Fundamentals Midterm

During a pain assessment, a nurse asks questions about the quality of an adult patient's pain. Which of the following statements by the patient refers to pain quality?

"My pain feels like I'm being stabbed by a knife."

A nurse is preparing to assist a patient with a tub bath. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

1. Gather all necessary supplies 2. place a rubber mat on the tub floor 3. assist the patient into the bathroom 4. instruct the patient on using safety bars when getting in and out of the tub 5.instruct the pt to remain in the tub for no longer than 20 mins

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? A) Administer the medication with the needle at a 45° angle. B) Administer the medication into the client's nondominant arm. C) Pull the client's skin laterally or downward prior to administration. D) Massage the injection site after administration.

A) Administer the medication with the needle at a 45° angle.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following by the nurse demonstrates proper surgical hand-washing technique? A. The nurse washes with her hands held higher than her elbows. B. The nurse washes from the elbows down to the hands. C. The nurse uses minimal friction when washing her hands. D. The nurse washes each part of her hands with 5 strokes.

A. The nurse washes with her hands held higher than her elbows.

Which of the following are appropriate choices for a patient prescribed a full liquid diet? (SATP) A.plain yogurt, B. custard, C. Ice cream D. pureed vegetables, E. gelatin

A.plain yogurt, B. custard, C. Ice cream E. gelatin

nurse has prepared a sterile field for assisting a provider with a chest tube injection. Which of the following events should the nurse recognize as contaminating the sterile field. (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse.

You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear? a) A sterile gown b) Goggles C) A face shield d) an n95 respirator

C) a face shield

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which id the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 feet away from client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organism into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

C. Place a mask on the client to limit the spread of micro-organism into the surgical wound.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up C. Raise the level of the bed. D. Inspect the clients mouth using a finger sweep.

C. Raise the level of the bed.

A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C. Vanilla custard

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? A) Encourage the client to relax and take deep breaths during the dressing change. B) Educate the client about the importance of the dressing change to prevent infection. C) Assist the client to a comfortable position for the dressing change. D) Administer pain medication 45 min before changing the client's dressing.

D) Administer pain medication 45 min before changing the client's dressing.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization.

D) Compare prescriptions with medications the client received during hospitalization.

A nurse is caring for a client who has had a cough for 3 week and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systematic lupus erythematous. D) Tuberculosis.

D) Tuberculosis

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy source? A. Fat B. Protein C. Glycogen D. Carbohydrates

D. Carbohydrates

When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supplies inside the pack?

Holding the sterile pack below waist or table level.

Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items do the team members don? Select all that apply: Gown Protective eyewear Hair cover Mask Shoe covers

Protective eyewear Hair cover Mask Shoe covers

Which area of the hands requires special attention before you begin a surgical hand scrub?

The area under each fingernail.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

The side hip between the iliac crest and anterior iliac spine.

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must a) wear a respirator. b) protect your eyes c) use an air filter. d) wear shoe covers.

b) protect your eyes

A nurse preparing to flush and change the dressing on a patient's central venous catheter should understand that the primary purpose for performing this intervention using surgical asepsis is to:

control the introduction of micro-organisms at the catheter site.

The goal of surgical asepsis is to:

create and maintain a micro-organism-free environment.

A patient has a healthcare-associated infection (HAI). This terminology menas that the patient a) became infected due to compromised immunity. b) was infected during a therapeutic procedure. c) inhaled pathogens in a healthcare setting d) acquired the infection while hospitalized.

d) acquired the infection while hospitalized.

Contact precautions would be mandated for a hospitalized adult patient diagnosed with a) hepatitis B. b) measles c) meningitis d) infectious diarrhea

d. infectious diarrhea.

During surgical hand washing, the hands are kept above the elbows to:

encourage the water and soap to flow away from clean hands

When donning sterile gloves using the open-glove method, it is important to remember to:

grasp only the inside of the glove with your ungloved hand.

a nurse is preparing to administer a dose of intravenous morphine sulfate (an opioid) for a postoperative pt. which of the following is a pain management protocol that should be used by the nurse

have an opioid antagonist available during the administration

A patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. The patient asks the nurse to describe how this pain-relief method works. The nurse would replay that biofeedback involves

measuring skin tension and using learned techniques to relieve pain

A nurse preparing a sterile field knows that the field has been contaminated when... select all that apply:a cotton ball dampened with sterile normal saline is placed on the field. A contaminated instrument touches the outer edge of the sterile field. A sterile instrument is dropped onto the near side of the sterile field. The nurse turns to address the patient's question concerning the procedure. the procedure is postponed for 30 minutes to accommodate the patient. a liquid is poured into a sterile container from a distance of 4 inches.

-A cotton ball dampened with sterile normal saline is placed on the field. -A nurse turns to address the patient's question concerning the procedure. -the procedure is postponed for 30 minutes to accommodate the patient.

When opening a sterile pack, what is the proper sequence for opening the sterile pack?

1. open the flap furthest from your body 2. open the side flaps 3. open the flap closest to your body

nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A) Pad the client's wrist before applying the restraints. B) Evaluate the client's circulation once per shift after application. C) Remove the restraints every 4 hr to evaluate the client's status. D) Secure the restraint ties to the client's bed side rails.

A) Pad the client's wrist before applying the restraints.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to this client? A) use a bed exit alarm system B) raise 4 side rails while client is in bed C) apply one soft wrist restraint D) dim the lights in the clients room

A) use a bed exit alarm system

A nurse in an outpatient clinicis caring for a client who hasa new prescription for anantihypertensive medication.Which of the following instructionsshould the nurse give the client? A. "Get up and changepositions slowly." B. "Avoid eating aged cheeseand smoked meat." C."Report any usual bruisingor bleeding to thedoctor immediately." D."Eat the same amount of foodsthat contain vitamin K every day."

A. "Get up and changepositions slowly."

A nurse educator is teaching a module on safe medication administration to newly hired nurses. Which of the following statements by a newly hired nurse indicate understanding of the nurse's responsibility when implementing medication therapy? (Select all that apply.) A. "I will observe for medication side effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a medication if I believe it is unsafe."

A. "I will observe for medication side effects." B. "I will monitor for therapeutic effects." E. "I will refuse to give a medication if I believe it is unsafe."

A nurse is teaching an assistiv e personnel (AP) about proper hand hygiene. Which of the following statement by the AP indicate A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands B. washing my hands I will dry them from the elbows down." C. I will apply friction for at least 10 seconds while washing my hands." D. "I will use cold water when I wash my hands to protect my skin from becoming too dry."s an understanding of the teaching?

A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands.

a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should the nurse manger plan to include in the teaching? A. "use the complete name of the medication magnesium sulfate." B. "delete the space between the numerical dose and the unit of measure." C. "write the letter U when noting the dosage of insulin." D. "use the abbreviation SC when indicating an injection."

A. "use the complete name of the medication magnesium sulfate."

A nurse is preparing to administer a medication to a client. The medication was scheduled foradministration at 0900. Which of the following are acceptable administration times for this medication?(Select all that apply.) A. 0905 B. 0825 C. 1000 D. 0840 E. 0935

A. 0905 D. 0840

A nurse is reviewing a clients prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? SATA A. A once daily multivitamin B. eye drops prescribed every 3hr C. An antibiotic prescribed every 8hr D. A blood pressure pill prescribed twice daily E. A subcutaneous injection prescribed once weekly

A. A once daily multivitamin E. A subcutaneous injection prescribed once weekly (REMEMBER time limit is 30 mins before or after)

A nurse observes an assistive personnel reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False Imprisonment D. Invasion of Privacy

A. Assault

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurses priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the clients environment. D. Make sure the client uses assistive aids in his possession.

A. Complete a fall-risk assessment.

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (select all that apply) A. Fever B. Malaise C. Edema D. Pain E. Increase in pulse and respiratory rate

A. Fever B. Malaise E. Increase in pulse and respiratory rate

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (select all that apply) A. Inspect feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. Use over the counter products to treat abrasions. E. Wear cotton socks

A. Inspect feet daily B. Use moisturizing lotion on the feet E. Wear cotton socks

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (select all that apply.)

A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form.

A nurse is caring for a patient who is on long-term bedrest and requires frequent linen changes due to excessive diaphoresis. Which of the following is the priority rationale for frequent linen changes? A. Moisture from excessive diaphoresis can cause skin breakdown. B. Moisture on the sheets can cause discomfort to the patient. C. It provides an opportunity to frequently evaluate the patient's skin on his backside. D. It provides an opportunity to turn the patient from side to side.

A. Moisture from excessive diaphoresis can cause skin breakdown.

A nurse prepares an injection of morphine (Duramorph) to administer to a client who reports pain. Prior to administering the medication, the nurse is called to another room to assist another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? A. Offer to assist the client needing the bedpan. B. Administer the injection prepared by the other nurse. C. Prepare another syringe and administer the injection. D. Tell the client needing the bedpan she will have to wait for her nurse.

A. Offer to assist the client needing the bedpan.

A nurse in a senior center is counseling a group of older adults about their nutritional needs andconsiderations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are. B.Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

A. Older adults are more prone to dehydration than younger adults are. B.Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationales for reporting? (select all that apply) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr.

A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to com in to bathe the client

A. Schedule rest periods during morning care

A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutynin (Ditropan XL). Which of the following are appropriate to include in the teaching? (Select all that apply.) A. Take frequent sips of water. B. Wear sunglasses when exposed to sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication.

A. Take frequent sips of water. B. Wear sunglasses when exposed to sunlight. E. Urinate prior to taking the medication.

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side B. Place two fingers in the client's mouth to open C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth.

A. Turn the client's head to the side

a nurse is preparing to administer an injection of an opioid medication to a client. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take? A. ask another nurse to observe the medication wastage B. notify the pharmacy when eating the medication C. lock the remaining medication in the controlled substance cabinet D. dispose of the vial with the remaining medication in a sharps container

A. ask another nurse to observe the medication wastage

a nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. notify the provider D. ask the client to describe how she felt prior to the fall

A. check the client for injuries

A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (Select all that apply. A. edema B. crackles in lungs C. oliguria D. elevated BP E. jugular venous distention

A. edema B. crackles in lungs D. elevated BP E. jugular venous distention

a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? A. gently shake the container of medication prior to administration B. transfer the medication to a medicine cup C. place the client in a semi-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it

A. gently shake the container of medication prior to administration

A nurse at a clinic is collecting data about pain from a client who reports sever abdominal pain. The nurse asks the client whether he has nausea or has been vomiting. which of the following pain characteristics is the nurse attempting to determine A. presence of associated manifestations B. location of pain C. pain quality D. aggravating and relieving factors

A. presence of associated manifestations

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A) Contact B) Droplet C) Airborne D) Protective

B) Droplet

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A) Make sure the client's room has at least 6 air exchanges per hour. B) Make sure the client wears a mask when outside her room if there is construction in the area. C) Place the client in a private room with negative-pressure airflow D) Wear an N95 respirator when giving the client direct care.

B) Make sure the client wears a mask when outside her room if there is construction in the area.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) Carry a client's soiled linens out of the room in a mesh linen bag. B) Place a client who has tuberculosis in a room with negative-pressure airflow .C) Provide disposable plates and utensils for a client who is HIV-positive. D) Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

B) Place a client who has tuberculosis in a room with negative-pressure airflow

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? A) Have the client wear a mask when receiving visitors. B) Wear a gown when caring for the client and Wash her hands before and after contact with the client. C) Assign the client to a room with negative-pressure airflow exchange. D) Instruct all visitors to limit their time with the client.

B) Wear a gown when caring for the client and Wash her hands before and after contact with the client.

A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which ofthe following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer medications as prescribed." D. "I will be prepared to insert an airway."

B. "I will go to the nurses' station for assistance." (patient should not be left alone)

a nurse is caring for a client who report pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "the pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "the pain makes me feel nauseous."

B. "the pain is like a dull ache in my stomach."

A nurse is preparing to perform denture care for a client. Which of the following actions shoudl the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storaterm-69ge container after cleaning them

B. Brush the dentures with a toothbrush and denture cleaner

An nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following info should the nurse include? (select all) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurse's station D. A client can request a copy of her medical record E. A nurse my photocopy a client's medical record for transfer to another facility.

B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurse's station D. A client can request a copy of her medical record E. A nurse my photocopy a client's medical record for transfer to another facility.

A nurse is assessing a client who takes haloperidol (Haldol) for the treatment of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply.) A. Orthostatic hypotension B. Fine motor tremors C. Acute dystonias D. Decreased level of consciousness E. Uncontrollable restlessness

B. Fine motor tremors C. Acute dystonias E. Uncontrollable restlessness

A nurse is changing bed linens for a client who is on bed rest. Which action should the nurse take? A. Place the soiled linens on the chair while making the bed. B. Hold the linens away the body and clothing. C. Place the linens on the floor until able to place it in a linen bag. D. Shake the clean linens to unfold.

B. Hold the linens away the body and clothing.

A nurse is reviewing the reported medications of a client who was recently admitted. The medications include cimetidine (Tagamet) and imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine hydrochloride toxicity C. Decreased risk of adverse effects of cimetidine D. Increased therapeutic effects of imipramine hydrochloride

B. Increased risk of imipramine hydrochloride toxicity

A nurse is reviewing hand hygiene technique with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (select all that apply) A. Place the client in a room that has negative air pressure. B. Wear a mask when providing care within 3 ft. of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions

B. Wear a mask when providing care within 3 ft. of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable E. Wear a gown when performing care that might result in contamination from secretions

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A. A second nurse enters the prescription into the client's medical record B. another nurse should listen to the phone call C. the provider can clarify the prescription when the sign the health record D. I should omit the 'read back' if this is a one-time prescription

B. another nurse should listen to the phone call

a nurse is admitting a client who has influenza. which of the following types of transmission precautions hold the nurse initiate? A. airborne B. droplet C. contact D. protective environment

B. droplet

a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity

B. pupil clarity D. visual fields E. visual acuity

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take? A) Assist the client into a prone position. B) Place a sleeve over the top of each leg with the opening at the knee. C) Make sure two fingers can fit under the sleeves. D) Set the ankle pressure at 65 mm Hg.

C) Make sure two fingers can fit under the sleeves.

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient? A. "I'll swab the patients mouth with lemon-glycerin swabs." B. "I'll swab the patients mouth with mouthwash." C. "I'll swab the patients mouth with chlorhexidine." D. "I'll swab the patients mouth with a very small amount of mineral oil.

C. "I'll swab the patients mouth with chlorhexidine."

A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse? A. "Since you are not eating, we can wait and do it before bedtime" B. "Oral care is still important even though you are not eating." C. "Ill give you a sip of water to swish around in your mouth." D. "We will wait until your family gets here to help."

C. "Ill give you a sip of water to swish around in your mouth."

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include? A. Inform the patient when moving hygiene care is provided. B. Schedule to provide care to the patient and her roommate at the same time. C. Ask the patient in what order she typically performs her morning routine. D. Plan to provide care before the next schedule dose of pain medication.

C. Ask the patient in what order she typically performs her morning routine.

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection.

C. Carefully remove the gloves and follow with hand hygiene.

A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. Thisclient is oriented to person, place, and time and can follow directions. Which of the following actions bythe nurse are appropriate to decrease the risk of a fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in low position with full side rails up. C. Ensure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

C. Ensure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

A nurse observes smoke coming from under the door of the staff lounge. Which of the following is thepriority action by the nurse? A. Extinguish the fire. B. Pull the fire alarm. C. Evacuate the clients. D. Close all open doors on the unit.

C. Evacuate the clients. Rescue Alarm Contain Extinguish

A nurse in an outpatient surgicalcenter is admitting a client for alaparoscopic procedure. The clienthas a prescription for preoperativediazepam. Prior to administering themedication, which of the followingactions is the nurse's priority? A. Teaching the client about thepurpose of the medication B. Giving the medication atthe administration timethe provider prescribed C. Identifying the client's medication allergies D. Documenting theclient's anxiety level

C. Identifying the client's medication allergies

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique. (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the meds. which of the following effects should the nurse anticipate (select all that apply) A. urinary incontinence B. diarrhea C. bradypnea D. orthostatic hypotension E. nausea

C. bradypnea D. orthostatic hypotension E. nausea

While performing a complete bed bath for a patient, the nurse should A. add soap to the water in the basin before beginning the bath. B. completely remove the linens. C. raise the room temperature. D. complete the bathing for one side of the body at a time.

C. raise the room temperature.

a nurse is evaluating a client's use of a cane. which of the following actions should the nurse identify as an indication of correct use? A. the top of the cane is parallel to the client's waist B. when walking, the client move the cane 46 cm (18 in) forward C. the client holds the cane on the stronger side of her body D. the client moves her stronger limb forward with the cane

C. the client holds the cane on the stronger side of her body

A nurse reviewing a clients health record notes a new prescription for lisinopril 10mg PO once every day. The nurse should identify this as which of the following types of prescription? A.Single B.Stat C.Routine D. Now

C.Routine

A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection? A. Massaging reddened areas of the patient's skin B. Washing eyes from the outer cants to the inner canthus. C. Washing the patient from the shoulder down to the fingertips. D. Cleaning the least-soiled areas prior to cleaning the most-soiled areas

D. Cleaning the least-soiled areas prior to cleaning the most-soiled areas

Nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse? A. I will tape electrical cords to the baseboards in each room B. I will hire someone to trim that tree that overhangs the front porch stairs C. I will remove the table from the hall D. I will replace the old throw rug in the kitchen with a new one

D. I will replace the old throw rug in the kitchen with a new one

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of the infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D. Illness

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room.

D. Place wet towels along the base of the door to the client's room.

A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task? A. The AP records the task when it is complicated. B. The AP wears sterile gloves while making the bed. C. The AP makes a mitered corner with the blanket. D. The AP reuses the patient's blanket and spread.

D. The AP reuses the patient's blanket and spread.

A nurse has removed a sterile pack form its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closet to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. The flap farthest from the body

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanation of the procedure. D. The signature on the preoperative consent form is the client's.

D. The signature on the preoperative consent form is the client's.

A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPPA? A. the assigned nurse views the medical chart with a nursing student B. a nursing student discusses a client status with the assigned nurse at the bedside C. the assigned nurse returns a call to the client's POA to discuss client's care D. a nursing student consults a former class mate to assist with her documentation

D. a nursing student consults a former class mate to assist with her documentation

a nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of the following types of transition precautions hold the nurse initiate? A. protective environment B. airborne precautions C. droplet precautions D. contact precautions

D. contact precautions

a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following information should the nurse include in the teaching? A. assign the client to a room with a negative air-flow system B. use alcohol-based hand sanitizer when leaving he client's room C. clean contaminated surfaces in the client's room with a phone solution D. have family members wear gown and gloves when visiting

D. have family members wear gown and gloves when visiting

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following action should the nurse take?

Don clean gloves to remove the old dressing

Which of the following dietary modifications should an adolescent make if they are involved in sports?

Drink water before and after sports

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication in the outer third of the lower conjunctival sac

A patient feels his privacy has been violated and wants to file a formal complaint. Through which of the following agencies should the nurse instruct the patient to file the complaint?

Office of Civil Rights (OCR)

a nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. Initial assessment reveals long term use of opioids for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question

Pentazocine (Talwin) (it is an opioid agonist antagonist. may cause opioid withdrawal)

A nurse donning sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the non contaminated glove because...

The inner edge of the cuff will lie against the skin and thus will not be sterile.

While waiting for a sterile procedure to begin, how do you position your hands and arms?

With your hands clasped together in front of your body above waist level.

To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this is that a) drying provides the full antiseptic effect b) residual alcohol can easily stain clothing c) excess gel could transfer to the patient d) slippery gel can make you drop supplies

a) drying provides the full antiseptic effect

Which of the following is an advantage of using alcohol-based gel? a) its use takes less time than washing with soap and water does. b) it removes gross contamination better than soap and water does. c) its protective nature reduces the need for frequent hand washing. d) it provides adequate protection before surgical applications.

a) its use takes less time than washing with soap and water does.

After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? a) The gloves b) The gown c) The face shield d) The N95 respirator

a) the gloves

You are washing your hands with a nonantimicrobial soap and water prior to repositioning a patient in bed. During the hand washing procedure, it is important to a) make sure that the water is hot b) continue for at least 15 seconds. c) use a liquid soap preparation d) remove rings and watches first.

b) continue for at least 15 seconds.

After assisting a newly admitted patient in removing his shoes and outerwear, you notice what appears to be soil or grime on your hands. You a) cleanse your hands with an alcohol-based gel. b) wash your hands with soap and water. c) brush off the soil against a cloth surface. d) use a wet paper towel to remove the soil.

b) wash your hands with soap and water.

A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? a. taking all medications out of the unit-does wrappers before entering the client's room b. checking with the provider when a single dose requires administration of multiple tablets c. administering a medication, then looking up the usual dosage ranged. d. relying on another nurse to clarify a medication prescription

b. checking with the provider when a single dose requires administration of multiple tablets

Standard precautions mandate a) rinsing gloves that become visibly soiled during use. b) using antimicrobial soap for routine hand washing. c) disinfecting hands immediately after removing gloves. d) keeping gloves on when touching environmental surfaces.

c) disinfecting hands immediately after removing gloves.

Which products can affect the permeability of gloves? a) antimicrobial soap and water b) alcohol-based antiseptic gel c) petroleum-based hand lotion d) water-based hand lotion

c) petroleum-based hand lotion

a nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery 2 hrs ago. Which should the nurse expect to be the same for both patients?

class of medication used to treat acute postoperative pain