Module 1

An older adult client tells the nurse, "I do not understand why I have had so many episodes of infection lately." How should the nurse respond?

"As we age, our immune system does not function as well."

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? Clostridium difficile and diabetic ketoacidosis Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus Tuberculosis and pneumonia Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs? once per day every 4 hours according to medical orders immediately

immediately

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature? axilla mouth ear rectum

rectum

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."

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? 1100 1500 0300 1700

1700

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? noncommunicable disease communicable disease contagious disease infectious disease

A noncommunicable disease is caused by food or environmental toxin.

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

Contact

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 specimen containers face shields bath blanket

indwelling catheter

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? listen with the stethoscope at the fifth intercostal space at the sternum listen with a stethoscope at the second intercostal space left sternum listen with the stethoscope at the fifth intercostal space left mid-clavicular line listen with a stethoscope at the neck to the right of the coracoid process

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

When providing care to a client with dementia, which interventions would be most appropriate? Select all that apply. maintain levels of sensory stimulation that are tolerable employing reality orientation continually correcting the client for mistakes using validation therapy ensuring the use of assistive sensory devices

maintain levels of sensory stimulation that are tolerable ensuring the use of assistive sensory devices using validation therapy

A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse? "The antibiotics we are giving you will boost your immune system and help fight off whatever pathogen is present." "We give antibiotics to treat the virus that are causing your the pneumonia." "We are giving you broad spectrum antibiotics because they are active for many types of bacteria." "You cannot be admitted to the hospital with pneumonia without receiving some sort of antibiotics."

"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as:

Abandonment

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? Perform a pain assessment. Administer oxygen. Auscultate the lung sounds and count respirations. Notify the health care provider.

Auscultate the lung sounds and count respirations.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus?

Avoid contact with mosquitoes

The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client? respiratory droplet contact airborne

Droplet precautions are appropriate, because microorganisms exit the body during coughing, sneezing, and procedures such as suctioning. Airborne precautions are not used, because droplets do not remain suspended in air.

Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? Providing entertainment for a client on bedrest Encouraging a client to have regular checkups Arranging for social services to assist with meals for a homebound client Counseling a client who complains of being depressed

Encouraging a client to have regular checkups

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature? Set up a fan to blow warm air on the client. Apply a blanket on the client. Increase the client's metabolic rate. Give the client a bath in tepid water.

Give the client a bath in tepid water.

The nurse provides a hypothermia blanket as ordered for an unconscious client with an uncontrolled fever. The client develops facial muscle and extremity twitching. Which best action should the nurse take? Observe skin, lips, and nails for change in color or edema. Increase the temperature of the hypothermia blanket. Discontinue the hypothermia blanket and notify the primary care provider. Turn the client and reapply lanolin cream as needed.

Increase the temperature of the hypothermia blanket.

In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? Grieving Noncompliance Social isolation Sleep deprivation

Sleep deprivation

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature? Temporal artery Tympanic Oral Axillary

Temporal artery

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. The client has a blood pressure of 122/70 mm Hg The client has a temperature of 101.8°F (38.8°C) The client has been drinking water The client just finished ambulating with physical therapy The client has reports of pain of 8 on a scale of 0 to 10

The client has reports of pain of 8 on a scale of 0 to 10 The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C)

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? The client's respiratory rate is less than 18 breaths per minute. The client is unable to stay upright when blood pressure is checked. The client's pulse rate is below 60 beats per minute. The client's systolic blood pressure is less than 100 mm Hg.

The client's pulse rate is below 60 beats per minute.

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 After direct contact with clients Before direct contact with clients After completing a wound dressing

When hands are visibly soiled

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? droplet contact airborne none

airborne

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

an incontinent client in a nursing home who has diarrhea

Which pulse site is generally used in emergency situations? radial carotid temporal apical

carotid The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

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 admitted with a rash who reports recent exposure to measles the client placed in contact isolation who was admitted with a draining abdominal wound the client who is 48-hours postsurgical procedure the client admitted with diarrhea who tested positive for Escherichia coli (E. coli)

the client who is 48-hours postsurgical procedure

Which is not appropriate regarding the use of gowns as PPE? use of one gown per person per shift use of a new gown each time the nurse enters the room use of paper or cloth gowns donning a gown when splashing

use of one gown per person per shift

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 care and interaction with this client

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? Reassess the client's radial pulse in 15 minutes. Auscultate the client's apical heart rate. Page the client's primary care provider. Palpate the radial pulse on the opposite wrist.

Auscultate the client's apical heart rate.

A group of nursing students is reviewing information about the older adult and mobility. The students demonstrate a need for additional study when they identify which statement as accurate? Medications in the older adult play a major contributing role to the risk for falling. An older adult experiences numerous factors that increase the risk for falls. Older adults are faced with challenges related to the fear of falling and striving for independence. Falls are the leading cause of death due to injury in individuals who are over the age of 75 years.

Falls are the leading cause of death due to injury in individuals who are over the age of 75 years. (Correct- 65 years)

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? resolution stationary prodromal invasion

Often, the child will experience symptoms prior to the fever surfacing, which is called the prodromal phase and includes the nonspecific symptoms that occur before the body temperature rises. The onset or invasion phase indicates an elevation in body temperature, as well as symptoms related to the fever such as shivering. The stationary phase is when the fever is sustained. The final phase is the resolution or defervescence phase when the temperature abates and returns to the child's baseline temperature.

The home care nurse is visiting an older adult client in the home to assess a leg wound and change the dressings. The nurse is aware that the client receives money monthly but there is no food in the house, no adequate heat, and the client states, "My sister takes my check and cashes it every month." What is the correct action by the nurse? Call the police and tell them to swear a warrant for the arrest of the sister. Take the client to the local hospital Emergency Department. Report the incident to social service informing them the client has no food or heat. Tell the client to talk with the sister and have her replace the money she has stolen.

Report the incident to social service informing them the client has no food or heat.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms? The client's normal flora proliferated because of a nutritional deficit The client's normal flora began producing spores The resident microorganisms mutated and became virulent The client's immune system became further weakened

The client's immune system became further weakened

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client? postural hypotension lack of exercising new blood pressure medications poor dietary choices

The drop of blood pressure of more than 20 mm Hg between lying and standing, 1 to 2 hours after eating; the report of dizziness; and almost falling indicate the client has possibly developed postural or postprandial hypotension. The other choices may contribute to the situation, but are not the main concern.

Clients demonstrating apnea have what? normal respiratory rate of 20 increased rate and depth of respirations decreased rate and depth of respirations a temporary cessation of breathing

a temporary cessation of breathing Eupnea: normal breathing Tachypnea: increased/ bradypnea: decreased

A pulse deficit is the difference between: palpated and auscultated blood pressure readings. the apical and the radial pulse rates. the systolic and diastolic blood pressure readings. the radial pulse and the ulnar pulse rates.

the apical and the radial pulse rates.