Foundations Exam 1 Practice Test
The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?
"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin." Reference: Chapter 19: Asepsis and Infection Control - pg 382-383
The nurse observes a member of the nursing assistive personnel who is removing her personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team? Description of image: (nurse is pinching the front of her gown with gloved hands)
"Avoid touching the outside of your gown when removing it." Reference: Chapter 19: Asepsis and Infection Control - Page 400
The nurse observes a colleague performing the action above while preparing to care for a client with bacterial meningitis. What is the nurse's most appropriate statement to the colleague? Description of image: Nurse with gown on, putting on a mask without gloves
"Don't forget to put on your gloves" Reference: Chapter 19: Asepsis and Infection Control - pg 388
The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required?
"I can leave my room any time I want as long as I wear a mask." Reference: Chapter 19: Asepsis and Infection Control - pg 387
The nurse is educating the client on culture and sensitivity test. The client wants know to when the nurse could get the results back. Which response should the nurse use?
"It could take 24 to 36 hours to grow cultures and about 48 hours for sensitivity." Reference: Chapter 31: Infection Prevention and Management - pg 995
A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?
"It is because of the immature ability to regulate temperature in general." Reference: Chapter 18: Vital Signs - pg 332
The friend of a long-term care client comes to visit despite having an upper respiratory infection. What is the appropriate nursing response?
"Please use a mask when visiting with the client to prevent infection." Reference: Chapter 19: Asepsis and Infection Control - pg 386
The client is concerned about "catching the flu." Which statement by the nurse is most appropriate?
"The best way to prevent the spread of illness is by washing your hands." Reference: Chapter 19: Asepsis and Infection Control - pg 382-384
The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?
"This antibiotic is the best choice since the causative organism is not known." Reference: Chapter 19: Asepsis and Infection Control - pg 372-373
The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires **further teaching** by the nurse educator?
"Wearing an N95 respirator is critical when I care for clients in droplet precautions." Rationale: N95 respirators are used when caring for clients in airborne precautions; therefore, this statement requires further teaching. Reference: Chapter 19: Asepsis and Infection Control - pg 385
A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond?
"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." Reference: Chapter 17: Health Assessment - pg 294
A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?
"Your white blood cells have increased in the area." Reference: Chapter 31: Infection Prevention and Management - pg. 979, 991.
Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.
- Airborne precautions -Droplet precautions -Contact precautions Reference: Chapter 19: Asepsis and Infection Control - pg 387
The nurse is teaching a client how to take a daily blood pressure reading at home. The nurse includes instructions about obtaining an accurate blood pressure measurement. What additional information would the nurse include? Select all that apply.
-"Take your blood pressure every day prior to eating breakfast." -"Rest 3 to 5 minutes before taking your blood pressure." -"Keep both feet flat on the ground; do not cross your legs." -"Place your arm on a table that is level with your heart." Reference: Chapter 18: Vital Signs - pg 342, 365-367
The nurse is preparing to measure a 3-year-old child's vital signs. Which strategies should the nurse use to obtain accurate readings with minimal disruption? Select all that apply.
-Allow the child to remain on the parent's lap while measuring vital signs. -Allow the child to hold the blood pressure cuff and stethoscope before the measurement. -Before beginning measurement of the child's vital signs, demonstrate the techniques on a doll. Reference: Chapter 18: Vital Signs - pg 348-349
Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency? Select all that apply.
-During some care activities for an individual client, nurses may need to change gloves more than once. -Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. -To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. Reference: Chapter 19: Asepsis and Infection Control - pg 385-386
A veteran nurse is working with a new graduate nurse. The graduate nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply.
-Hepatitis B -Hepatitis C -HIV Reference: Chapter 19: Asepsis and Infection Control - pg 379
A nurse is caring for an older adult client at a long-term health care facility. Which infections pose a risk to long-term care residents and older adult clients admitted to health care facilities? Select all that apply.
-Pneumonia -Skin infection -Influenza Reference: Chapter 19: Asepsis and Infection Control - pg 392
The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.
-Redness -Swelling -Pain -Exudate Rationale: Cardinal signs of infection include redness (heat), swelling, pain, and loss of function. As leukocytes and neutrophils enter the area, exudate made up of fluid, cells, and inflammatory by-products may be released by the wound. Warmth and heat at the site versus coolness are a sign of infection. Reference: Chapter 19: Asepsis and Infection Control - pg 371
A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply.
-Soft, low-pitched, whispering sounds heard over most of the lung fields -Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly -Blowing, hollow sounds auscultated over the larynx and trachea Reference: Chapter 17: Health Assessment - pg 299-301
A nurse is assessing a client's blood pressure and is obtaining falsely high readings. What would the nurse identify as contributing to this error? Select all that apply.
-The cuff was wrapped unevenly. -The cuff was deflated too slowly. -Client is anxious when reading was taken. Reference: Chapter 18: Vital Signs - pg 343
A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply.
-The nurse's back is facing the sterile field. -The nurse touches an unsterile object to the instrument tray. -The nurse is talking with the scrub nurse over the sterile field Reference: Chapter 19: Asepsis and Infection Control - Page 390
After preparation, the nurse inserts a rectal thermometer into an adult client's rectum. To ensure an accurate reading, the nurse inserts the thermometer to which depth?
1.5 in (3.75 cm) Reference: Chapter 18: Vital Signs - pg 354
A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?
1500 Rationale: Peak levels are drawn shortly after the drug is administered Reference: Chapter 19: Asepsis and Infection Control - pg 997
The nurse is assessing the legs of a client and notes fairly normal contour with a 4 mm indentation when pressing on the shin and calf of each leg. How should the nurse interpret these findings?
2+ pitting edema Reference: Chapter 17: Health Assessment - pg 820
During assessment of the lower extremities, the nurse notes the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4 mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result?
2+ pitting edema noted on bilateral lower extremities Reference: Chapter 17: Health Assessment - pg 306
A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:
3 days Reference: Chapter 31: Infection Prevention and Management - pg 984
A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?
3+ pitting edema Reference: Chapter 17: Health Assessment - pg 306
A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis?
3.2 mmol/L **Rationale: Normal levels are 0.3 to 2.6 mmol/L. Reference: Chapter 31: Infection Prevention and Management - pg 995
A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?
30 to 60 breaths per minute Reference: Chapter 18: Vital Signs - pg 340
During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's right lower quadrant. How long should the nurse listen before documenting absent bowel sounds?
5 minutes Reference: Chapter 17: Health Assessment - pg 251
A nurse is assessing the cardiac output of a client at the health care facility. What would the nurse identify as the average cardiac output in a resting person?
5.5 L/min Reference: Chapter 18: Vital Signs - pg 341
A nurse is reviewing a client's complete white blood cell (WBC) count and differential. The nurse determines that the client is experiencing neutropenia based on which absolute neutrophil count?
800 cells/mm3 Reference: Chapter 31: Infection Prevention and Management - pg 1001
The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for?
A client in the Intensive Care Unit for acute pancreatitis asking for pain medications Reference: Chapter 17: Health Assessment - pg 291
Which client is most likely to require neutropenic precautions?
A client recovering from a bone marrow transplant Reference: Chapter 19: Asepsis and Infection Control - pg 388
Which practice is a correct application of infection control practices?
A nurse performs hand washing each time the nurse removes a pair of gloves. Rationale: An example of an infection control practice is that hand washing should be performed after the removal of a pair of gloves. Reference: Chapter 19: Asepsis and Infection Control - pg 383
The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis?
A pronounced lateral curvature of the spine Chapter 17: Health Assessment - pg 282
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
An 80-year-old woman Reference: Chapter 19: Asepsis and Infection Control - pg 392
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis Reference: Chapter 19: Asepsis and Infection Control - pg 392
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a non-particulate (N-95) respirator when entering the room. Rationale: TB is an airborne infection and the nurse should wear a non-particulate mask (N-95) respirator. Reference: Chapter 19: Asepsis and Infection Control - pg 385
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?
Applying a blanket Reference: Chapter 18: Vital Signs - pg 332
A group of nursing students is reviewing information about assessing blood pressure. The students demonstrate a need for additional study when they identify which device as an indirect method of measurement?
Arterial catheter Reference: Chapter 18: Vital Signs - pg 342
The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mm Hg. What is the priority nursing intervention?
Ask the client to demonstrate self-blood pressure assessment. Reference: Chapter 18: Vital Signs - pg 342
Which action best allows the nurse to assess a client's pupillary accommodation?
Ask the client to focus on an object as it is brought closer to the nose. Reference: Chapter 17: Health Assessment - pg 294
The nurse is preparing to assess a client's near vision. How should the nurse proceed?
Ask the client to read the print on a handheld Jaeger card. Reference: Chapter 17: Health Assessment - pg 293-294
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
Auscultate the lung sounds and count respirations. Reference: Chapter 18: Vital Signs - pg 341, 363.
The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions?
Be sure there are gloves of various sizes and gowns for use Reference: Chapter 19: Asepsis and Infection Control - pg 393
A nurse has just given an injection to a client and is preparing to dispose of the needle and syringe. Which action would be **least appropriate** for the nurse to do?
Break the needle off at the hub after recapping it. Reference: Chapter 19: Asepsis and Infection Control - pg 387
Which technique should the nurse use to assess the pupillary light reflex on a client?
Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Reference: Chapter 17: Health Assessment - pg 294
A nurse is performing auscultation. The nurse would use the bell of the stethoscope to auscultate which sounds?
Bruits Reference: Chapter 17: Health Assessment - pg 290
A nurse needs to count a client's apical heart rate. Which assessment site is most suitable for counting the apical heart rate?
Chest Reference: Chapter 18: Vital Signs - pg 360-361
During a physical exam, the nurse assesses a client's eyes for the accommodation response. When looking at a near object, what would the nurse observe for?
Constriction of the pupils Rationale: Accommodation is the ability to constrict when looking at a near object and dilate when looking at an object in the distance. Reference: Chapter 17: Health Assessment - pg 294
The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?
Contact Rationale: Contact contamination is most common in hospital settings because it can either be direct or indirect Reference: Chapter 19: Asepsis and Infection Control - pg 374
The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?
Contact Reference: Chapter 19: Asepsis and Infection Control - pg 374
A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe?
Coordinated movement of both eyes. Reference: Chapter 17: Health Assessment - pg 294
What would be considered a mechanical defense mechanism?
Coughing Reference: Chapter 31: Infection Prevention and Management - pg 979
A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings?
Crackles are audible in the posterior bases bilaterally and they are abnormal. Reference: Chapter 17: Health Assessment - pg 743-744
Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?
Cranial Nerve I Reference: Chapter 17: Health Assessment - pg 294
During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is being tested by this action?
Cranial nerve VII Reference: Chapter 17: Health Assessment - pg 294
The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?
Decreased cardiac output Reference: Chapter 17: Health Assessment - pg 306
Which is **not** a characteristic used to describe the pulse?
Depth Reference: Chapter 18: Vital Signs - pg 336
The nurse will assess a client who has a draining abscess. The nurse should perform what action to safely enter the room?
Description of image: (nurse has a gown and gloves) Reference: Chapter 19: Asepsis and Infection Control - pg 387
The nurse is providing care for a client on isolation precautions, necessitating the use of a gown. What action during the use of the gown best adheres to principles of infection control?
Description of image: Nurse is putting on gown without gloves Rationale: It is necessary to tie the gown securely both at the neck and at the waist. The gown should be removed by allowing it to fall away from shoulders, touching only the inside of the gown. Reference: Chapter 19: Asepsis and Infection Control - pg 400
The nurse will be entering the room of a client pneumonia to provide personal care. What action should the nurse perform while applying personal protective equipment (PPE) for this situation?
Description of image: Nurse with gown on, putting on a mask without gloves, no watch is exposed Reference: Chapter 19: Asepsis and Infection Control - pg 388
The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?
Don another pair of sterile gloves Rationale: If the nurse realizes that the sterile field is broken, the most appropriate response is to stop and don another pair of sterile gloves. Reference: Chapter 19: Asepsis and Infection Control - pg 390-391
Which describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. Reference: Chapter 18: Vital Signs - pg 341
A nurse is caring for a middle-age client who looks worried and flares his nostrils when breathing. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client's condition?
Dyspnea Reference: Chapter 18: Vital Signs - pg 341
The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?
Elevating the client's arm at heart level Reference: Chapter 18: Vital Signs - pg 343
Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?
Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. Reference: Chapter 19: Asepsis and Infection Control - pg 374
A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply.
Eosinophils Basophils Neutrophils Reference: Chapter 31: Infection Prevention and Management - pg 979
A nurse is teaching a client about testicular self-examination. What should be included in the teaching?
Examine testicles for lumps monthly while showering. Reference: Chapter 17: Health Assessment - pg 305-306
An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?
Exogenous healthcare-associated Rationale: The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated) Reference: Chapter 19: Asepsis and Infection Control - pg 375-376
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?
Fungi Reference: Chapter 19: Asepsis and Infection Control - pg 372
A nursing student is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?
Gather new sterile supplies and start over. Reference: Chapter 19: Asepsis and Infection Control - pg 390
Which piece of personal protective equipment (PPE) should be removed first?
Gloves Reference: Chapter 19: Asepsis and Infection Control - pg 400
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
Hand washing Reference: Chapter 19: Asepsis and Infection Control - pg 382
The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?
Handwashing Reference: Chapter 31: Infection Prevention and Management - pg 986
A nurse is developing a presentation for a local community group about infections and resistance to them. When describing acquired specific defenses, what would the nurse most likely include?
Humoral immunity Reference: Chapter 31: Infection Prevention and Management - pg 981-982
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
Increased pulse rate Rationale: When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output. Reference: Chapter 18: Vital Signs - pg 339, 341
The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?
Inflate the cuff about 30 mm Hg above the auscultatory gap. Reference: Chapter 18: Vital Signs - pg 346
A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?
Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared Reference: Chapter 18: Vital Signs - pg 366
A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?
Inform the physician about this finding Reference: Chapter 31: Infection Prevention and Management - pg 979
During assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action?
Inspect the sclera and mucous membranes Reference: Chapter 17: Health Assessment -pg 292
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?
Keeping sterile field above waist level Rationale: When setting up a sterile field, the correct technique is to keep the sterile field above the waist level. Reference: Chapter 19: Asepsis and Infection Control - pg 390
The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?
Keeping sterile field above waist level Reference: Chapter 19: Asepsis and Infection Control - pg 390
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds Reference: Chapter 18: Vital Signs - pg 338
The nurse is preparing to auscultate the lung sounds of a client with asthma. How should the nurse complete the assessment?
Listen to at least one full respiration in each location. Reference: Chapter 17: Health Assessment - pg 298
A client is brought to the health care center in a semi-conscious state following a suicide attempt. The nurse is assisting the physician in resuscitating the client. The client's skin appears to be bluish. What should the nurse document as the cause for this coloration?
Low tissue oxygen Rationale: The patient is experiencing cyanosis which is caused by a lack of oxygen to the tissue Reference: Chapter 17: Health Assessment - pg 292
Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?
Not all of the heartbeats are reaching the periphery. Rationale: Apical and radial pulse should always match Reference: Chapter 18: Vital Signs - pg 339
During a busy shift, Nurse R. admitted a postoperative client who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the client's upper arms have a large circumference. What are the potential consequences of Nurse R.'s action?
Nurse R. may obtain a blood pressure reading that is higher than the actual blood pressure. Reference: Chapter 18: Vital Signs - pg 343
Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?
Ongoing partial assessment Reference: Chapter 17: Health Assessment - pg 276
The nurse is preparing to perform a head-to-toe physical assessment. What approach will the nurse use?
Organize the assessment so the client does not change positions too often. Reference: Chapter 17: Health Assessment - pg 277
A nurse practitioner is preparing to examine a child with a suspected otitis media. Which instrument will be required?
Otoscope Reference: Chapter 17: Health Assessment - pg 295
The nurse is palpating a client's precordium. Which result is an expected clinical finding?
Palpable pulsation over the mitral area Reference: Chapter 17: Health Assessment - pg 301
A nurse is preparing to assess the integumentary system for texture, temperature, moisture, and edema. Which assessment technique will the nurse use?
Palpation Reference: Chapter 17: Health Assessment - pg 288-289
A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what?
Pathogenic Rationale: Pathogenicity is an organism's ability to cause infections. Reference: Chapter 19: Asepsis and Infection Control - pg 371
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?
Perform hand hygiene before and after entering the client's room. Reference: Chapter 19: Asepsis and Infection Control - pg 382
A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?
Perform the blood pressure measurement last Reference: Chapter 18: Vital Signs - pg 349
A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?
Place the specimens into plastic biohazard bags. Rationale: Specimens should be placed in sealed plastic bags to prevent them from becoming contaminated or causing the transmission of infective microorganisms. Reference: Chapter 19: Asepsis and Infection Control - pg 380
A nurse is preparing to add a sterile solution to a sterile container on a sterile field. After opening the container, what would the nurse do with the cap?
Position it with the inside facing up on a flat surface. Rationale: When opening a sterile container of solution to be added to a sterile field, the nurse should remove the cap and place it with the inside facing up on a flat surface. Reference: Chapter 19: Asepsis and Infection Control - pg 404
A nurse needs to visit the intensive care unit to administer an enema to a client. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit?
Pour and discard a small amount of the solution. Reference: Chapter 19: Asepsis and Infection Control - pg 405
A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature?
Proteins Rationale: Protein in the client's diet has the greatest thermic effect. Reference: Chapter 18: Vital Signs - pg 331-332
A nurse is examining a client and is testing the client's cranial nerves. Which action would the nurse use to evaluate cranial nerve III? Select all that apply.
Pupillary reaction to light Ability to open and close eyelids Rationale: Cranial nerve III is the oculomotor nerve. It is a motor nerve that is involved with pupil constriction and raising the eyelids. The nurse would test the pupillary reaction to light and the client's ability to open and close eyelids. Reference: Chapter 17: Health Assessment - pg 295
Which term indicates a potentially serious client condition?
Pyrexia Rationale: Pyrexia means an increase above normal in body temperature. Reference: Chapter 18: Vital Signs - pg 331
A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use?
Radial Reference: Chapter 18: Vital Signs - pg 337
A nurse needs to check the vital signs of a client with an infectious disease who is receiving intravenous therapy through an IV pump. Before entering the client's room, the nurse follows airborne and contact precautions. Which infectious disease does the client have?
SARS Rationale: The client has severe acute respiratory syndrome (SARS). Infectious diseases like chickenpox (varicella) and SARS require both airborne and contact precautions. Reference: Chapter 19: Asepsis and Infection Control - pg 387
The nurse is preparing to assess a client's deep tendon reflexes. When evaluating the biceps reflex, the nurse would position the client in which manner?
Sitting up with the elbow flexed, and forearm resting on the thigh, palm up. Reference: Chapter 17: Health Assessment - pg 309
The nurse is assessing a client with an elevated temperature. Which of the following would lead the nurse to determine that the client is in the fever phase?
Skin warm and flushed Reference: Chapter 31: Infection Prevention and Management - pg 980
A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?
T-Lymphocytes Reference: Chapter 31: Infection Prevention and Management - pg 980
The nurse has been collaborating with a colleague on a client's wound care, and the colleague is now removing gloves after completing the task. The nurse observes the colleague performing the above pictured action inside the client's room. What is the nurse's correct response? Description of image: Nurse is taking gloves off pinching from the outside as to not touch the skin under the glove
Take no further action Reference: Chapter 19: Asepsis and Infection Control - pg 408
The nurse observes a member of the care team removing her gown after assisting a client with hygiene, as seen in image above. What is the nurse's most appropriate action?
Teach the colleague to let the gown fall away rather than pulling on the sleeves Rationale: The individual should allow the gown to fall away from her shoulders, touching only the inside of the gown. Gloves are removed first and this should be performed inside the client's room, unassisted. Reference: Chapter 19: Asepsis and Infection Control - pg 400
A nurse is preparing to assess a client's temperature and finds the client to be perspiring profusely. Which method would be least appropriate for the nurse to use to assess this client's temperature?
Temporal artery temperature Reference: Chapter 18: Vital Signs - Page 355
The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?
The client is covered with a couple of thick blankets. Reference: Chapter 18: Vital Signs - pg 332
When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?
The client may alter the rate of respirations if the client is aware that his breaths are being counted. Reference: Chapter 18: Vital Signs - pg 363
A client in a physician's office has a blood pressure (BP) reading of 150/92 mm Hg. What must be considered prior to this client being diagnosed as having hypertension?
The client must have at least two blood pressure readings that are elevated for the diagnosis. Reference: Chapter 18: Vital Signs - pg 347
The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted?
The client's weak pulses may be indicative of cardiovascular disease Reference: Chapter 17: Health Assessment - pg 306
Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is **best for sensing temperature**?
The dorsum Reference: Chapter 17: Health Assessment - pg 288
The nurse, after receiving report on assigned clients, begins assessments of the clients. What is the primary purpose of assessing clients?
The nurse is able to identify actual and potential health problems of the client. Reference: Chapter 17: Health Assessment - pg 276
A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe about the client's posture?
The shoulder and upper back curves forward. Reference: Chapter 17: Health Assessment - pg 282
The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?
The tympanic membrane is translucent, shiny, and gray. Reference: Chapter 17: Health Assessment - pg 295
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap. Reference: Chapter 18: Vital Signs - pg 346-347
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?
Thready pulse Reference: Chapter 18: Vital Signs - pg 339
A nurse conducting physical assessment for a client is using the **percussion** technique. What is the purpose of using this technique?
To determine the location, size, and density of underlying structures Reference: Chapter 17: Health Assessment - pg 289
The client, Mrs. Rodrigquez, has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator?
Translators may need additional explanations of medical terms. Rationale: It is true that even professional translators don't understand all medical terms and may need some clarification at times. Reference: Chapter 17: Health Assessment - pg 279
The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. Which finding would most likely indicate the client has developed an infection?
Urine culture is positive for vancomycin-resistant enterococci (VRE). Reference: Chapter 19: Asepsis and Infection Control - pg 373
Which client would the nurse consider at risk for low blood pressure?
a client with low blood volume Reference: Chapter 18: Vital Signs - pg 341, 342, 347
It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?
a harsh, inspiratory sound that may be compared to crowing Reference: Chapter 18: Vital Signs - pg 341
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
airborne Reference: Chapter 19: Asepsis and Infection Control - pg 388
All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned?
an infant 2 months of age Rationale: Infants don't have temp. regulation Reference: Chapter 18: Vital Signs - pg 348, 357
The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?
applying a new dressing with the gloves that were used to remove the old dressing Reference: Chapter 19: Asepsis and Infection Control - pg 402-405
Which factor is not known to cause false blood pressure readings?
being in a warm environment Reference: Chapter 18: Vital Signs - pg 343
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?
contact precautions Rationale: VRE is transmitted via contact. Reference: Chapter 19: Asepsis and Infection Control - pg 372-373
A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?
has manicured nails that are 1-in (2.5-cm) long Reference: Chapter 19: Asepsis and Infection Control - pg 384
The nurse is assessing a child brought to the clinic with severe itching of the scalp and white patches on the hair follicles. What would the nurse look for when beginning the examination?
nits from a lice infestation Reference: Chapter 17: Health Assessment - pg 242
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate Rationale: An older male with an enlarged prostate can have urine trapped in the bladder leading to urinary tract infections. Reference: Chapter 19: Asepsis and Infection Control - pg 392
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?
remove gloves, remove gown, wash hands Rationale: The nurse will remove and dispose of the most contaminated items first, then dispose of other items, and then wash hands. Gloves should be first removed, then the gown. Then, hands are washed. Reference: Chapter 19: Asepsis and Infection Control - pg 388
A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope?
slightly below the left nipple Reference: Chapter 18: Vital Signs - pg 337, 360-361.
A nurse suspects that a client has abdominal ascites and prepares to assess the abdominal girth. How should this assessment be completed?
stretching a tape measure around the largest diameter and making guide marks on the skin Reference: Chapter 17: Health Assessment - pg 1079-1080
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
the client who is 48-hours postsurgical procedure Reference: Chapter 19: Asepsis and Infection Control - pg 382