoke detectors in your house and that they're in working order." A paramount fire-safety issue is smoke detectors, since approximately half of home fire deaths occur in a home without a smoke detector. This risk far exceeds that of fireplaces, even though these must be used with caution. Individuals should stop, drop and roll if clothing catches on fire. Old microwaves do not constitute a significant fire risk.

The nurse is getting ready to change the client's saturated, infected leg dressing. The client requests that the nurse delay it until the night shift. Which response does the nurse provide this client? a. "I will inform the incoming nurse of your request." b. "We can change it later; I will reinforce your dressing for now." c. "Saturated dressings increase the risk of the spread of infection." d. "You do not need to worry; I can change your dressing quickly."

"Saturated dressings increase the risk of the spread of infection." Stagnant secretions in the body provide a warm, moist environment that fosters bacterial growth. Normal defense mechanisms prevent stasis of body fluids, but these can be altered. It is not advisable to change the client's dressing at a later date or to just tell the client not to worry. These are not appropriate responses. Waiting for the incoming nurse and waiting until later delays the needed dressing change and can lead to infection.

A nurse is caring for a patient with long hair. The patient asks if something could be done about her hair to be more comfortable. How would the nurse respond? a. "Yes, I can braid it for you if you want me to." b. "Well I guess I could just cut it all off." c. "You will have to ask your family to do that." d. "No, that is not a part of my job as a nurse."

"Yes, I can braid it for you if you want me to." The best way to protect long hair from matting and tangling is to ask the patient for permission to braid it. Nursing responsibilities for hygiene include providing care of the hair.

The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate? a. "Your wound will heal slowly as granulation tissue forms and fills the wound." b. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." c. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." d. "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound." There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention.

Which client would be at highest risk for injury to the skin and mucous membranes? a. 10-day-old infant with no health problems b. 17-year-old adolescent with asthma c. 44-year-old adult with hemorrhoids d. 77-year-old client with diabetes

77-year-old client with diabetes Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, the amount of underlying tissue, and illness conditions. In this question, the older adult client with diabetes would be most at risk. Diabetes and high blood glucose put a client at a higher risk of infection. Hemorrhoids are swollen veins in the lowest part of the rectum and anus and are not associated with injury. Asthma is a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe.

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question? a. Do you experience incontinence?? b. How many meals a day do you eat?? c. Do you use any lotions on your skin?? d. Have you had any recent illnesses??

?Do you experience incontinence?? The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure ulcers. The number of meals eaten per day does not give a clear assessment of nutritional status. You want to question the client about skin care regimens, such as the use of lotions, but this would not be the priority in determining the risk for pressure ulcer development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure ulcer development.

A nurse is caring for elderly clients. Which of the following is the most important safety issue in older clients? a. Drowning b. Accidental falls c. Poisoning d. Electrical injury

Accidental falls Among elderly clients, accidental falls are the most important safety issue of which nurses and caregivers should be aware. Falls may result in major life-changing events, robbing the older person of his or her independence. Drowning, poisoning, and electrical injury are safety issues in toddlers.

An acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? a. Activate the fire code system and notify the appropriate person. b. Attempt to extinguish the fire. c. Alert the local fire department of the fire. d. Answer all telephone calls and call bells.

Activate the fire code system and notify the appropriate person. The "A" in the acronym RACE stands for "activate the fire code system and notify the appropriate person."

Which type of mobility aids would be most appropriate for a client who has poor balance? a. A cane with four prongs on the end (quad cane) b. A single-ended cane with a half-circle handle c. A single-ended cane with a straight handle d. Axillary crutches

A cane with four prongs on the end (quad cane) Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation.

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces? a. A patient sitting in a chair who slides down b. A patient who lifts himself up on his elbows c. A patient who lies on wrinkled sheets d. A patient who must remain on his back for long periods of time

A patient sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed or from bed to chair or stretcher are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

For which of the following patients is foot care likely the highest priority? a. A patient who is obese and has a diagnosis of type 1 diabetes b. A patient who has experienced postoperative pneumonia and has been placed on a ventilator c. A patient who has chronic renal failure and requires hemodialysis three times weekly d. A patient who has been diagnosed with Alzheimer disease and whose mobility is decreasing

A patient who is obese and has a diagnosis of type 1 diabetes Patients with diabetes mellitus have an increased need for vigilant foot care, due to the risk of skin breakdown and foot wounds that often accompany the disease.

You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately? a. A sterile, flexible applicator moistened with saline b. A small plastic ruler c. A sterile tongue blade lubricated with water soluble gel d. An otic curette

A sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile

Which of the following does the nurse recognize as the most important component of the oral care process when providing oral care? a. A thorough mechanical cleaning b. Application of moisturizing ointment to the lips c. Selection of toothpaste d. Use of a mouthwash or breath freshener

A thorough mechanical cleaning Following the steps for cleaning the mouth thoroughly is more important than the agent used. No mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning of the oral cavity.

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments? a. Use an aquathermia pad during the treatment to create heat and circulate the water. b. Administer analgesics 30 minutes prior to the treatment to act on pain receptors. c. Dangle leg for 15 minutes before the treatment to increase blood flow to necrotic tissue. d. Ambulate in the hallway before the treatment to promote blood flow and relax tense muscles.

Administer analgesics 30 minutes prior to the treatment to act on pain receptors. Warm soaks and dressing changes can be painful for clients with abscesses. Often, nurses will premeditate with pain medications, often narcotics, 20-30 to make the treatments more comfortable for clients. Increasing client comfort can increase effectiveness by allowing the nurse time to adequately perform the treatment, assess the wound, and apply the new dressing. Aquathermia pads are used to promote wound healing, but they are not used simultaneously with water therapies. Dangling the legs and ambulating will not increase comfort.

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? a. Adolescents b. School-aged children c. Middle-aged adults d. Older adults

Adolescents As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. As a person ages, bathing frequently decreases, and older people may not use deodorant due to excessive drying of the skin.

A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development? a. Hemoglobin A1C 5% b. Blood urea nitrogen (BUN) 7 mg/dL c. Albumin 2.8 mg/dL d. White blood cell count 14,800 mm3

Albumin 2.8 mg/dL An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure ulcer. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which of the following clients? a. An 84-year-old male with four recent driving violations b. A 12-year-old male who sprained his wrist skateboarding c. A 42-year-old female who is a single mom with a sick child home from school d. A 16-year-old pregnant female who has morning sickness

An 84-year-old male with four recent driving violations An elderly adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycussis, cognition, and/or response time impairments. The 12-year-old should not experience sensory issues with a sprain of the wrist. The 42-year-old may be stressed but is not experiencing illness. The 16-year-old is experiencing illness, but it is not a sensory-perceptual alteration.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a. An infant's skin and mucous membranes are easily injured and at risk for infection. b. In children younger than 2 years, the skin is thicker and stronger than in adults. c. A child's skin becomes less resistant to injury and infection as the child grows. d. An individual's skin changes little over the life span.

An infant's skin and mucous membranes are easily injured and at risk for infection. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

The nurse would recognize which of the following patients as being particularly susceptible to impaired wound healing? a. An obese woman with a history of type 1 diabetes mellitus b. A patient whose breast reconstruction surgery required numerous incisions c. A man with a sedentary lifestyle and a long history of cigarette smoking d. A patient who is NPO (nothing by mouth) following bowel surgery

An obese woman with a history of type 1 diabetes mellitus Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process and short-term lack of food intake is not as significant as longer-term lack of nutrition.

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which of the following articles can be a threat to the client's safety? a. A laundry bag at the corner of the room b. Skid-resistant small area rugs on the floor c. Area rugs kept on the stairs without carpet d. Carpet on the floor of the living room

Area rugs kept on the stairs without carpet The area rugs kept on the stairs are a health hazard and may cause falls. The elderly client should remove the area rugs from the stairs to prevent accidental injury. Laundry bags, skid-resistant small area rugs, and carpets are not harmful.

A nurse making a home visit for a client living in a high-crime area observes that the apartment building does not have outside lighting. The nurse understands this is an important assessment for which reason? a. This assessment finding will make the client less able to go to social gatherings. b. Assessment includes risk factors in the home including individual risk and unsafe environment c. Although important, this assessment is irrelevant to care. Nurses in home healthcare are not concerned with safety.

Assessment includes risk factors in the home including individual risk and unsafe environment Nursing assessment includes identifying individuals at risk and recognizing unsafe situations in the environment, both the healthcare agency and the home. Certain environmental areas, like high-crime neighborhoods, have proven to be more hazardous. Living in an area where crime is prevalent can pose a threat to physical security and emotional well-being. Violence, acts of aggression, and terrorism are components of 21st-century life. Security measures such as locks, security systems, and exterior lighting can promote safety.

When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for a. Assessment of tissues b. Increasing circulation c. Promotion of conversation d. Relaxation of muscles

Assessment of tissues Bathing promotes assessment of the client's physical condition by noting injured areas, bruises, rashes, or any other unusual signs.

An 18-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following? a. Falls from beds b. Automobile accidents c. Play-related injuries d. Falls from staircases

Automobile accidents Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-aged children, and falling from staircases is a common injury among toddlers.

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown? a. Before entering the client?s room b. After entering the client's room c. Before taking the client's pulse d. After taking the client's pulse

Before entering the client?s room The nurse should don the gown before entering the client?s room to prevent soiling/contamination of the nurse?s clothing with infectious bacteria/viruses and/or the client?s blood and body fluids.

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development? a. Glascow scale b. Braden scale c. FLACC scale d. Morse scale

Braden scale The Braden scale is an assessment tool used to assess the client?s risk for pressure ulcer development. The Glascow scale is used to assess a client?s neurological status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client?s risk for falls.

A nurse is caring for a female client with diarrhea. What information does the nurse teach the client about perineal care and self-care? a. Bathe the perineal area with a mild soap and water. b. Clean the perineal area from the front to back. c. Insert any suppository medication prior to cleaning the perineal area. d. Wear gloves while performing perineal self-care.

Clean the perineal area from the front to back. The nurse should instruct the client to clean the perineal area from the front to back toward the rectal area to prevent urinary tract infections. Bathing with a mild soap and water are not specific perineal hygiene instructions, and washing the perineal area. Having the client wear gloves while performing perineal self-care is unnecessary. Inserting any suppository medication prior to cleaning is not required.

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which of the following? a. Client will participate in self-care measures by the end of the week. b. Client will recognize the need for self-care. c. Client will verbalize the need to use to use the bedpan by the end of shift. d. Client will consent to no hygiene measures.

Client will participate in self-care measures by the end of the week. Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not mean the client does not want to participate in hygiene and personal care. An appropriate goal would be to have the client actively participate in hygiene and self-care.

A nurse is caring for a client who has been transported for a diagnostic test. The nurse is changing the client's bed linens and moves them to the location in the image. Which anticipated outcome is most plausible based on the nurse's actions? a. Contaminants can be transferred onto the furniture and spread microorganisms. b. Some hospital policies allow for temporary placement of soiled lines on furniture. c. An incident report will be created and sent to risk management. d. The furniture will be tagged for removal from the hospital premise due to contamination.

Contaminants can be transferred onto the furniture and spread microorganisms. Placing soiled linens on the floor or on furniture in a client's room is not appropriate. This action could further soil and contaminate the furniture because the floor is heavily contaminated. It is not an acceptable infection control practice for health care facilities to allow temporary placement of soiled lines on furniture and would not be noted in hospital policies. An incident report is not required, education and reinforcement of hospital procedures and infection control principles is warranted. It is not cost-effective for health care institutions to remove furniture that is soiled by linens. The furniture will be cleaned per hospital guidelines depending on the degree of contamination.

You are donning a pair of sterile gloves. You correctly don the first glove, but inadvertently insert the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which of the following actions is most appropriate? a. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. b. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of your ability. c. Don a second pair of sterile gloves over the first pair. d. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field.

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. It is appropriate to adjust the gloves but touching sterile surface to sterile surface.

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform? a. Ask several staff to be in the room for safety since the client is sometimes agitated. b. Create a calming environment with little stimuli. c. Refuse to bathe the client because the nurse and client have not established a rapport. d. Delegate this task to someone else since it's not the nurse's responsibility to perform hygiene for clients.

Create a calming environment with little stimuli. Bathing sometimes increases stimulation in clients who are confused or have dementia. Reducing the stimuli and providing a calm environment will decrease agitation. Turning down the lights, ensuring the adequacy of the environment where the client is being bathed and playing soft, relaxing music are possible interventions to calm the client. Nurses are responsible for the care of their clients and the staff that care for them. Delegating care of a client with dementia may require special instructions for the UAP.

An acute medicine unit of a hospital currently has a number of patients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following measures should the nursing staff prioritize in preventing the spread of MRSA to patients who are currently MRSA-negative? a. Diligent handwashing practices b. Reduced length of stay for MRSA-positive patients c. Constant use of gloves when on the unit d. Prophylactic antibiotic therapy for MRSA-negative patients

Diligent handwashing practices As with all forms of infection, thorough handwashing is the most important infection-control measure. It is inappropriate to reduce patients' length of stay based on their MRSA status, and prophylaxis is not normally used. It is unnecessary to wear gloves at all times on the unit.

A nurse enters a patient's room and finds that the patient has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this patient? a. Briefly leave the patient in order to call the primary physician to assess the patient's condition. b. Order x-rays or CT scans for the patient, as needed. c. Document the incident, assessment, and interventions in the patient's medical record. d. Do not file an event report unless the patient is seriously injured in the fall.

Document the incident, assessment, and interventions in the patient's medical record. The nurse is responsible for documenting the incident in the patient's record. Assess the patient immediately and provide appropriate care and interventions based on patient status and ensure prompt follow-through for any physician orders for diagnostic tests. An event report should be filed in the case of a fall, as per facility policy.

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. How should the nurse record the findings in the client's medical record? a. Caries b. Tartar c. Gingivitis d. Periodontal disease

Gingivitis The nurse should record the findings as gingivitis. Gingivitis is a condition in which there is inflammation of the gums. This usually happens when there is improper cleaning of teeth or injury to the gums from overly vigorous brushing or flossing. Bleeding gums is usually associated with gingivitis. Caries, tartar, or periodontal disease does not show inflammation of the gums. Cavities usually occur when there is combination of sugar, plaque, and bacteria in the teeth, which eventually erode the tooth enamel. Periodontal disease is a condition that results in the destruction of the tooth-supporting structures and jawbone.

Which nursing action is a component of medical asepsis? a. Handwashing after removing gloves b. Insertion of an indwelling urinary catheter c. Insertion of an intravenous catheter d. Drawing blood from a central line

Handwashing after removing gloves Medical asepsis (clean technique) involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Surgical asepsis (sterile technique) includes practices used to render and keep objects and areas free from microorganisms (insertion of urinary or intravenous catheters).

When educating families on fire safety in the home, which information is important for the nurse to emphasize? a. Have a meeting place outside the home in case of fire. b. Account for all members and then exit together. c. Use extension cords to prevent shock. d. Keep a fire extinguisher in a closet.

Have a meeting place outside the home in case of fire. The whole family should regularly practice a fire escape plan, such as crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in a area with access and not a closet.

A child is learning to ride a bicycle. He should be instructed to use which of the following protective devices? a. Helmet b. Wrist guard c. Knee pads d. Light

Helmet Children should wear properly fitted helmets when cycling, riding, or playing contact sports. Helmets will help to protect against head injury. Knee pads and wrist gards will protect but not with the same degree of importance as a helmet.

The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select? a. Hydrocolloid b. Wet to dry c. Negative wound pressure therapy d. Telfa

Hydrocolloid The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement.-Telfa pads are non stick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

Which of the following is a recommended guideline for maintaining a sterile field? a. When a portion of the sterile field becomes contaminated, the nurse should remove the contaminated objects and continue with the procedure. b. If a supply is missing, you may leave the sterile field briefly to obtain it. c. If the patient touches the sterile field, you should discard the supplies and prepare a new sterile field. d. If the patient touches the nurse's gloves during the procedure, you may still proceed with the procedure.

If the patient touches the sterile field, you should discard the supplies and prepare a new sterile field. If the patient touches the sterile field, discard the supplies and prepare a new sterile field. When any portion of the sterile field becomes contaminated, all portions of the sterile field must be discarded. Call for help if a supply is needed and do not leave the sterile field unobserved.

When the nurse cleanses the client's leg during a bed bath, it will allow for a. Assessment of pain b. Increased circulation c. Decreased restless leg syndrome d. Promotion of social interaction

Increased circulation Bathing increases circulation and helps maintain muscle tone and joint mobility.

A nurse is taking stock of the equipment in the room of an elderly client with pneumonia who has been on parenteral nutrition for a long time. Which of the following equipment can transmit infection to elderly clients? a. Indwelling catheter b. Bath blanket c. Face shields d. Specimen containers

Indwelling catheter Infections are often transmitted to elderly clients through equipment reservoirs, such as indwelling urinary catheters, humidifiers, and oxygen equipment, or through incisional sites, such as those for intravenous tubing, parenteral nutrition, or tube feedings. Use of proper aseptic techniques is essential to prevent the introduction of microorganisms. Bath blankets, face shields, and specimen containers are not part of the equipment reservoir that transmits infection easily because they are disposed of immediately after one-time use.

Which priority action should be implemented by the charge nurse when observing a new graduate nurse perform the procedure displayed in the image? -nurse is not wearing gloves while collecting specimens from a patient's stool. a. Refer the new nurse to the policy and procedure manual b. Ask the new nurse to leave the client's room immediately c. Instruct the new nurse to put more stool in the specimen container to send to the laboratory d. Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids

Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids Glove use remains the critical step for preventing transmission, and contact precautions. Standard precautions apply to blood, all body fluids, secretions, excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes.

During range-of-motion exercises, the nurse turns the sole of a patient's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions? a. Internal and external rotation of the ankle b. Dorsiflexion and plantar flexion of the ankle c. Flexion and extension of the ankle d. Inversion and eversion of the ankle

Inversion and eversion of the ankle Inversion and eversion are movements of the ankle. Inversion is the movement of the sole of the foot inward. Eversion is the movement of the sole of the foot outward. Internal rotation is the turning of a body part on its axis toward the midline of the body. External rotation is the turning of a body part on its axis away from the midline of the body. Dorsiflexion is the backward bending of the hand or foot. Plantar flexion is flexion of the foot. Flexion is the state of being bent. Extension is the state of being in a straight line.

A nurse working in a long-term care facility institutes interventions to prevent falls in the elderly population. Which intervention would be an appropriate alternative to the use of restraints for ensuring patient safety and preventing falls? a. Involve family members in the patient's care. b. Allow the patient to use the bathroom independently. c. Keep the patient sedated with tranquilizers. d. Maintain a high bed position so the patient will not attempt to get out unassisted.

Involve family members in the patient's care. Family members are an invaluable resource in assessing a patient's risk for a fall because they can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls. Allowing the patient to ambulate independently may further increase the risk of a fall. Sedating a patient is a form of chemical restraint, and may cause the patient to have an unsteady gait when ambulating. If the patient attempts to get of bed a high bed position would cause more injury to the patient if a fall occurs.

When educating parents of preschoolers, what is most important to include in your presentation? a. Use wrist guards with rollerblades b. Teach preschoolers to tread water c. Keep chemicals in a locked cabinet d. Strict discipline with potty training

Keep chemicals in a locked cabinet Increasing mobility, lack of life experience and judgment, and still immature musculoskeletal and neurologic systems lead to potentially hazardous encounters for toddlers and preschoolers.

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? a. Closely monitor the toddler's activity. b. Label poisonous solutions. c. Keep cleaning solutions locked up. d. Do not leave the toddler alone.

Keep cleaning solutions locked up. The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

A student is walking down the hall carrying soiled linen against her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student? a. Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. b. Linen should always be handled with gloves and left in the client's room to prevent spread of microorganisms. c. Linen should be changed weekly to prevent the spread of microorganisms. d. Linens do not spread microorganisms.

Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms Dirty linen should be held away from contact with the uniform to prevent the spread of microorganisms. Soiled linen should not be carried in the hallway because dropping the linen spreads microorganisms. Linen should be handled with gloves if soiling is present. If the client is in isolation precautions, linens are disposed of in special bags and linen is taken from the room in those protective receptacles. Linens do spread microorganisms and should not be shaken in the room when making the bed, but rather unfolded.

Logrolling requires the nurse to use supportive devices in turning the client to a. Maintain the natural alignment of the body b. Allow the client's leg to rest on the bed c. Decrease the chance for skin breakdown d. Prevent the stasis of urine in the bladder

Maintain the natural alignment of the body Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine.

A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. b. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c. Pick the crusts off the sutures with the forceps before removing them. d. Do not attempt to remove the sutures because they need more time to heal.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing sutures.

What best describes the nurse's role in disaster preparedness? a. Administration of all of the medications b. Counseling the victims and families c. Multiple roles including triage and the distribution of resources d. Performance of all of the skills such as IV insertion and wound care

Multiple roles including triage and the distribution of resources Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

The nurse observes the client for signs of Stage I pressure ulcer development, which is most likely to include which finding? a. Nonblanchable redness b. A shallow, open ulcer c. Visible subcutaneous fat d. Exposed bone with eschar

Nonblanchable redness A Stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. A Stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A Stage III ulcer presents with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Stage IV ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

Which of the following is one of the most important benefits of a nurse helping with bathing? a. The patient sees professional staff. b. The nurse improves technical skills. c. Staff-nurse relationships are more collegial. d. Nurse-patient relationships are facilitated.

Nurse-patient relationships are facilitated. The simple act of bathing a patient is a vital and caring intervention. A nurse whose primary focus is the patient can use the time to establish a rapport with the patient and strengthen the nurse-patient relationship.

A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety? a. Assist the client in taking a stand-up shower b. Obtain a shower chair so the client can take a sit-down shower c. Give the client a bed bath d. Give the client a towel or bag bath

Obtain a shower chair so the client can take a sit-down shower This client is still able to bathe by oneself but has difficulty standing for long periods of time. In order to foster independence and provide the client with a safe bathing environment, a sit-down shower with shower chair would be most appropriate.

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a. Contact the surgeon for deibridement. b. Using sterile technique, debride the wound. c. Off-load pressure from the heel. d. Place a TED hose on the client's leg.

Off-load pressure from the heel. The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. Utilizing TED hose on the client will not impact the status of the heel wound.

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What should the nurse do? a. Restrain the client's hands b. Open a new sterile dressing kit c. Continue changing the dressing d. Wash the client?s hands

Open a new sterile dressing kit The nurse should obtain a new sterile dressing kit before continuing with the dressing change procedure. Continuing the dressing change without obtaining a new kit would increase the client?s risk for infection. The client?s hands do not need to be cleansed after touching the contents of the kit, and it would be inappropriate to restrain the client?s hands.

The nurse would recognize which of these devices as an open drainage system? a. Penrose drain b. Jackson-Pratt drain c. Hemovac d. Negative pressure dressing

Penrose drain A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.

When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. Which of the following is the appropriate action by the nurse? a. Report the incident to the supervisor immediately b. Have the client tested for HIV and hepatitis C c. Go to the emergency room at the end of the shift d. Perform hand hygiene after removing the glove

Perform hand hygiene after removing the glove Explanation: Because the client's blood contaminated the nurse's glove versus the nurse's hand, no exposure occurred. The nurse should perform hand hygiene after removing the glove. There is no need for further action.

Which of the following health problems is most clearly suggestive of a history of inadequate dental care? a. Periodontitis b. Cheilosis c. Dry oral mucosa d. Alopecia

Periodontitis Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene. Cheilosis is indicative of vitamin deficiency while dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss.

The nurse is caring for a client with a latex sensitivity. Which of the following resources would be the most appropriate for the nurse to access when developing the client's plan of care? a. Policy for clients with latex sensitivity b. The emergency room charge nurse c. The infectious disease nurse d. Human resources department

Policy for clients with latex sensitivity The nurse should access the facility?s policy for clients with latex sensitivity as a resource when developing the plan of care for a client with a latex sensitivity. The emergency room charge nurse and the infectious disease nurse may or may not know the policy for latex sensitivity, so the nurse should consult the policy directly. The human resources department would not be an appropriate resource.

The nurse educator has just completed a lecture regarding the elderly and hazards in the home. The nurse educator recognizes that teaching was effective when the students state that common dangers in the home setting of an elderly adult include which of the following? a. Polypharmacy and use of multiple extension cords b. Household cleaners stored under the sink and hanging cords on window blinds c. Peeling paint and easy access to the backyard pool d. Risky behaviors and cyber-bullying

Polypharmacy and use of multiple extension cords The elderly have significant risk of falls at home, due to aging changes such as diminished cognition, vision, hearing, and balance. Multiple medications, especially those altering level of consciousness, and household objects that challenge safe mobility are common dangers. Cleaners, hanging cords, peeling paint, and bodies of water are dangers to young children due to the potential for accidental poisoning, drowning, asphyxiation, and lead toxicity. Risky behaviors and cyber-bullying are common issues in the adolescent and young adult age groups.

Which of the following is an indication for the use of negative pressure wound therapy? a. Bone infections b. Malignant wounds c. Wounds with fistulas to body cavities d. Pressure ulcers

Pressure ulcers Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008; Thompson, 2008).

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? a. Providing a backrub before bed b. Giving the client something to drink c. Engaging in a therapeutic conversation d. Providing multiple stimuli to make the client tired

Providing a backrub before bed A backrub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client.

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following? a. Recapping a needle b. Needles left in the patient's linen c. Full needle boxes d. Faulty needles and syringes

Recapping a needle Most needlesticks occur during recapping, so nurses are instructed to never recap needles.

An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse? a. No action is needed at this time b. Remind coworker of the need to wear gloves c. Remind coworker that artificial nails increase infections d. Remind coworker to wash hands for 2 minutes

Remind coworker that artificial nails increase infections Artificial nails are associated with higher bacterial counts and therefore increase the client's risk for infection. Washing hands and wearing gloves do not make wearing artificial nails appropriate. In fact, wearing artificial nails in the OR is a citable offense during the Joint Commission accreditation process.

The nurse on a medical surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. Which of the following should be the nurse's first action? a. Remove the client from the room. b. Obtain the fire extinguisher. c. Activate the fire alarm. d. Close the client's door.

Remove the client from the room. In case of a fire, the nurse should rescue anyone in immediate danger; activate the fire code system and notify the appropriate person; and confine the fire by closing doors and windows in this order. Therefore, in this instance, the nurse's first action should be to remove the client from the room.

A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action? a. Removing dead or infected tissue to promote wound healing b. Stimulating the wound bed to promote the growth of granulation tissue c. Removing purulent drainage from the wound bed in order to accurately assess it d. Removing excess drainage and wet tissue to prevent maceration of surrounding skin

Removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed and the goal is neither assessment nor the prevention of maceration.

A nurse is preparing discharge teaching for a client being discharged with a newborn baby. What is the highest priority item that must be included in the teaching plan? a. Lock all cabinets that contain cleaning supplies. b. Keep all pots and pans in lower cabinets. c. Give warm bottles of formula to the baby. d. Restrain the baby in a car seat.

Restrain the baby in a car seat. The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings.

The nurse is performing range-of-motion exercises on a patient's arm. The nurse starts by lifting the arm forward to above the head of the patient. Which action would the nurse perform next? a. Move the opposite arm forward to above the head of the patient. b. Return the arm to the starting position at the side of the body. c. Rotate the lower arm and hand so the palm is up. d. Move the arm across the body as far as possible.

Return the arm to the starting position at the side of the body. The nurse would return the joint to a neutral position, that is, its normal position of alignment, when finishing each exercise.

After changing the bed linens for a client, the nurse uses an alcohol-based handrub to perform hand antisepsis. What is the proper way to use an alcohol-based handrub? a. a drop of the handrub, scrub, and rinse with water b. Distribute the product over the nails and wash with soap c. Rub the product between the hands until they are dry d. Rub the product between the hands for 5 seconds

Rub the product between the hands until they are dry When decontaminating with an alcohol-based handrub, the nurse should apply about a nickel- to quarter-sized amount of the product to the palm of one hand, distribute the product to cover all surfaces of the hands and fingers, and rub the product between the hands for 15 to 25 seconds until they are dry. The nurse need not rinse the hands with water after using an alcohol rub.

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which of the following drainage types should the nurse document? a. Serous b. Sanguineous c. Serosanguineous d. Purulent

Serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

A nurse is caring for a patient with lower extremity paralysis. Which action will the nurse take to prevent external rotation of the hip and foot? a. Use a trochanter roll. b. Apply SCDs. c. Obtain a prescription for antiembolism stockings. d. Have the patient maintain low-Fowler's position. e. Have the patient cross their arms on their chest and place a pillow between their knees. f. Place a cervical collar on the patient's neck and gently roll them to the other side of the bed.

a. The trochanter roll is used to support the hips and legs to prevent external rotation. SCDs and antiembolism stockings are used to prevent DVT. Fowler's position allows for foot rotation and increases sacral pressure.

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

Stage II A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater. A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling. Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which of the following stages should the nurse assign to this client's wound? a. Stage I b. Stage II c. Stage III d. Stage IV

Stage III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse? a. Stop and obtain appropriate PPE b. Complete the task, then obtain PPE c. Ask a colleague to perform the task d. Leave PPE in the room

Stop and obtain appropriate PPE The nurse should stop the task and obtain the appropriate protective wear. Completing the task without the appropriate equipment is inappropriate, as is asking a colleague to finish the task. Protective equipment should be left outside of the room so that it can be donned prior to entering.

A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field? a. Finish the procedure and perform handwashing immediately afterward. b. Finish the procedure, remove damaged glove, and open new sterile gloves. c. Stop the procedure, remove damaged glove, and open new sterile gloves.d d. Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.

Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves. If a hole or tear is noticed in one of the gloves during the procedure, stop the procedure, remove damaged gloves, wash hands or perform hand hygiene (depending on whether soiled or not), and put on new sterile gloves.

A nurse is explaining the use and handling of dentures to an elderly client. Which of the following measures should the nurse mention to the client? a. Store the dentures in water in a covered cup. b. Clean the dentures in hot water. c. Clean the dentures with a tissue. d. Keep the dentures wrapped in tissue.

Store the dentures in water in a covered cup. The nurse should tell the client to remove and store the dentures in water in a covered cup. The nurse should tell the client to clean the dentures and removable bridges with a toothbrush, toothpaste, and cold or tepid water—not hot water—to prevent damage. The nurse should not tell the client to clean dentures with a tissue or to keep them wrapped in a tissue as the tissue can stick to the dentures, leading to possible contamination and transfer of microorganisms.

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents? a. Teaching nurses how to prevent falls b. Reviewing safe medication administration c. Teaching nurses how to prevent wandering by confused residents d. Reviewing resuscitation for cardiac and respiratory arrest

Teaching nurses how to prevent falls Falls remain the leading cause of death among elderly Americans. Teaching that aims to reduce the incidence of falls is likely to be of more benefit than measures that address medication administration, prevention of wandering, or resuscitation procedures, even though such topics may be of importance.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? a. The client should be allowed to complete as much of the bath as he can. b. The nurse should have a male nurse bathe the client. c. The nurse should bathe the man herself, as he has dementia. d. The nurse should call a family member and have him or her bathe the man.

The client should be allowed to complete as much of the bath as he can. When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should let the client bathe himself to the extent that he can effectively do so. Bathing is performed in a matter-of-fact and dignified manner. If this approach is followed, clients generally do not find care by a person of the opposite gender to be offensive or embarrassing. Just because the man has dementia does not mean that he is not capable of bathing himself, at least in part. Calling a family member to bathe the client is both unnecessary and impractical.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include? a. The importance of consistent seat belt use b. The importance of practicing moderation when consuming alcohol c. Avoiding workplace injury d. Identification of hazards associate with falls

The importance of consistent seat belt use Seat belt use is an important safety precaution to teach audience of all ages. Improper or lack of seat belt use increases the risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls.

A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? a. The nurse is caring for a client with a C. difficile infection. b. The nurse performs routine care and is moving to another patient. c. The nurse finishes cleaning a patient's table. d. The nurse finishes patient care and hands are not visibly soiled.

The nurse is caring for a client with a C. difficile infection. Controversy exists regarding the use of alcohol-based handrubs when C. difficile organisms have been identified. Alcohol does not kill C. difficile spores.

A team of inner city school nurses attends a community conference on child safety during the summer months. Which of the following would be the priority health outcome that these nurses would expect to achieve in summer school? a. The students will only swim in the community pool when it hasn?t rained for 2 days. b. The students will demonstrate proper use of safety equipment while playing sports. c. The students will sign up for Fall afterschool programs. d. The students will read 400 pages from the summer booklist.

The students will demonstrate proper use of safety equipment while playing sports. Teaching safety when playing sports and other physical activities to school age children is an important responsibility of school nurses. Rainfall does not necessarily exclude treated pool water from usage. Afterschool programs and reading programs are the purview of the academic faculty in the schools.

A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room? a. Thorough handwashing b. Spraying of disinfectant c. Placing one bag of contaminated items within another d. Removing personal protective equipment that is most contaminated first

Thorough handwashing Since the client has an infectious disease, the most important nursing action is to perform thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care item. Spraying a disinfectant before leaving the client's room or placing one bag of contaminated items in another is not the most important nursing action in this case. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Nurses remove the personal protective equipment that is most contaminated first to preserve the clean uniform underneath.

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should a. Understand that his culture may influence his hygiene and ask him his preference b. Ask another nurse to assist in giving the client a complete bath every other day c. Give the client a bath pan and tell him she will return when he has finished d. Encourage the client to bathe daily as part of protection from infection

Understand that his culture may influence his hygiene and ask him his preference Preferences for hygiene vary widely among individuals and across cultures.

Which of the following modifications to bathing should be implemented for a patient who is incontinent? a. Use special perineal skin cleaners and moisture barriers. b. Use a topical antiseptic, such as povidone-iodine, in the perineal area. c. Decrease the frequency of bathing to preserve skin integrity. d. Perform a full bedbath each time the patient has an episode of incontinence.

Use special perineal skin cleaners and moisture barriers. Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation.

When is hand hygiene with an alcohol-based rub appropriate as opposed to using handwashing? a. When hands are not visibly soiled b. Before eating and after using the restroom c. When hands have been in contact with blood or body fluids d. When hands have been in contact with blood or body fluids, but there is no visible soiling

When hands are not visibly soiled Alcohol-based hand rubs may be used if hands are not visibly soiled, or have not come in contact with blood or body fluids. They should be used before and after each patient contact, or when in contact with surfaces in the patient's environment. Handwashing is required before eating or after using the restroom.

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client? a. No, the indentations will go away. b. No, knee-high hose are more comfortable. c. Yes, these are a safety hazard and should not be worn. d. Yes, these can obstruct lower extremity circulation.

Yes, these can obstruct lower extremity circulation. Knee high stockings may obstruct circulation. This is particularly true in the older woman. The individual with diabetes has an increased risk for circulatory impairments and should avoid them. Although the indentations will eventually go away they pose a hazard. Some individuals may feel that knee-high hose may be more comfortable; however, they do present a potential health hazard. Safety of the hose is not a consideration in this scenario.

When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply. a. Comparing bilateral parts for symmetry b. Proceeding in a head-to-toe, systematic manner c. Using standard terminology to communicate and document findings d. Avoiding using data from the nursing history to direct the assessment e. Documenting only skin abnormalities on the health record f. When risk factors are identified, following up with a related skin assessment

a, b, c, f. During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response? a. To help with pain management b. To provide comfort c. To communicate to patients through touch d. To energize patients, especially those with dementia e. To facilitate healing after back or spinal surgery f. To help increase circulation

a, b, c, f. The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs.

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply. a. Promoting the patient's sense of well-being b. Preventing deterioration of the oral cavity c. Contributing to decreased incidence of aspiration pneumonia d. Eliminating the need for flossing e. Decreasing oropharyngeal secretions f. Compensating for an inadequate diet

a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene and use of chlorhexidine gluconate (CHG) in critical care areas, can limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of ventilator-associated pneumonia, aspiration pneumonia, and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A patient is admitted with a nonhealing surgical wound. Which nursing interventions will the nurse use to promote wound healing? Select all that apply. a. Applying sterile dressing supplies b. Discussing zinc supplementation with the health care provider c. Maintaining bedrest d. Performing careful hand hygiene e. Teaching the patient to increase protein in the diet f. Suggesting the patient consume vitamin C-containing foods.

a, b, d, e, f. Careful hand washing (medical asepsis) is the most important. The nurse will use sterile dressings and supplies and promote intake of vitamins, zinc, and protein. Depending on the site of the wound and condition of the patient, bedrest may be indicated.

The nurse is cleaning an open abdominal wound that has edges that are not approximated. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least 1 inch beyond the end of the new dressing if one is being applied. f. Clean to at least 3 inches beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning an open wound with edges that are not approximated is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 inch beyond the end of the new dressing, and (6) clean to at least 2 inches beyond the wound margins if a dressing is not being applied.

Nursing students enrolled in a medical-surgical nursing course are learning about infection control measures. They have learned that nurses use droplet precautions for patients with which infections? Select all that apply. a. Rubella b. Herpes simplex c. Varicella d. Tuberculosis e. MRSA f. Adenovirus

a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-droplet particles; droplet precautions and standard precautions are indicated. Airborne precautions refer to small, infectious particles spread through the air; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

A nursing unit has multiple patients with MRSA infections requiring contact isolation. In which situations is it appropriate for the nurses to use an alcohol-based hand sanitizer to decontaminate their hands? Select all that apply. a. Before providing a bed bath b. Having visibly soiled hands after patient contact c. Removing gloves after patient care d. Inserting a urinary catheter e. Assisting with a surgical placement of a cardiac stent f. Removing old magazines from a patient's table

a, c, d, f. An alcohol-based handrub is used in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices not requiring surgical placement; before donning sterile gloves prior to an invasive procedure; when moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. It is essential to note that handrubs are not appropriate for use after caring for a patient with C. diff infection.

A nurse has finished providing care for a patient in contact isolation for a MRSA infection. Place the steps the nurse should follow to remove PPE in the correct order. a. Untie gown at the front waist b. Remove mask c. Remove gloves d. Remove gown e. Remove goggles

a, c, e, d, b. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask. Hands should be washed thoroughly after the equipment has been removed and before leaving the room.

A nurse works in a facility stating they support a culture of safety. What will the nurse expect to find operationalized in this culture? Select all that apply. a. Support for reporting errors and near misses without blame b. Nurses being the employees responsible for safety in the organization c. Commitment of resources to address actual/potential safety issues d. Emphasis placed on individuals, their departments, and resources e. Promotion of teamwork and collaboration throughout the organization f. Administrators' and managers' commitment to safe operations

a, c, e, f. The key features of a culture of safety include: (1) acknowledging the high-risk nature of health care and the commitment to safe operations, (2) maintaining a blame-free environment where reporting is protected and expected, (3) promoting teamwork and collaboration to prevent and seek solutions to patient safety issues, and (4) valuing safety as a focus in all health care facilities, the home, workplace, and community.

A nurse on a surgical unit is working with a nursing student and discussing various phases of wound healing for postoperative patients. Which statements accurately describe these stages? Select all that apply a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury, and exudate occurs in this phase as plasma and blood components leak out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse is providing active-assistive range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient reports that they are "too tired to go on." What actions are appropriate at this time? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Reevaluate the plan of care. d. Move to the patient's other side to perform exercises. e. Encourage the patient to finish the exercises and then rest. f. Assess the patient for additional symptoms of intolerance.

a, c, f. When a patient reports fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the plan of care, and assess the patient for further symptoms indicating the activity is not tolerated. The exercises can be rescheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply. a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. d. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d. For male and female patients, use a clean portion of the washcloth for each stroke. e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.

When performing a dressing change requiring surgical asepsis, a nurse opens sterile supplies and dons sterile gloves. What additional action by the nurse is appropriate? a. Avoiding splashing while pouring irrigant onto the sterile field b. Covering the nose and mouth with gloved hands if a sneeze is imminent c. Using forceps soaked in a disinfectant to place dressings on the sterile field d. Considering the outer 1 inch of the sterile field sterile

a, d. Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture, such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

A nurse is developing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. Teach the patient to avoid sudden position changes that may cause dizziness. b. Recommend that the patient restrict fluid intake until after exercise. c. Instruct the patient to push a little further beyond fatigue each session. d. Tell the patient to avoid exercising in very cold or very hot temperatures. e. Encourage the patient to modify exercise if weak or ill. f. Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to remain adequately hydrated, respect fatigue as a sign of activity intolerance and not push to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. a. Wash the skin twice a day with a mild cleanser and warm water. b. Use cosmetics liberally to cover blackheads. c. Apply emollients on the area. d. Squeeze blackheads as they appear. e. Keep hair off the face and wash hair daily. f. Avoid tanning booth exposure and use sunscreen.

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection.

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. What should be the focus of this education? a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to age 2 years (or the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children age older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to age 2 years (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than age 6 years should still be in a booster seat.

A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? a. Carefully assessing the patient care environment b. Using two nurses to lift a patient who cannot assist c. Wearing a back belt to perform routine duties d. Properly documenting the patient lift

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and mobility should be documented but are not the primary focus of interventions related to injury prevention.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate? MAR -Acetaminophen 650 mg every 6 hours prn fever -Cefazolin (antibiotic) 1 g 1 hour preoperatively -Cefazolin 1 g, every 6 hours 3 times, postoperatively a. Documenting the findings and continuing to monitor the patient b. Administering antipyretics and contacting the provider for an antibiotic prescription c. Increasing the frequency of assessment to every hour and notifying the patient's primary care provider d. Obtaining a wound culture and increasing the frequency of wound care

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

An experienced nurse and new graduate nurse are caring for a confused older adult who gets out of bed and wanders. The preceptor intervenes when observing which action by the graduate nurse? a. Raising all four side rails to keep the patient in bed b. Performing documentation in the patient's room c. Suggesting obtaining a patient "sitter" d. Using a bed alarm to alert staff the patient leaving the bed

a. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. People of small stature are more likely to be injured slipping through or between the side rails. A history of falls from a bed with raised side rails carries a significant risk for a serious incident. The nurse uses creative measures while promoting safety and respect for the patient's dignity.

The hospital's fire alarm sounds, and an announcement is made that there is a fire in a patient room. What is the priority for nurses on the unit? a. Removing patients from the room or vicinity b. Attempting to put out the fire with water or appropriate extinguishers c. Closing all the doors on the unit to contain the fire d. Running to the closest unit and requesting help

a. The nurse uses the acronym RACE and rescues and/or removes the patient and those in nearby rooms as the safety priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Remaining on the unit allows you to assist patients and is more appropriate; assistance can be summoned by phone.

A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan? a. Support weight on the stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Avoid using the cane to rise from a sitting position, as this is unsafe.

a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

A nurse caring for a patient with a stage 3 pressure wound with tunneling. How will the nurse best assess the tunneled area? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Photograph the wound per policy and describe the estimated depth in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface.

a. To measure the depth of a wound, the nurse should perform hand hygiene and apply gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

The nurse is caring for a patient 1 day postoperative abdominal surgery. The nurse identifies the patient is at risk for wound dehiscence. What patient risk factor is consistent with development of this problem? a. Cigar smoker b. Wound drainage 120 mL over 24 hours c. Height, 5′ 6″ and weight 240 lb d. WBC count 9,500 c/mm3

a. Wound dehiscence is the partial or total separation of wound layers as a result of excessive stress on unhealed wounds. Patients at greater risk include obese or malnourished individuals; tobacco smokers; and those taking anticoagulants, who have infected wounds, or who experience excessive coughing, vomiting, or straining (Hinkle & Cheever, 2018). An increase in the flow of (serosanguineous) fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The patient may say that "something has suddenly given way."

Health care workers may be exposed to a common occupational injury such as: a. accidental needlestick. b. sensory deprivation. c. carbon monoxide exposure. d. intimate partner violence

accidental needlestick. One of the most prevalent safety issues for health care workers is accidental needle stick injuries. Sensory deprivation, carbon monoxide poisoning, and IPV are not common health care accidental injuries.

A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus? a. alcohol consumption and smoking b. infant hygiene and feeding c. the stages of labor with possible complications d. the role of the father in proper prenatal care

alcohol consumption and smoking Safety considerations for the neonate and infant begin with an awareness of behaviors that may harm the developing fetus. Risks to the fetus include excess alcohol consumption and smoking.

A nurse is providing oral care to a client who is unconscious. When planning this intervention, the nurse should prioritize which nursing concern? a. aspiration risk b. failure to thrive, adult c. nausea d. trauma risk

aspiration risk Providing oral care to a client who is unconscious or otherwise unable to swallow creates a significant risk for aspiration. Failure to thrive is unrelated to oral care. A client who is unconscious may potentially vomit but will not experience nausea. Trauma risk is low; trauma resulting from oral care is unlikely.

A nurse is developing a care plan for an older adult patient who is recovering from a hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for this patient to develop area(s) of pressure injury? Select all that apply. a. The patient takes time to think about responses to questions. b. The patient is an older adult with a poor appetite. c. The patient reports inability to control their urine. d. The patient's albumin level is <3.2 mg/dL (normal, 3.4 to 5.4 g/dL). e. Lab findings include BUN 12 (older adult, normal 8 to 23 mg/dL) and creatinine 0.9 (adult female, normal 0.61 to 1 mg/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. A low albumin level signals a risk for poor wound healing related to malnutrition. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development; however, taking time to formulate responses is consistent with normal aging. This patient's BUN and creatinine are within normal range; however, dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply. a. Patient taking antibiotics for chronic bronchitis b. Patient with type 2 diabetes c. Patient who has obesity d. Patient who frequently bites their nails e. Patient with prostate cancer f. Patient who frequently washes their hands

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems.

The nurse on a medical-surgical unit is admitting a patient with a diagnosis of active tuberculosis. Which infection control precautions will the nurse put in place? a. Wearing sterile gloves for patients with visible body fluids b. Placing the patient on airborne precautions c. Wearing an N95 respirator mask when in the room d. Placing the patient in a single-occupancy room e. Ensuring the room provides positive pressure f. Restricting visitors for the duration of the patient's stay

b, c, d. Airborne precautions are used for patients who have infections with small particles that spread through the air, for example, tuberculosis, varicella, and rubeola. An N95 respirator mask is worn and the patient placed in a private room, preferably with negative air pressure. Sterile gloves are used for procedures requiring surgical asepsis. Standard precautions are for all patient care when contact with blood or body fluids, nonintact skin, and mucous membranes are likely. Visitors must wear PPE, including a mask.

During morning huddle, a nurse manager and some nurses are identifying patients on the unit who are at risk for hospital-acquired infections (HAIs). Which patients will the nurses identify? Select all that apply. a. Smoker, two packs of cigarettes daily b. White blood cell count of 2,000/mm3 c. Indwelling urinary catheter in place d. Vegetarian and slightly underweight e. Central venous catheter present f. Postoperative colostomy

b, c, e, f. Leukopenia (low white blood cell count), indwelling urinary catheters, central venous catheters, and surgeries in which the wound is classified as dirty have been implicated in most HAIs. Cigarette smoking and a vegetarian diet have not been implicated as risk factors for HAIs.

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

b, c, f. Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

The nurse manager and nurses in an acute care hospital are participating in a safety huddle to identify patients at risk for falling. Which patients will the nurses determine require follow-up? Select all that apply a. Age >50 years b. History of falling c. Taking antibiotics d. Presence of postural hypotension e. Nausea from chemotherapy f. Transferred from long-term care

b, d, f. Risk factors for falls include age >65 years, documented history of falls, postural hypotension which can cause dizziness, and unfamiliar environment. A medication regimen that includes diuretics creating urinary urgency and tranquilizers, sedatives, hypnotics, or analgesics causing altered mental status and impaired judgment are also risks. Chemotherapy or antibiotics are not included as factors leading to falls.

A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply. a. Bathing the feet thoroughly in a mild soap and tepid water solution b. Soaking the resident's feet in warm water and bath oil c. Drying the feet and area between the toes thoroughly d. Applying an alcohol rub for odor and dryness to the feet e. Applying an antifungal foot powder f. Cutting the toenails at the lateral corners when trimming the nail

b, d, f. The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.

A nursing student is performing hand hygiene after providing care to a patient who is in isolation for C. diff related to antibiotic therapy. Which actions by the nursing student will the primary nurse need to correct? Select all that apply. a. Removing all jewelry including a platinum wedding band b. Decontaminating the hands with an alcohol-based hand sanitizer c. Using approximately 1 teaspoon of liquid soap d. Keeping hands higher than elbows when placing under the faucet e. Using friction motion when washing for at least 20 seconds f. Rinsing thoroughly with water flowing toward the fingertips

b, d. After caring for patients with C. diff infection, proper handwashing includes using soap and water, then rinsing thoroughly with water flowing toward fingertips. Proper hand hygiene permits a plain wedding band to be worn; other jewelry is removed. The nurse uses about 1 teaspoon (5 mL) of liquid soap, using friction motion for at least 20 seconds, washing to 1 inch above the wrists using friction.

After an initial skin assessment, the nurse documents the presence pressure area that is reddened and has a 1-cm blister. How will the nurse document the wound stage? a. Stage 1 dark maroon wound, skin intact b. Stage 2 with 1-cm blister noted c. Stage 3 wound base with red granulation tissue d. Stage 4 blanchable reddened area, 2 cm

b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. Dark maroon or purple wounds with intact skin represent deep tissue injury. Red granulation tissue is present in stage 3 or 4 pressure injuries that are healing. A blanchable, red area is a stage 1 pressure injury.

A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is "itchy." Which intervention is appropriate? a. Bathe the patient more frequently. b. Use an emollient on the dry skin. c. Explain that this is expected as people age. d. Limit the patient's fluid intake.

b. An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.

A nurse caring for patients in a pediatric office assesses children's achievement of developmental milestones. Which patient finding requires follow-up with the pediatrician? a. 4-month-old infant who is unable to roll over b. 6-month-old infant who is unable to hold head up c. 11-month-old infant who cannot walk unassisted d. 18-month-old toddler who cannot jump

b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

An outbreak of measles has occurred at the local elementary school. The parents of a child in the prodromal phase of the illness are told the child should stay home until well. What is important for the nurse to teach the parents about the prodromal phase? a. The organisms enter the body and multiply while the patient is asymptomatic. b. A person typically has vague, nonspecific symptoms and is highly contagious. c. The presence of infection-specific signs and symptoms develop, manifesting as local or systemic responses. d. The signs and symptoms of the illness disappear, and the person returns to their preillness state.

b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and symptoms are more specific and apparent during the full stage of illness, disappearing in the convalescent period.

A nursing student asks the primary nurse why an immobile patient developed two urinary tract infections (UTIs) in the 6 months. How does the nurse best explain this patient's risk for UTI? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation

b. In a nonerect patient, the kidneys and ureters are level, limiting or delaying urinary drainage from the kidney pelvis to ureter and bladder. The resulting urinary stasis favors the growth of bacteria that can promote urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to bone demineralization, resulting in increased urinary calcium levels and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A home health nurse teaches a patient to a change the dressing for a chronic venous stasis ulcer using clean technique. Which principle of asepsis will the nurse consider when preparing the teaching plan? a. The nurse chooses clean or sterile technique based on personal preference. b. The use of clean technique is considered safe in the home setting. c. Surgical asepsis is the safest method to use in a home setting. d. The patient can use clean technique; their partner must wear sterile gloves.

b. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. This is usually recommended in the home setting, where the patient's environment is more controlled. Injections require surgical asepsis. The patient and partner share the same home; medical asepsis is appropriate.

An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct? a. When providing perineal care, washing the area from front to back b. Insisting the older adult must take a bath or shower each day c. Telling the patient to avoid soaking feet, helps the patient dry between the toes d. Covering areas not being bathed with a bath blanket

b. Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.

A nurse notes a pressure wound base is red. Using the RYB system for documentation, what intervention is indicated? a. Irrigating the wound and applying an absorbent dressing b. Gently cleansing the wound and applying a moist dressing c. Discussing consultation for surgical debridement with the provider d. Performing frequent dressing changes to keep the wound and dressing dry

b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and dressing changes only when necessary (or based on product manufacturer's recommendations). To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigation. The eschar found in black wounds requires debridement (removal) before the wound can heal.

A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage? Graphic Record T 99.9 P100 RR 20 BP 138/88 Nursing note: Patient postoperative day 2. Dry sterile dressing changed on abdominal incision. Incision edges are well approximated with a slight ½-cm opening at inferior edge; incisional edges reddened. Hemovac draining sanguineous material, 60 mL for the shift. Patient reports moderate pain, relieved by oxycodone X1. a. Sanguineous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria. d. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.

b. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

A nurse has exhausted every effort to keep a confused, postoperative patient safe and in bed. Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice? a. Positioning the patient in the supine position prior to applying wrist restraints b. Ensuring that two fingers can be inserted between the restraint and patient's wrist c. Applying a cloth restraint to the left hand of the patient with an IV catheter in the right wrist d. Tying an elbow restraint to the raised side rail of the patient's bed

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. Restraining the patient in a supine position increases the risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? a. Lean on the crutches using the axillae to bear body weight. b. Keep elbows close to the sides of the body. c. When rising, extend the uninjured leg to prevent weight bearing. d. To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg when rising to prevent weight bearing, and advance the unaffected leg first when climbing stairs.

A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene? a. When the patient had their most recent bath b. The patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is convenient for the AP

b. The patient's preferences, practices, and rituals should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6

b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A nurse is caring for a patient who is on bedrest following a spinal injury. Which action is appropriate to prevent foot drop? a. Maintain the supine position with supination on the feet. b. Ask the family to bring in high-top sneakers to maintain foot dorsiflexion. c. Encourage hyperextension of the feet with adaptive devices or splints. d. Use pillows to keep the feet in the abducted position.

b. To prevent foot drop, the nurse should support the feet in dorsiflexion using a footboard and/or high-top sneakers for further support. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions do not prevent foot drop.

A nurse is preparing to admit a patient with urinary sepsis related to vancomycin-resistant enterococci (VRE). While awaiting the patient's arrival, which of these actions will the nurse take? a. Prepare a negative-pressure room b. Ask the AP to get a supply of protective gowns c. Post a sign that visitors must wear a mask d. Obtain sterile gloves for personal care

b. VRE is spread via contact with the feces, urine, or blood of an infected or colonized person. Contact precautions, meticulous hand hygiene, reducing the use of invasive devices, environmental cleaning, and decolonizing high-risk patients are indicated. Some institutions have discontinued using contact precautions and use standard precautions, with no significant change in the incidence of MRSA or VRE.

A nurse administering an injection to a patient who tested positive for HIV sustains a needlestick. What action should the nurse take first? a. Report the incident to the nurse manager and file an injury report b. Wash the exposed area with warm water and soap c. Consent to postexposure prophylaxis (PEP) at the appropriate time d. Set up counseling sessions regarding safe practice to protect self

b. When a needlestick injury occurs, the nurse should wash the affected area immediately with warm water and soap, report the incident to the nurse manager or appropriate person and complete an injury report, consent to and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe practice to protect self and others.

A nurse is caring for a 25-year-old patient who is unresponsive following a head injury. The patient has several piercings in the ears and nose that appear crusted and slightly inflamed. What is the most appropriate action to care for this patient's piercings? a. Avoiding removing or washing the piercings until the patient is responsive b. Rinsing the sites with warm water and remove crusts with a cotton swab c. Washing the sites with alcohol and apply an antibiotic ointment d. Removing the jewelry and allow the sites to heal over

b. When providing care for piercings, the nurse performs hand hygiene, applies gloves, then cleanses the site of all crusts and debris by rinsing the site with warm water and removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser, per policy, to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site and should avoid removing piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)

When bathing a patient with C. diff infection, the nurse wears personal protective equipment (PPE). Which additional intervention promotes safe, effective care? a. Donning PPE after entering the patient room b. Bathing the perianal area last c. Personalizing care by substituting glasses for goggles d. Removing PPE after bathing the patient to talk with them in the room

b. When using PPE, the nurse should work from clean areas to soiled ones, don PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom just before exiting.

A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, "Something is falling out of my incision!" The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last. a. Notify the health care provider of the situation. b. Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c. Place the patient in the low Fowler position. d. Document the findings and outcome of interventions. e. Maintain NPO status for return to the OR for repair.

c, b, a. e. d. The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). The patient is kept NPO, as prompt surgical repair will be needed. After the patient has received attention, the nurse documents all assessments and interventions in a timely manner.

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

c, d, e. Eighty percent of fire deaths in the United States occur in the home. Most fatal home fires occur while people are sleeping, and most deaths result from smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the decline in fire-related injury and death. People with limited financial resources may use space or kerosene heaters, wood stoves, or a fireplace as the sole source of heat if utilities are turned off. Bedroom doors should be kept closed when sleeping and monitors used to listen for children.

A school nurse is teaching about adolescent safety with students entering high school. What will the nurse include in the discussion about the major causes of death in this group? Select all that apply. a. Choking b. Diving accidents c. Car accidents d. Suicide e. Intimate partner violence f. Cigarette smoking

c, d. Car accidents and suicide are common causes of death in adolescents. Choking is more typical in children younger than age 3 years. While diving accidents can occur in adolescents due to poor judgment, this is not as common. Intimate partner violence is more common in adults. Smoking, while ill advised, takes many years or decades to become a cause of death.

A nurse assists a patient with ambulation for the first time following a knee replacement. Shortly after beginning to walk, the patient tells the nurse that they are dizzy and feel like they might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: a. Grasp the gait belt. b. Stay with the patient and call for help. c. Place feet wide apart with one foot in front. d. Gently slide the patient down to the floor, protecting their head. f. Pull the weight of the patient backward against your body. e. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b. When a patient is being moved or ambulated and starts to fall, the nurse places their feet wide apart with one foot in front, rocks their pelvis out toward the side of the patient, grasps the gait belt, supports the patient by pulling the patient's weight backward against their body, gently slides the patient down their body toward the floor while protecting the patient's head, and remains with the patient while calling for help.

The nurse preceptor is supervising a new graduate nurse as they assess a patient with a pressure injury. The graduate nurse documents the presence of biofilm in the wound. The preceptor recognizes the graduate nurse understands this concept when the graduate makes which of these statements? Select all that apply. a. Enhanced healing occurs due to the presence of sugars and proteins. b. Delayed healing develops due to dead tissue present in the wound. c. Antibiotics against the bacteria become less effective. d. Skin loses its integrity due to overhydration of the cells of the wound. e. Delayed healing due to cells dehydrating and dying occurs. f. Decreased effectiveness of the patient's normal immune process results.

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2020). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse is changing a patient's bed linens after drainage from an infected abdominal wound leaked. Which nursing action reflects proper use of medical asepsis? a. Carrying soiled bed linens close to the body to prevent spreading microorganisms into the air b. Placing soiled bed linens and hospital gowns on the floor when making the bed c. Moving the patient table away from the body when wiping it off d. Cleaning the most soiled items at the bedside first, followed by cleaner items

c. According to the principles of medical asepsis, the nurse should move equipment and soiled items away from the body to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first, then move to the more soiled ones to prevent contamination.

While discussing home safety with the nurse, a patient admits that they smoke a cigarette in bed before falling asleep at night. Which health problem is the priority for this patient? a. Impaired gas exchange: etiology, cigarette smoking b. Acute anxiety: etiology, inability to stop smoking c. Nonadherence: etiology, nonadherence to recommendation to stop smoking d. Knowledge deficiency: etiology, risk for burn and suffocation in a house fire

c. Because the patient is not aware or denies that smoking in bed poses a danger for fire and toxic fumes, education about the risk for burns and suffocation is needed. The other three nursing diagnoses are correctly stated but are not a priority in this situation.

A nurse on a medical-surgical unit notes a patient with pneumonia and is experiencing dyspnea. What action will the nurse take to improve the dyspnea? a. Encourage the patient to ambulate. b. Suggest the patient use music or television as distraction. c. Place the patient in Fowler's position. d. Tell the patient to take several deep breaths, then hold their breath for 5 seconds.

c. High-Fowler's position promotes maximal lung expansion and is the position of choice during episodes of dyspnea. Encouraging ambulation during distress will increase dyspnea. Distracting the patient is not addressing the underlying cause of dyspnea, which is activity. Holding the breath increases demands on the heart.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? a. Supporting the patient as she stands, waiting a few moments, then continuing the move to the chair b. Calling for assistance and continuing the move with the assistance of another nurse c. Lowering the patient back to the side of the bed and pivoting her back into bed d. Having the patient sit down on the bed and dangle her feet before moving

c. If a patient becomes faint and their knees buckle when moving from bed to a chair or ambulating, the nurse should stop the activity, as the patient has demonstrated a clear risk for falling. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. When vital signs are stable, another attempt can be made with the assistance of another staff. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position and prevent hypotension related to a sudden change from the supine position.

A nurse and health care provider are preparing for insertion of a central venous catheter when the patient accidentally touches the sterile field. What action will the nurse take next? a. Ask another nurse to hold the patient's hand and continue setting up the field b. Remove any objects the patient touched and resume setting up the sterile field c. Have someone hold the patient's hand, discard the supplies, and prepare a new sterile field d. No action since the patient has touched their own sterile field

c. If a patient touches a sterile field, the nurse should discard all supplies and prepare a new sterile field. If the patient is restless or confused, the nurse obtains an assistant to hold the patient's hands and explain what is happening.

A community health nurse is providing education on child safety. Who does the nurse identify as at highest risk for choking and suffocation? a. A toddler playing with his older brother's wooden blocks b. A 4-year-old eating yogurt and strawberries for lunch c. An infant sleeping in the prone position d. A 3-year-old drinking a glass of juice

c. Infants should be placed on their backs to sleep. A young child may place small or loose parts in the mouth. Anything that will fit through the average toilet paper roll is not safe for a toddler. A 3-year-old and a 4-year-old drinking juice and eating yogurt are developmentally appropriate.

A nurse is providing education to a patient and their family regarding the use of negative pressure wound therapy (NPWT). The nurse documents that the teaching has been effective when the patient and family make which statement? a. "This therapy is used to collect excess blood loss and prevent formation of a scab." b. "The suction created will prevent infection and promote wound healing with less scar tissue." c. "Suction stimulates blood flow to the wound, removes excess fluid, and promotes a moist environment for healing." d. "This treatment irrigates the wound, suctions the irrigation fluid from the wound, and keeps it free from debris wound exudate."

c. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? a. Adding bath oil to the water to prevent dry skin b. Allowing the patient to lock the door to guarantee privacy c. Assisting the patient in and out of the tub to prevent falling d. Keeping the water temperature very warm because older adults chill easily

c. Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? a. "There will be more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "Redness and swelling should decrease after cold treatment." d. "My incision may bleed more when the ice is first applied."

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety? a. Shifting the focus of the interaction to the "process of bathing" b. Washing the face and hair at the beginning of the bath c. Using music to soothe anxiety and agitation d. Avoiding towel baths or forms of bathing with which the patient is unfamiliar

c. The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing "body sections" one day at a time, as well as dry shampoo or "shower cap" shampoos, are additional options.

A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed? a. Quickly disconnecting the IV tubing closest to the patient and thread it through the gown sleeve b. Cutting the gown with scissors to allow arm movement c. Threading the bag and tubing through the gown sleeve, keeping the line intact d. Temporarily disconnecting the tubing from the IV container, threading it through the gown

c. Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly performed, any disconnection of IV tubing results in a breach of the sterile system, creating risk for infection. Cutting a gown is not an alternative except in an emergency.

A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient? a. "Stand on the weaker leg and pivot toward the chair." b. "I will call the lift team to carry you to the chair." c. "The chair is by your non-affected leg for smoother movement." d. "Avoid putting your hospital socks on, as that will restrict your feet moving."

c. When transferring a patient, the chair is placed on the unaffected or stronger side, rather than the weaker or affected side. Lifting and carrying a patient unless absolutely necessary poses an unnecessary risk for injury to patient and staff. Patients should wear proper shoes, sturdy slippers, or hospital-issued socks with grips to prevent sliding and/or falling.

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, psychosocial problem will the nurse plan to address? a. Pain b. Wound healing c. Body image d. Change in cognition

c. Wounds cause emotional as well as physical stress.

When performing sterile wound irrigation and dressing change for a postoperative patient, a new graduate nurse creates a sterile field. Which actions require correction by the preceptor? Select all that apply. a. Placing the bottle cap for the irrigating solution off the sterile field with the edges down b. Holding the bottle of irrigating solution inside the edge of the sterile field c. Applying the second sterile glove by lifting it from beneath the cuff with the thumb held away from the glove d. Pouring the irrigating solution into a sterile container from a height of 4 to 6 inches (10 to 15 cm) e. Opening packages of sterile gauze dressings, prior to applying sterile gloves

d, e. To add a sterile solution to a sterile field, the nurse opens the solution container according to directions and places the cap on the table away from the field with the edges up. The nurse then holds the bottle outside the edge of the sterile field with the label side facing the palm of the hand and pours from a height of 4 to 6 inches (10 to 15 cm) to prevent splashing.

A nurse is filing a safety event report for a confused patient who fell while getting out of bed. Which action is most appropriate during documentation? a. Including suggestions on how to prevent the incident from recurring b. Providing minimal information about the incident c. Discussing the details with the patient before documenting them d. Recording the circumstances and effect on the patient in the health record

d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient's response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports.

A nurse in a long-term care facility is on an interprofessional safety committee focusing on protecting older adults from injury and trauma. Which action does the nurse suggest they prioritize? a. Ensuring proper function of fire alarms b. Preventing exposure to temperature extremes c. Screening for partner or elder abuse d. Maintaining clutter free rooms and hallways

d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms and hallways should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults.

A nurse is performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next? a. Recommend a consultation with an oral surgeon. b. Communicate the condition to the health care team. c. Gently scrape the oral cavity with a tongue depressor. d. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

d. If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor.

Nursing students are invited to participate in the clinical agency's annual disaster drill, simulating the release of an airborne infectious agent and ensuing panic. Which assignment is most appropriate for the students? a. Cleansing and dressing wounds sustained during the panic b. Triaging patients with respiratory symptoms and traumatic injuries c. Providing information to families of missing loved ones d. Ensuring everyone entering and working has an N95 mask

d. Rapid assessment and triage are essential during a disaster. Delegating tasks appropriate to students are based on skill level and ability to complete skills independently. Ensuring masks are worn and the education for this, if needed, are within the educational and clinical skills of nursing students.

During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority? a. Explaining how to use the telephone b. Introducing the patient to their roommate c. Reviewing the hospital policy on visiting hours d. Demonstrating how to operate the call bell

d. Teaching the patient to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury.

A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes? a. Using diluted hydrogen peroxide on a clean washcloth to wipe the eyes b. Wiping the eye from the outer canthus toward the inner canthus c. Positioning the patient on the opposite side of the eye to be cleansed d. Cleansing the eye using a different section of the cloth for each stroke until clean

d. The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to cleanse the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until the eye is clean.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested a toxic substance from under the sink. How will the nurse advise the parents? a. Administer activated charcoal in tablet form and take child to the ED. b. Administer syrup of ipecac and take child to the ED. d. Bring the child in to the primary care provider for gastric lavage. e. Call the PCC immediately before attempting any home remedy.

d. The nurse tells the parents to call the PCC immediately, before attempting a home remedy. Parents may be instructed to bring the child to an emergency facility for immediate treatment. Activated charcoal is not appropriate to use at home but under medical supervision, after the risks and benefits have been assessed. Syrup of ipecac is no longer recommended because vomiting may exacerbate the hazard as it vomited up. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses? a. Telling the patient to cross their arms and legs b. Pulling the patient from underneath the axilla toward the top of the bed c. Avoiding using a draw sheet to lift or reposition the patient d. Ensuring the bed is at the level of the nurses' hips e. Facing the head of the bed and rocking in synchrony

d. The nurses should face the direction the patient will move and rock in synchrony prior to moving the patient in that direction. A lifting or repositioning sheet or device is used to decrease friction and facilitate movement. While the patient can cross their arms, they can also be instructed to press their feet into the mattress to assist movement. The bed should be at the level of the nurses' elbows.

Determine the patient's risk for pressure injury using the Braden scale found in Figure 33-7, based on information in the electronic health record (EHR). EHR 1430 Admission Assessment S: Patient admitted from nursing home for sepsis, confusion, ambulatory dysfunction. B: 87-year-old patient, with history of heart failure and hypertension; comes to ED with shortness of breath and yellow sputum. A: Lungs with crackles, pale, short of breath on exertion, pulse oximetry 88%, skin fragile. Bedrest maintained. States has not eaten nor drank fluids for last 36 hours; incontinent of small amount of urine × 2. Responding to painful stimuli, not participating in turning or care. R: Need orders for oxygen, sputum culture, activity level. Consider IV fluids. J. Smith RN. a. No risk b. Moderate risk c. High risk d. Very high risk

d. The patient is at very high risk for pressure injury. This patient responds only to painful stimulate (1); is occasionally moist (3); is bedridden (1); has not eaten (1), and requires maximum assistance for moving (1) for a total of 7 points. The Braden scale scoring is: a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk (Braden & Maklebust, 2005). In addition, nurses use clinical judgment to incorporate risk factors and/or other health problems into preventative interventions.

A nurse is caring for a patient who is incontinent of stool and has developed a stage 3 pressure wound on the buttocks. What intervention will the nurse set as the priority of care? a. Increasing nutrition b. Promoting mobility c. Managing chronic pain d. Preventing infection

d. The priority in this situation is to prevent infection through contamination of the wound by stool. The other actions may be taken as needed, after infection prevention is addressed.

A disoriented older resident likes to wander the halls of their long-term care facility but becomes agitated when they cannot find their room. Which action is most appropriate as an alternative to restraints? a. Placing them in a geriatric chair near the nurses' station b. Using the sheets to secure them snugly in the bed c. Keeping the bed in the high position d. Identifying their door with his photograph and a balloon

d. This allows the resident to be on the move and be more likely to find their room when they want to return. Many facilities use this kind of approach, rather than restrict patients' movements. Identifying the patient's door with their photo and a balloon may resolve the issue without restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would likely result in a fall.

A nurse is developing education for nurses and UAPs related to prevention of pressure injuries for residents in a long-term care facility. Which action to prevent pressure injury will the nurses delegate to the UAP? a. Maintaining the head of the bed elevated consistently b. Massaging over bony prominences c. Repositioning bedbound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

d. To prevent pressure injuries, the nurse teaches the UAP to cleanse the skin routinely and whenever soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse educates the UAP to minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position? a. Side-lying b. Fowler's c. Sims' d. Prone

d. While placing the patient in the prone position for 30 minutes two or three times daily helps prevent knee and hip flexion contractures, it is contraindicated in patients who have spinal problems. The pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

The nurse is caring for a client who reports having sexual intercourse with someone infected with HIV. The client may have contracted HIV due to which route of transmission? a. direct contact b. indirect contact c. vector d. fomite

direct contact Sexual intercourse provides a direct contact means of transmission of infection. Indirect contact involves using a vector (an organism) or fomite (an object) to transmit infection.

The nurse has been teaching the client about how to use a walker safely. The nurse knows the teaching has been effective when the client: a. uses the sides of the walker to rise up out of a chair. b. places the walker far in front when walking. c. steps into the walker when walking. d. leans over the walker when walking

steps into the walker when walking. A walker is mechanical aide that enhances the client's balance and ability to bear weight. Teaching is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client?s ability to use it properly. The client should step into the walker when walking, rather than walking behind it. When rising from a seated position, the arms of the chair should be used for support, not the walker. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker, but should stay upright as he/she moves.

Pressure ulcers are caused by unrelieved compression of the skin that results in damage to underlying tissues. a. True b. False

true