3015 Final Exam

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? Asking the client when he or she had last urinated Determining any pain when palpating the lower abdomen Palpating the bladder above the symphysis pubis Obtaining the bladder scanner to check the urine volume

Asking the client when he or she had last urinated

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

Before entering the client's room

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action? Check health record for provider's order. Gather equipment and supplies. Assess urine characteristics. Explain the procedure to the client.

Check health record for provider's order.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound

Which quality is essential to being a nurse leader? Physical stamina Vulnerability Flexibility Independence

Flexibility

Which statement about ostomy irrigation is true? For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. Daily irrigation is necessary to assure passage of stool from an ileostomy. Clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use. Postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery.

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination.

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? Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms. Linen should always be handled with gloves and left in the client's room to prevent spread of microorganisms. Linen should be changed weekly to prevent the spread of microorganisms. 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.

The nurse in the pediatric unit is caring for a 10-year-old client admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism? Wearing gloves when taking the client's blood pressure and pulse Bagging soiled pajamas in a labeled paper bag for the parents to take home Washing hands before and after providing the client care Removing the chicken from the client's meal tray

Washing hands before and after patient care.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority? Using an appropriate measuring container Wearing gloves when handling the urine Measuring the urine container at eye level Noting the color and clarity of the urine

Wearing gloves when handling the urine

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk? a client 45 years of age who has paraplegia a client 92 years of age who uses a walker, is incontinent, and has an extensive cardiac history a client 75 years of age who uses a cane and has dementia a client 68 years of age who is bedfast related to severe head trauma

a client 68 years of age who is bedfast related to severe head trauma

Which practice is a correct application of infection control practices? A nurse performs hand washing each time the nurse removes a pair of gloves. A nurse dons a pair of gloves prior to any client contact. A nurse uses an alcohol-based hand rub each time that the nurse's hands are visibly soiled. A nurse rinses hands thoroughly after the application of an alcohol-based hand rub.

A nurse performs hand washing each time the nurse removes a pair of gloves.

Which interventions will be most effective in preventing the spread of infection in the health care setting? Sterilizing all client supplies Frequent room air exchanges Proper handwashing Donning gloves for all client care

Proper Hand washing

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? exerting equal, but not excessive, tension with each turn of the bandage wrapping distally to proximally elevating and supporting the stump keeping the bandage free of gaps between turn

elevating and supporting the stump

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Pasta salad Fish Banana Green beans

fish

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? Monitor vital signs Contact the health care provider Encourage fluids Instruct on proper wiping technique

Contact the health care provider

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. Contact the health care provider to ask for an order for catheter discontinuation. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). Perform, or allow client to perform, perineal hygiene at least once daily. Ensure that the drainage bag is above the level of the bladder at all times. Discontinue to catheter and report this to the healthcare provider.

Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily.

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 (on a chair) in the image. Which anticipated outcome is most plausible based on the nurse's actions? Contaminants can be transferred onto the furniture and spread microorganisms. Some hospital policies allow for temporary placement of soiled lines on furniture. An incident report will be created and sent to risk management. The furniture will be tagged for removal from the hospital premise due to contamination.

Contaminants can be transferred onto the furniture and spread microorganisms.

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." "Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." "That's correct, but be sure that you don't increase your laxative doses over time."

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

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

"Do you experience incontinence?"

A nurse is carrying out a prescription to remove an indwelling catheter. Which explanation should the nurse use with the client prior to removing an indwelling catheter? "I am going to remove the catheter after cutting the tubing and deflating the balloon." "I will need you to take several deep breaths when I withdraw the tubing." "I want to warn you that intense burning may initially occur." "I am going to remove the catheter after withdrawing the fluid from the balloon."

"I am going to remove the catheter after withdrawing the fluid from the balloon."

The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states: "I do not need to wash my hands if I am using gloves." "I will wash my hands before touching a client." "I can wash my hands before a clean procedure." "If I am able, I will wash my hands after touching the client's surroundings."

"I do not need to wash my hands if I am wearing gloves"

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."

"I will use clean gloves to handle the catheter and other equipment."

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."

"That is necrotic tissue, which must be removed to promote healing."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

A female client is asked to provide a specimen for a routine urinalysis. Which instructions should the nurse give the client? "After cleansing the labia, urinate into the toilet first and then fill the container midstream." "Urinate directly into the specimen container." "Urinate into the toilet first and then fill the container midstream." "Urinate a bit directly into the specimen container then cleanse the labia and continue to fill the container."

*"After cleansing the labia, urinate into the toilet first and then fill the container midstream."

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first? Administer a dose of digoxin that is two hours behind schedule. Perform a dressing change to an abdominal abscess that is three hours behind schedule. Obtain discharge orders for a client who is ready to be transferred to a long-term nursing facility. Complete a medication reconciliation form on a client who has recently been admitted to the hospital.

Administer a dose of digoxin that is two hours behind schedule.

The nurse is delegating care to an unlicensed assistive personnel (UAP). Which intervention would be most important for the nurse to perform independently? Assess the client with difficulty breathing Obtain a postprandial blood sugar reading Measure the client's blood pressure Assist the client with turning in bed

Assess the client with difficulty breathing

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Assess the need for assistance with ambulation. Put the client's bedside rails up. Apply socks to the client's feet. Arrange furniture so that the client has something to hold on to.

Assess the need for assistance with ambulation.

The nurse is doing preoperative teaching with a client who has a prescription for Golytely® before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner? Room temperature Chilled Warm In fruit juice

Chilled

A nurse is considering the delegation of administering topical medications to an unlicensed assistive personnel (UAP). What is the first question the nurse must ask oneself before doing so? Has the UAP been trained to perform the task? Have I evaluated the client's response to this task? Do the nurse practice act and agency policy allow this delegation? Is appropriate supervision available for the UAP?

Do the nurse practice act and agency policy allow this delegation?

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply. The determination of a nursing diagnosis for a client with breast cancer Giving a bed bath to a client Planning education for a client with a colostomy Taking routine vital signs Administering medications to clients Transferring a client to another floor

Giving a bed bath to a client Taking routine vital signs Transferring a client to another floor

What technique should the nurse use to implement infection control in the home? Avoid touching any object in the home, including door knobs. Practice hand hygiene when beginning and ending the home visit. Wear gloves at all times when in the home or traveling in the car. Take prescribed antibiotics on a regular basis on working days.

Hand Hygiene when beginning and ending the home visit.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? Having the client sign a consent form for the procedure Explaining to the client that the procedure will be painful Maintaining the client without liquids before the procedure Inserting a Foley catheter the morning of the procedure

Having the client sign a consent form for the procedure

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply. Help the client into a Sims' position. Cool the container holding the solution. Compress the container as the solution instills. Wipe the lubricated tip of the container before insertion. Encourage the client to retain the solution.

Help the client into a Sims' position. Encourage the client to retain the solution. Compress the container as the solution instills.

The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. (blowing on recently cleansed wound) What is the most important reason this technique does not adhere to the standards of care for dressing changes? Promotes coolness to the site, which further constricts blood flow Increases the risk of infection by contaminating the wound Causes an uncomfortable sensation to the client's skin Reduces itching to the wound as it is healing

Increases the risk of infection by contaminating the wound

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP? Initiating intravenous therapy Securing the client on a papoose board Soothing the client during the procedure Gathering equipment needed for intravenous therapy

Initiating intravenous therapy

A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction? Insert a lubricated, gloved finger into the rectum. Obtain a sharp intestinal x-ray. Insert a lubricated rectal tube into the rectum. Administer an oil retention enema into the rectum.

Insert a lubricated, gloved finger into the rectum.

The charge nurse on the orthopedic unit believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which the charge nurse contributes. The charge nurse's style of leadership can be described as which? Democratic Laissez-faire Autocratic Transformational

Laissez-faire

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action? Place the client on bedpan in the supine position while receiving enema. Remove the tube and check for any fecal contents. Modify the amount and length of the administration. Lower solution container and check temperature and flow rate.

Lower solution container and check temperature and flow rate.

The nurse and unlicensed assistive personnel (UAP) are working together to admit a client newly diagnosed with diabetes to a nursing unit. Which task would be inappropriate to delegate to the UAP? Measuring blood pressure Offering sugar-free popsicles Performing a fingerstick blood glucose test Monitoring insulin requirements

Monitoring insulin requirements

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

The nurse has completed a client's personal care and is now removing personal protective equipment. What is the nurse's best action when removing gloves? Picture - pull down outer cuff with gloved fingers pictures - pulling on gloved fingers with gloved hand

Picture - pull down outer cuff with gloved fingers

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

Policy for clients with a latex sensitivity

A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document? Length, width, and depth of the wound Staging of the surgical wound Cardiac and respiratory function Presence of abnormalities that would impede healing

Presence of abnormalities that would impede healing

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation? Place the sterile solution on the bed. Prime the tubing with the solution. Empty the balloon with a syringe. Clean around the urinary meatus.

Prime the tubing with the solution.

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? Encouraging the client to stay close to home Fluid restriction Indwelling catheterization Regular toileting routine

Regular toileting routine

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? No action is needed at this time Remind coworker of the need to wear gloves Remind coworker that artificial nails increase infections Remind coworker to wash hands for 2 minutes

Remind the nurse that artificial nails increase infection

A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment? Transparency Individualization Control Safety

Safety

A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. Which would be the appropriate action to take to maintain a sterile field? Finish the procedure and perform hand washing immediately afterward. Finish the procedure, remove damaged gloves, and put on new sterile gloves. Stop the procedure, remove damaged gloves, and put on new sterile gloves. Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves.

Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves.

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

Stop the task and obtain PPE

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action? Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. Allow the new nurse to continue with the insertion and discuss the error later away from the client. Report the new nurse's error to the nurse manager for corrective action. Assign the new nurse to view videos on sterile catheter insertion.

Tell the new nurse that a break in sterile field has occurred and the procedure must be stopped

The registered nurse (RN) has received orders to perform an unsafe practice on a client. The RN voices concern with the physician who gave the order, but the physician refuses to change the order. Whom should the nurse consult next regarding the order? The client The charge nurse The nurse manager The licensed practice nurse (LPN)

The charge nurse

A client is prescribed a diuretic for swelling of the lower extremities. What would the nurse teach the client about the effect of the medication on the client's urinary output? The client's urinary output will be decreased. The client's urinary output will be increased. The client's urine will be a medium-amber color. The client's urine will have a strong ammonia odor.

The client's urinary output will be increased.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? The largest part of a regular bedpan should be placed under the client's buttocks. A regular bedpan is generally more comfortable for clients than a fracture bedpan. A fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation. A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.

The largest part of a regular bedpan should be placed under the client's buttocks.

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

The nurse is caring for a client with a C. difficile infection.

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? To implement evidence-based practice To ensure the order follows hospital policy To be sure interventions are individualized To be sure the intervention is safe

To be sure the intervention is safe

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. Wet the hand and wrists. Turn the faucet off with a paper towel. Turn on the faucet and adjust force and temperature of the water. Wash the palms and backs of the hands for at least 20 seconds. Apply soap. Pat the hands dry with a paper towel.

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who lifts himself up on his elbows a client who lies on wrinkled sheets a client who must remain on his back for long periods of time

a client sitting in a chair who slides down

For which client would the use of standard precautions alone be appropriate? a client with diphtheria who needs p.m. care a client with TB who needs medications administered an incontinent client in a nursing home who has diarrhea a child with chickenpox who is treated in the emergency room

an incontinent client in a nursing home who has diarrhea

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should: deflate the balloon, insert the catheter further, and slowly attempt reinflation. wait for 30 seconds, help the client to relax, and attempt inflation again. stop, deflate the balloon, withdraw the catheter 0.75 to 1.5 in (2 to 4 cm), and slowly reinflate. deflate the balloon, withdraw the catheter, and use a smaller sized catheter.

deflate the balloon, insert the catheter further, and slowly attempt reinflation.

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel? tap water mineral oil water, soap hypertonic saline

hypertonic saline

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing? With the double-bag technique In the client's trash container In a bag marked "biohazards" In the sharps container

in a bag marked biohazard

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? increased bowel sounds abdominal tenderness areas of distention muscular resistance

increased bowel sounds

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? document the assessments and intervention reinforce the dressing with additional layers administer pain medications intramuscularly notify the physician and prepare for surgery

notify the physician and prepare for surgery

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing: oliguria. anuria. nocturia. polyuria.

oliguria.

A client 75 years of age is being discharged to home following a fall in the kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need? Sleep and rest Support from family members Protection from potential harm Feeling a sense of accomplishment

protection from potential harm

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client? increases the volume of the stool, making defecation easier removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit softens and facilitates the removal of intestinal polyps

removes hardened fecal impactions from the rectum

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority? Extinguish the fire. Rescue the client. Raise an alarm. Confine the fire.

rescue the client

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: first degree or superficial second degree or partial thickness third degree or full thickness fourth degree or fat layer

second degree or partial thickness

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as: serous. sanguineous. serosanguineous. purulent.

serosanguineous.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV

stage IV

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart? stethoscope belonging to the nurse stethoscope that remains in the client's room stethoscope that hangs outside the client's room stethoscope that has been purchased by the client

stethoscope that remains in the client's room

A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? urinary incontinence urinary incompetence normal micturition uncontrolled voiding

urinary incontinence

Which action should the nurse perform first after an exposure to a client's body fluids? Change the clothing that was exposed. Wash the exposed area with soap and water. Take the postexposure prophylaxis. Get tested for both HIV and hepatitis.

wash the exposed area with soap and water