Foundations Prep U
The nurse observes a member of the nursing assistive personnel who is removing 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?
"Avoid touching the outside of your gown when removing it."
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
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?"
The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?
"Hold dentures over a plastic basin or towel when cleaning them."
A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting?
"I hold the boxes away from my body so I don't drop them on my feet."
A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?
"I will obtain a mask from the staff and wash my hands before touching my family member."
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?
"I will put a layer of cloth between my skin and the ice pack."
The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?
"I've set up this sterile field for your procedure, so please do not touch anything around the tray."
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?
"Put your arm in this sleeve."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
"To prevent the legs from rotating outward."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form."
The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?
"You are free to move onto the stretcher without assistance, but I will supervise for your safety."
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?
"Your elbows will be slightly bent when you are using your crutches."
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?
"Your wound will heal slowly as granulation tissue forms and fills the wound."
The nurse is caring for a client with third-degree, or full-thickness, burns. What aseptic intervention(s) would the nurse implement for this client when admitted to the general medical unit? Select all that apply.
-Place the client in a private room with protective isolation. -Instruct all staff, the client, and family members to practice strict and meticulous hand washing. -Restrict visitors to family members who are not ill.
The nurse observes an unlicensed assistive personnel (UAP) placing a client in the Fowler position. To prevent complications for the client, in which situation should the nurse intervene? Select all that apply.
-There is a large pillow under the client's head. -The knee gatch on the bed is engaged -The client's foot is in the plantar flexion position.
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?
Acts to prevent injury to the client and/or nurse
When removing a wound dressing, the nurse observes some skin irritation next to the right side of the wound edge where the tape was removed. Because the client requires frequent dressing changes, the nurse decides to use Montgomery straps to secure the dressing from now on. How will the nurse apply the skin barrier needed before applying the straps?
Apply skin barrier at least 1 in (2.5 cm) away from the area of irritation.
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?
Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.
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
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?
Decontaminate hands using an alcohol-based hand rub.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
Which mask should the nurse don when caring for a client with tuberculosis?
Filtered respirator
The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply.
Fowler Semi-Fowler Upright
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?
Fowler's
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?
Incentivizing health care workers to utilize hand hygiene
A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?
Independent showering
A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?
Keep the diaper and buttocks clean and dry and apply zinc oxide.
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?
Local capillary pressure must be lower than external pressure.
What is the primary goal of the observable action associated with the removal of contaminated gloves?
Prevent contamination of ungloved hand
A nurse is shaving a male client's face. Which should the nurse do?
Pull the skin taut and shave in the direction of hair growth using short strokes.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?
Raise the head of the bed to a sitting position.
Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?
Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)
The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?
The client is aware of spatial relationships to avoid the table.
The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response?
The client will continue to grow rapidly and will refine both gross and fine motor skills.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?
The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall?
The nurse should gently slide the client down his or her body to the floor.
Using proper body mechanics, which motions would the nurse make to move an object?
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?
The nurse washes at least 1 in (2.5 cm) above the area of contamination if present.
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
Use a sterile cotton-tipped applicator to apply the prescription to the site
The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention?
Use bath oil in the tub to decrease dry skin.
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
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?
a transparent film
Surgical asepsis is defined as:
absence of all microorganisms
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?
adduction
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
airborne
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
an 80-year-old woman
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes
A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?
applying sterile dressings with normal saline over the protruding organs and tissue
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:
assessment of tissues
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
Which is not considered a skin appendage?
connective tissue
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
When moving a client up in bed with the assistance of another caregiver, the nurse should:
have the client fold the arms across the chest.
A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?
indwelling catheter
A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day 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
A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?
positioning a friction-reducing sheet under the client to facilitate movement
The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?
pull the shoulder blade forward and out from under the client
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:
steps into the walker when walking.
A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?
stress
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
supine
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?
supporting the client's back
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
surgical asepsis
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?
tertiary intention
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.
-"I may transmit the virus to my child during pregnancy and childbirth." -"If someone is exposed to my blood, I may transmit the virus to him or her." -"I may transmit the virus if I share needles with another person."
What should the nurse assess before application of sitz bath therapy? Select all that apply.
-Client's ability to ambulate to the bathroom -Client's ability to sit for 15 to 20 minutes -Client's perineal/rectal area -Client's need to void
The nurse assesses a 68-year-old client being treated for heart failure who reports dyspnea with mild activity, sitting at a desk most of the day while working, and preferring an orthopneic position. Recognizing that the client is at risk for disuse syndrome, which intervention(s) will the nurse initiate? Select all that apply.
-Instruct client to sit upright to prevent dyspnea -Offer activity options and their benefits that match the client's interests and address the client's needs -Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program -Encourage active range-of-motion exercises
The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.
-Pain with redness and swelling -Localized heat -Purulent or malodorous drainage
The nurse is caring for four clients. For which client is a sitz bath most appropriate?
51-year old with hemorrhoids
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?
A client who has leg strength and can cooperate with the movement
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter?
Alcohol-based hand rub
A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?
An infant's skin and mucous membranes are easily injured and at risk for infection.
A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?
Breaks in skin integrity and fungal nail infection
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?
Client is in supine position with arms in functional position and pillow support under the knees.
A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?
Hold sterile objects above waist level to prevent accidental contamination
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?
If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?
Reduce the time interval between dressing changes.
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?
Shift their weight back and forth, from back leg to front leg.
In an assessment for proper body alignment of a standing client, which finding is normal?
The weight of the body is distributed on the soles and heels.
A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.
Toothbrush Toothpaste Emesis basin Towel Disposable gloves
The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?
When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.
In which situation is an alcohol-based rub an inappropriate option for hand hygiene?
When the nurse's hands are visibly soiled
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of:
ataxia
The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?
changing the soiled dressing
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
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?
contact
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
contusion
A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not:
decrease appetite.
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?
dehydration
The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client?
droplet
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?
fish
A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:
foot drop
The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?
hand hygiene
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?
handwashing before leaving the client's room
The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
into a private room
The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?
is demonstrating a common gait for the older adult.
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
maintain the natural alignment of the client's body.
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.
removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing
A nurse is documenting on 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 drainage type should the nurse document?
serosanguineous
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?
sims
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?
thrombus formation
The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?
urinal
Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?
wearing a particulate respirator for all client care and interaction
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.
-"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"Hygiene measures have no affect on skin."
A nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which strategy(ies) does the nurse include about maintaining proper body mechanics and preventing self-injury? Select all that apply.
-When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. -Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. -Always keep your spouse close to your body during the transfer. -Use the muscles in your legs to lift and/or pull.
A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
A commercially packaged surgical item is not considered sterile if past expiration date.
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a nonparticulate (N-95) respirator when entering the room.
A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met?
Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.
What is the primary purpose for the demonstrated glove application?
Cover exposed wrist skin
The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?
Create an area for sterile field and opening packages
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?
MRSA in the wound
A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?
Migration of leukocytes to the area of the wound
Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?
Perform hand hygiene
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled.
The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?
Review the current infection control protocols
A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals?
She has motivation to participate in self-care.
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?
Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.
The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?
When hands are visibly soiled
Which type of mobility aid would be most appropriate for a client who has poor balance?
a cane with four prongs on the end (quad cane)
The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action?
move the client to edge of the bed opposite the side that client will be turning
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?
sims
The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?
staff education on utilizing hand hygiene
A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?
surgical asepsis
The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?
the 24-month-old child who is unable to walk unassisted
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
the importance of completely finishing the prescribed treatment
A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that:
there is a need to determine if the bottled water has fluoride.
The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?
traditional bed bath with linen change
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?
transfer belt
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
transparent
The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?
trapeze bar
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?
trochanter rolls
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
true