NUR 101 Exam 1
Which of these clients need to be placed in protective isolation? Select all that apply. A. A client with severe burns over 50% of the body B. A client taking antibiotics for an infection C. A client receiving large doses of corticosteroids D. A client with bronchitis E. A client receiving a bone marrow transplant
A. A client with severe burns over 50% of the body B. A client taking antibiotics for an infection D. A client with bronchitis E. A client receiving a bone marrow transplant
A client has been involved in a motor vehicle crash and has multiple injuries. Which guiding principles of Florence Nightingale would assist this client's recuperation and health maintenance? Select all that apply. A. Clean air and water B. Cleanliness C. Blood administration D. Light E. Efficient drainage
A. Clean air and water B. Cleanliness D. Light E. Efficient drainage
Which client requires a negative pressure room? A. A client with pneumonia B. A client with pharyngitis C. A client with a draining leg wound A client with pulmonary tuberculosis
A client with pulmonary tuberculosis
A client has been prescribed an antibiotic for a bacterial infection. Which information is important for the nurse to tell the client? A. "Be sure to complete the drug for the entire period prescribed even if symptoms are better." B. "It is advisable to take any 'leftover' medications if another type of infection develops." C. "The antibiotics can also be used if you develop a virus." D. "The medication may be given to a family member if they develop the same symptoms."
A. "Be sure to complete the drug for the entire period prescribed even if symptoms are better."
On entering the room of a client with chronic obstructive pulmonary disease (COPD), the nurse observes that the client is receiving oxygen at 4 L/minute by way of a nasal cannula. The nurse's next action should be based on which statement? A. "The flow rate is too high." B. "The flow rate is too low." C. "The flow rate is correct." D. "The client shouldn't receive oxygen."
A. "The flow rate is too high." Explanation: The administration of oxygen at 1 to 2 L/ minute by way of a nasal cannula is recommended for clients with COPD; therefore, a rate of 4 L/minute is too high. The normal mechanism that stimulates breathing is a rise in blood carbon dioxide. Clients with COPD retain blood carbon dioxide, so their mechanism for stimulating breathing is a low blood oxygen level. High levels of oxygen may cause hypoventilation and apnea. Oxygen delivered at 1 to 2 L/ minute should aid in oxygenation without causing hypoventilation. Oxygen therapy is the only therapy that has been demonstrated to be life-preserving for clients with COPD.
Which of the following is not true of an HMO? A. A client can receive care anywhere B. Preventative health screenings are covered C. Doctors are paid a capitation fee for every client who belongs to the HMO D. Drugs that the HMO will pay for are limited to an approved list.
A. A client can receive care anywhere
Which client would need to be transferred to another unit? A. A client who has just delivered a baby. B. A client who is going home to self care. C. A client who returns after leaving the facility without information. D. A client who
A. A client who has just delivered a baby.
Which clients would be appropriate for protective ( aka reverse/neutropenic) isolation? Select all that apply? A. A client with 2nd-3rd degree burns over 50% of their body B. A client taking antibiotics for a wound infection C. A client being treated for pneumonia D. A client on ant-rejection medications following an organ transplant E. A client with a severe congenital immune system defect
A. A client with 2nd-3rd degree burns over 50% of their body D. A client on ant-rejection medications following an organ transplant E. A client with a severe congenital immune system defect
The nurse is preparing to perform a dressing change for a client who has an open surgical wound of the abdomen. Which action by the nurse is most appropriate when finding the seal on the sterile 4 × 4-dressing package is broken? A. Discard the 4 × 4 closest to the broken seal and use the others. B. Proceed with using the 4 × 4s. C. Discard them and obtain a new package. D. Use them for the outside of the dressing only.
C. Discard them and obtain a new package.
A long-term care facility has a room set aside for "respite care", what kind of client does the nurse anticipate being admitted to that room? A. A hospice client who is usually cared for at home, but whose family needs a break B. A hospice client who needs more aggressive symptom relief C. A home health client whose usual nurse is on vacation D. A client who has been released from the hospital, but isn't ready to go home.
A. A hospice client who is usually cared for at home, but whose family needs a break
Which of the following people can legally say they are a "nurse" on the job? (Select all that apply.) A. A registered nurse B. A licensed practical nurse C. A CNA 2 with 20 years of experience D. Anyone trained to provide nursing care E. A nursing student at clinicals or preceptorship
A. A registered nurse B. A licensed practical nurse
A client is placed on neutropenic precautions. What observation by the nurse would require immediate intervention? A. A volunteer starts to bring a fresh flower arrangement into the room. B. Housekeeping personnel don masks before entering the room C. The healthcare provider washes his hands thoroughly for 30 seconds before entering D. Dietary dons PPE, and double checks the meal order when bringing in the meal tray
A. A volunteer starts to bring a fresh flower arrangement into the room.
A client who is undergoing chemotherapy is wearing elastic bands on his wrists with flat beads that press into the palmar side of the wrist, he says they help with his nausea. The nurse recognizes that this is probably an example of what alternative/complementary healthcare modality? A. Accupressure B. Reflexology C. Homeopathy D. Chiropracty
A. Accupressure
A nurse admits an older adult client with a history of osteoporosis experiencing a right wrist and hip fracture after a fall. Which intervention by the nurse is priority? A. Administer opioid analgesics as prescribed. B. Assist with activities of daily living. C. Give the client water as requested. D. Obtain data regarding skin integrity.
A. Administer opioid analgesics as prescribed. Explanation: Relieving pain and making the client more comfortable should have priority. Water should not be administered unless cleared by the surgeon in case the client requires surgery. Obtaining data regarding skin integrity and assisting with activities of daily living are important but not the priority at this time.
Why are patients being treated for other resistant bacteria susceptible to Clostridium Difficile infections? A. Because their normal gut flora have been destroyed B. Because all facilities are infected with c. diff. C. Because the food in facilities is too low in fiber D. Because they are not maintaining hygienic surroundings
A. Because their normal gut flora have been destroyed
Several large boxes of supplies need to be relocated to another room on a client care area. Which action should be taken to prevent the staff from experiencing back injuries when moving these supplies? A. Break the boxes into smaller and lighter loads. B. Pull the boxes across the floor to the new location. C. Stack the boxes so more can be moved at one time. D. Push the boxes across the floor with the legs to the new location.
A. Break the boxes into smaller and lighter loads. Explanation: When needing to move large loads of boxes or heavy items, the loads should be broken into smaller loads. Loads should be limited to 35 pounds (16 kg). Pulling the boxes places strain on the lower back. Stacking the boxes so that more can be moved at one time increases the risk of a back injury. Pushing the boxes places strain on the arms and lower back.
To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this? A. By swabbing the labia minora from front to back B. By cleaning the labia minora from back to front C. By cleaning the labia majora from back to front D. By swabbing the entire perineal area
A. By swabbing the labia minora from front to back Explanation: The client should swab the labia minora from front to back, using one swab for each wipe, because this technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because this increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back — not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water.
The first practical nursing school was a 3-month course. What was the primary role of the practical nurse after graduation from this program? A. Care of infants, children, older adults, and disabled in the client's home B. Care of all client populations in the hospital setting C. Advanced care of adult clients in home and hospital D. Assisting the physician in surgical procedures
A. Care of infants, children, older adults, and disabled in the client's home
A client is suspected of having respiratory MRSA, what precautions should be followed? A. Airborne and contact B. Airborne and droplet C. Droplet and contact D. Droplet and protective
C. Droplet and contact
A client has been NPO (nothing by mouth) for several days preparing for, and then having GI tract testing. The surgeon comes and orders the another 24 hours of NPO status for the client to prepare for surgery. The nurse calls to tell the surgeon that the client has not had anything to eat for several days already, and asks for some nutrition to be provided to the client first. The nurse is acting in which role? A. Client advocate B. Care provider C. Educator D. Leader
A. Client advocate
An 8-year-old child is brought to the clinic with watery eyes and clear nasal drainage that has lasted more than 10 days, without fever. The nurse observes that the child has dark circles under the eyes and a crease above the tip of the nose. Which intervention should be the nurse's priority? A. Collect data about potential environmental allergy triggers. B. Prepare to administer amoxicillin 25 mg/kg. P.O. every 12 hours. C. Prepare to administer trivalent inactivated influenza vaccine 0.5 mL P.O. D. Prepare the child for sinus x-rays.
A. Collect data about potential environmental allergy triggers. Explanation: Cold symptoms that last longer than 10 days without fever, dark circles under the eyes (from increased blood flow near the sinuses), and a crease near the tip of the nose (from upward nose wiping) are all signs and symptoms of perennial allergic rhinitis. The nurse's priority is to collect data about potential indoor and outdoor environmental allergen triggers. Amoxicillin is used to treat bacterial infections, not allergies. Additionally the nurse will not prepare medication for administration without the appropriate orders from the health care provider. Influenza vaccination is indicated annually. Sinus x-rays may be necessary to check for structural abnormalities, but they are not the priority at this time.
A client has a draining sacral wound which is suspected to be infected with MRSA. What precautions should the nurse be sure are followed? A. Contact B. Droplet C. Airborne D. Protective
A. Contact
A client is admitted with diarrhea and dehydration. A stool culture shows Clostridium difficile. The nurse should institute which isolation precaution for this client? A. Contact B. Standard C. Airborne D. Droplet
A. Contact Explanation: The nurse should institute contact precautions for the client with Clostridium difficile infection because the microorganism can be transmitted by direct contact or indirect contact with environmental surfaces. Standard precautions should be used with every client when contact with blood or other body fluids is likely. Airborne precautions are necessary for clients known or suspected infection with microorganisms transmitted by airborne droplet nuclei, such as tuberculosis. Droplet precautions are used for clients infected with microorganisms contained in large droplets, such as influenza.
The nurse is performing a dressing change on a client with a large open abdominal wound, and notes that the wrapper of the pack of sterile 4 x 4 gauze appears to have gotten wet, although it is dry now. What should the nurse do? A. Discard the entire package B. Remove the 3 closest to the wrapper and use the rest C. Clean them with antibacterial soap before use D. Make sure they are dry before using them
A. Discard the entire package
While performing a sterile dressing change, the nurse drops the gauze for wound packing onto the client's skin about 7cm from the open wound. What should the nurse do? A. Dispose of the gauze and obtain another one B. Cleanse the gauze with iodine solution before use C. Moisten the gauze with povidone iodine after packing the wound D. Pick up the gauze with sterile gloves and continue with the dressing.
A. Dispose of the gauze and obtain another one
A nurse is caring for an elderly client with urine incontinence. How can the nurse care for the client while maintaining their privacy? A. Explain that street clothes are not convenient to perform tests and procedures. B. Ask the client not to leave the room without prior permission. C. Ask the client to change into hospital clothes as per hospital rules. D. Explain that gowns help to identify the unit to which the client belongs.
A. Explain that street clothes are not convenient to perform tests and procedures.
A nurse is assigned to care for a client who is being admitted to the healthcare facility. What care should the nurse take with respect to the client's bed? Select all that apply. A. Explain the bed controls to the client and family. B. Adjust the height of the bed according to the client's height. C. Adjust the entire bed to the lower position. D. Adjust the foot of the bed for the clients comfort.
A. Explain the bed controls to the client and family. C. Adjust the entire bed to the lower position. D. Adjust the foot of the bed for the clients comfort.
The nurse is assisting a client with cerebrovascular accident (CVA) with feeding. Which nursing action(s) promote(s) safety when feeding the client? Select all that apply. A. Have the client in a sitting position. B. Elevate the head of the bed. C. Position the client on the right side. D. Chat with the client while the client is eating. E. Check the mouth after feeding.
A. Have the client in a sitting position. B. Elevate the head of the bed. E. Check the mouth after feeding.
Which trends in nursing are expected to influence nursing in the 21st century? Select all that apply. A. Higher client acuity in hospital and long-term settings B. Traditional nursing education programs C. Shift to community-based care D. Advancements in technology E. Greater life expectancy
A. Higher client acuity in hospital and long-term settings C. Shift to community-based care D. Advancements in technology E. Greater life expectancy
A client has end-stage kidney disease with a life expectancy of a few months. He has decided to give up dialysis and just wants to be as comfortable as possible while he dies. What care agency would be most appropriate for him? A. Hospice care in the home B. Acute care hospital C. Long term care facility D. Sub- acute facility
A. Hospice care in the home
The nurse hears a client crying out, "Someone please help!" After meeting the client's immediate needs, which nursing action should be provided? A. Instruct and have the client demonstrate use of the call bell. B. Inform the client that the call bell must be used in order for someone to come. C. Place the client in the chair at the nurse's station. D. Sedate the client with medication.
A. Instruct and have the client demonstrate use of the call bell.
A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation? A. Isolation is not required at this time. B. Immediate isolation in a private room is required . C. Isolation would be required 10 days after exposure. D. Isolation would be required 12 days after exposure.
A. Isolation is not required at this time. Explanation: The incubation period for varicella (chickenpox) is 2 to 3 weeks, usually 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of a breakout. A person is infectious from 1 day before eruption of lesions to 6 days after the vesicles have formed crusts.
A client has low vision, what are some steps the nurse can take to help prevent falls? (Select all that apply.) A. Keep all furniture where the client is used to having it. B. Keep pathways clear of obstacles and tripping hazards C. Answer Mark the edge of steps with contrasting color D. Put a pressure alarm on bed and chair E. Tell the client not to get up without assistance
A. Keep all furniture where the client is used to having it. B. Keep pathways clear of obstacles and tripping hazards C. Answer Mark the edge of steps with contrasting color
A client is poor and unsure whether she can pay for the surgery her child needs. The nurse would suggest a Social Work consult to see about signing the client up for what program? A. Medicaid B. Medicare C. SSDI D. Campus
A. Medicaid
A client has difficulty caring for himself due to nerve damage in his hands. What department can provide strategies to increase the client's independence? A. OT B. Neurology C. PT D. ST
A. OT
Which of the following contributed to the low status of nursing in England in the early 19th century? (Select all that apply.) A. Often done by prostitues B. Having to pay a nurse indicated lack of close family C. Often done by felons D. Originally tied to the Catholic church E. The lower-class background of Florence Nightingale F. The fact that nursing was in disrepute throughout Europe
A. Often done by prostitues B. Having to pay a nurse indicated lack of close family C. Often done by felons D. Originally tied to the Catholic church
A high school student interested in becoming a nurse asks the nursing instructor what the role of the LVN/LPN is. Which are the best responses by the instructor? Select all that apply. A. The LVN/LPN provides bedside care. B. The LVN/LPN develops the plan of care for clients. C. The LVN/LPN performs wound care. D. The LVN/LPN supervises RNs. E. The LVN/LPN administers prescribed medications to clients.
A. The LVN/LPN provides bedside care. C. The LVN/LPN performs wound care. E. The LVN/LPN administers prescribed medications to clients.
A nurse needs to administer prescribed medications to a client with heart failure. Prior to administering the medications, what actions should the nurse take? Select all that apply. A. Perform handwashing. B. Hold all the medications until the primary health care provider has examined the client. C. Check the client's medical record number and name on the identification bracelet. D. Check the client's allergies in the medical record, and verify them with the client. E. Ask the client if there are any medications that will be refused.
A. Perform handwashing. C. Check the client's medical record number and name on the identification bracelet. D. Check the client's allergies in the medical record, and verify them with the client. Explanation: To verify a client's identity, the nurse should read the identification bracelet and check at least two client identifiers, such as the name and medical record number. Handwashing is always performed prior to preparing medications for administration. The primary health care provider does not need to have examined the client before administration of previously prescribed medications. While clients have the right to refuse a medication, this is not something the nurse would ask the client in advance.
A client has an HIV positive status. What are appropriate interventions for the nurse to perform? A. Practice thorough handwashing B. Observe standard precautions C. Be sure that all facility employees are aware of the client's status D. Be sure to wear full PPE whenever in the room E. Keep the client in a negative pressure room
A. Practice thorough handwashing B. Observe standard precautions
What is the nurse's most important intervention for a client having a tonic-clonic seizure? A. Protect the client from further injury B. Time the duration of the seizure C. Note the origin of seizure activity D. Insert a padded tongue blade to prevent the client from biting his tongue
A. Protect the client from further injury Explanation: protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.
Observing standard precautions includes which of the following actions? (Select all that apply.) A. Protecting mucous membranes and not intact skin from blood and body fluid splashes B. Safe disposal of sharps C. Wearing gloves whenever in the client's room D. Disposing of potentially infective material in a leak-proof bag. E. Washing hands frequently F. Wearing mask whenever in the room of a client with the flu G. Keeping the client's room door closed whenever possible.
A. Protecting mucous membranes and not intact skin from blood and body fluid splashes B. Safe disposal of sharps D. Disposing of potentially infective material in a leak-proof bag. E. Washing hands frequently
Which observation made by the charge nurse requires that the LVN/LPN receive further education? A. Recapping a needle after injecting a client. B. Placing the safety lock on the needle after injecting a client. C. Washing their hands after injecting a client with medication. D. Placing a syringe and needle in the sharps container.
A. Recapping a needle after injecting a client.
The nurse was irrigating a client's catheter to remove blood clots when the syringe became dislodged and urine splashed into the nurse's face. What should the nurse do after washing? A. Report to the supervisor B. Change the catheter C. Discontinue that urinary catheter and put it in the biohazard bin D. Discontiue the catheter and send it to the pathology lab
A. Report to the supervisor
A client no longer requires care in the coronary intensive care unit after coronary artery bypass graft surgery. Where should the nurse prepare to transfer the client? A. Subacute or step-down unit B. Skilled care unit C. Medical floor D. Long-term care facility
A. Subacute or step-down unit
The nurse is caring for a client on an oncology unit who is refusing further chemotherapy treatment after the rationale for the treatment has been clearly explained. What is the nurse's best action? A. Support the client's decision and hold all treatments. B. Continue to provide treatment because it will benefit the client. C. Involve the client's family for encouragement to continue treatment. D. Tell the client that it is wrong not to accept treatment.
A. Support the client's decision and hold all treatments. Explanation: Supporting the client's decision is in concert with the ethical principle of autonomy. The other options violate autonomy and privacy of the client.
A nurse is helping supervise a new CNA. What action by the CNA would cause the nurse to intervene? A. The CNA assists the client with the bedpan, then places the bedpan on the bedside table while assisting the client back into a comfortable position B. The CNA covers the bedpan with a waterproof pad while carrying it to the bathroom C. The CNA uses the same gloves to clean the bedpan that were worn to assist the client onto the bedpan D. The CNA disposes of the used wet wipes in the trash
A. The CNA assists the client with the bedpan, then places the bedpan on the bedside table while assisting the client back into a comfortable position
Prospective Payment means: A. The care facility will receive a set amount for the care of the client based on the diagnosis B. Cost of care will be estimated and the facility will only get a portion of the costs that run over estimate C. The facility provides an estimate of caring for the client and the insurance company will pay that D. The insurance company pays in advance for the estimated cost of care.
A. The care facility will receive a set amount for the care of the client based on the diagnosis
The nurse is concerned about a newly developed policy regarding scheduling on the unit. Who is the appropriate person for the nurse to discuss the concerns with? A. The nurse manager B. The nurse's peers C. The chief nursing officer D. The board of directors
A. The nurse manager
A client has been admitted to a sub-acute hospital following heart surgery and to care for a pressure ulcer. Given the trend in inpatient stays, what would the nurse expect? A. The nurse will have to teach the client's family how to care for the ulcer and arrange for home health follow-up B. The client's discharge will be delayed while the wound heals C. The diagnosis of a pressure ulcer will permit a longer stay D. The client will be sent back to the acute care hospital after discharge to have the ulcer cared for.
A. The nurse will have to teach the client's family how to care for the ulcer and arrange for home health follow-up
Which patient assignment should an LPN question? A. The patient with an acute exacerbation of heart failure whose condition is rapidly changing B. The client with an IV C. The client who will be having surgery the next day D. The Hospice patient actively dying from COPD
A. The patient with an acute exacerbation of heart failure whose condition is rapidly changing
Careful use of hand sanitizer may be substituted for handwashing in all of the following instances except (select all that apply): A. There is visible soil on the hands B. Entering or leaving a client room C. When changing gloves D. When there has been skin contact with blood or body fluid E. Before touching anything outside of the client room
A. There is visible soil on the hands D. When there has been skin contact with blood or body fluid
The nurse is preparing to administer an injection from an ampoule. To avoid injury, how should the nurse open the ampoule? A. Using a pad, break ampoule away from the body. B. Wearing gloves, break ampoule toward the body. C. Use a syringe without the needle attached to withdraw the medication. D. Ask the patient care technician to open the ampoule.
A. Using a pad, break ampoule away from the body. Explanation: Using a pad and breaking the ampoule away from the nurse protects the nurse from cutting from the sharp edge of the broken ampoule. Gloves are thin and can easily be cut by a broken glass. Using a syringe without a needle puts the nurse's fingers in direct contact with the broken glass. Asking the technician to open the ampoule without the proper technique puts the technician at risk of injury.
Which of the following behaviors contribute to the development of antibiotic resistance in bacteria? (Select all that apply.) A. Using antibiotics for viral infections B. Continuing to take the rest of the antibiotic prescription despite symptoms improving. C. Obtaining another prescription if there are still bacteria present on the follow-up culture D. Saving "leftover" antibiotic in case an infection recurs E. Using anti-fungal medications for fungal infections
A. Using antibiotics for viral infections D. Saving "leftover" antibiotic in case an infection recurs
Which I.M. injection site might the nurse use for a 2-year-old child? A. Ventrogluteal muscle B. Pectoral muscle C. Femoral muscle D. Deltoid muscle
A. Ventrogluteal muscle Explanation: When administering an I.M. injection to a 2-year-old child, the nurse might select the ventrogluteal muscle if the muscle is well developed. However, the preferred site is the vastus lateralis. The pectoral, femoral, and deltoid muscles aren't appropriate injection sites for a child.
The nurse is preparing to do wound care, after checking the order, the client's identity, and explaining the procedure, what should the nurse to first? A. Wash hands B. Put on gloves C. Assess the condition of the skin around the old dressing D. Carefully remove the old dressing without touching the inside surface.
A. Wash hands
A client is admitted with active pulmonary Tuberculosis. Which intervention is appropriate? A. Wear an N95 or HEPA respirator whenever in the room B. Instruct the client to wear a mask at all times C. Wear gown, gloves and shoe protectors at all times while in the room. D. Keep windows open for air flow
A. Wear an N95 or HEPA respirator whenever in the room
Which of the following precautions should the nurse take to ensure the correctness of a telephone message to a healthcare facility? Select all that apply. A. Write down the message. B. Paraphrase the message. C. Verify the message. D. Remember the message. E. Repeat the message.
A. Write down the message. C. Verify the message. E. Repeat the message.
A nurse is planning care for a client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A? A. fecal contamination and oral ingestion B. exposure to contaminated blood C. sexual activity with an infected partner D. sharing a contaminated needle or syringe
A. fecal contamination and oral ingestion Explanation: Hepatitis A is predominantly transmitted by the ingestion of fecal contaminated food. Transmission is more likely to occur with poor hygiene, crowded conditions, and poor sanitation. Hepatitis B and C are transmitted via exposure to contaminated blood and blood products; such exposure can occur during sexual activity with an infected partner or by sharing contaminated needles or syringes.
Several children at a day care center have been infected with hepatitis A virus. Which instruction reinforced by the nurse would reduce the risk of spreading hepatitis A to other children and staff members? A. hand washing after diaper changes B. isolation of the sick children C. using masks during contact with children D. sterilization of all eating utensils
A. hand washing after diaper changes Explanation: Children in day care centers are at risk of hepatitis A infection, which is transmitted via the fecal-oral route due to poor hand hygiene practices and poor sanitation. Isolation of sick children, use of masks during contact, and sterilization of all eating utensils would not be useful in breaking the chain of infection.
A nurse is caring for a client who is admitted to the hospital with a bowel obstruction. Which nursing action requires the use of sterile gloves? A. inserting a urinary catheter B. performing oral suctioning C. changing an oxygen system D. drawing blood for laboratory testing
A. inserting a urinary catheter Explanation: Inserting an indwelling urinary catheter is the only sterile procedure listed here. Gloves are not necessary when changing an oxygen system. The nurse should wear nonsterile gloves when drawing blood and performing oral suctioning.
A nurse is preparing a young client for surgery. The nurse understands that the client is worried and afraid of the surgery. Which nonverbal expression helps the nurse to understand the client's feelings? A. wringing hands B. slouched appearance C. twitching feet D. bouncing feet
A. wringing hands
Why is it inadequate for the nurse to perform hand sanitization if the nurse has been in contact with clients' body fluids?
Hand sanitization is inadequate if there is visible soil on the hands or if the nurse has been in contact with clients' body fluids because excess biological material will inactivate the sanitizer.
A client is suspected to be infected with methicillin-resistant Staphylococcus aureus (MRSA) in a sacral wound. Which precautions would the nurse follow during wound care? A. Droplet B. Contact C. Airborne D. Standard
B. Contact
A hospitalized client has been taking antibiotics for several days and develops C. difficile. Which symptom of this infection should the nurse expect to provide care for? A. Cough B. Diarrhea C. Vomiting D. Vaginal discharge
B. Diarrhea
A client has been admitted to the healthcare facility for the first time. The client is anxious about being alone in an unfamiliar environment, especially when he is ill. What should the nurse do to alleviate anxiety and fear in the client? A. Ask a family member to accompany the client at all times. B. Explain how the signal light in the bathroom can help the client. C. Tell the client to wait until the nurse comes by during rounds. D. Assume that the client is aware of the "nurse call" signal.
B. Explain how the signal light in the bathroom can help the client.
What statement by a nursing student indicates that they understand the place of hand washing in standard precautions? A. Wearing gloves is more important than hand washing in preventing infection transmission B. Frequent, thorough washing of hands is the single most effective tool to prevent infection transmission C. Careful use of hand sanitizer is always an acceptable substitute for washing D. Waterless cleansing products should never be used when water is available
B. Frequent, thorough washing of hands is the single most effective tool to prevent infection transmission
A client in airborne isolation asks, "Can you leave the door open, please?" What is the best response by the nurse? A. No, but let's open your window for some fresh air B. I'm sorry, the door must remain closed to prevent to keep pathogens from getting into the rest of the facility C. Sure, for these precautions the door may be open or closed. D. Since you've been on antibiotics for 24 hours, your door may be open now.
B. I'm sorry, the door must remain closed to prevent to keep pathogens from getting into the rest of the facility
The nurse smells cigarette smoke coming from a client's hospital bathroom. Which action by the nurse is the priority? A. Inform the client discharge from the hospital is likely. B. Inform the client that the hospital has a no-smoking policy. C. Call the security officer to handle the situation. D. Do nothing because the client has the right to smoke.
B. Inform the client that the hospital has a no-smoking policy.
A client has been treated with IV antibiotics for several days, and now has copious, loose, mucoid, foul-smelling diarrhea. What is a priority action by the nurse? A. Call the physician for a different antibiotic B. Institute contact precautions and contact the provider for stool culture order C. Call the provider for orders for a strong anti-diarrheal medication D. Insert a rectal tube to protect the client's bedding and skin
B. Institute contact precautions and contact the provider for stool culture order
A school-age child begins to have a seizure while walking to the bathroom after an appendectomy. The nearby staff do not have the child's medical history. What is the nurse's first action? A. Notify the health care provider. B. Position the child on the side. C. Administer diazepam. D. Call a rapid response team.
B. Position the child on the side. Explanation: The child should first be eased to the floor and turned to the side to prevent aspiration. Notifying the health care provider will not be the first action or calling a rapid response team is not the immediate action, because the child's safety is of primary importance. Diazepam would be administered only if it had been ordered, but the nurse does not have that information at this time.
A nurse is providing care to a client when the client's IV becomes dislodged and blood splatters in the nurse's eye. After using the eyewash, which is the next appropriate action? A. Call the physician to see if another IV should be started. B. Report the incident to the supervisor. C. Apply Neosporin ophthalmic ointment. D. No further action is required at this time.
B. Report the incident to the supervisor.
A nurse is caring for a client who does not understand the language spoken by the nurse. Which would be an appropriate method of developing defective communications with the client? A. Avoid any verbal interaction with the client. B. Request the assistance of an interpreter. C. Ask a family member to translate. D. Use sign language to communicate.
B. Request the assistance of an interpreter.
A home health nurse finds a client canning food in the home. The client notes that they aren't too worried about making sure they process the food for the proper amount of time, just make sure it reaches boiling because that will kill all the pathogens. What is the nurse's best response? A. Make sure you boil it well when you use it. B. Some bacteria form spores that can survive boiling, and can live in the sealed cans making bolulinum toxin C. Molds aren't killed by boiling D. Make sure the cans are stored in a dark place to prevent pathogen growth.
B. Some bacteria form spores that can survive boiling, and can live in the sealed cans making bolulinum toxin
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis? A. Hold the neonate loosely and gently. B. Support the neonate's head and back with the forearm. C. Use one hand to support the neonate's head. D. Strap the neonate into the bath basin.
B. Support the neonate's head and back with the forearm. Explanation: To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with her forearm. A loose hold may increase the risk of dropping the neonate. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.
The student nurse in a practical nursing program asks the instructor what an RN does. Which are the best responses by the instructor? Select all that apply. A. The RN performs surgical procedures. B. The RN cares for acutely ill clients. C. The RN teaches professional and practical nursing students. D. The RN takes charge in various healthcare settings. E. The RN manages personnel.
B. The RN cares for acutely ill clients. C. The RN teaches professional and practical nursing students. D. The RN takes charge in various healthcare settings. E. The RN manages personnel.
A nurse is caring for a client with a diagnosis of dissociative identity disorder (DID). Which client behavior should the nurse identify as a safety risk? A. The client experiences periods of lost time. B. The client expresses a desire to do self harm. C. The client expresses gladness to be in the unit. D. The client is hearing loud voices.
B. The client expresses a desire to do self harm. Explanation: The nurse needs to initiate safety precautions to prevent self-harm. The sensation of lost periods of time is not a safety issue. Being glad to be in the unit indicates a feeling of security. The client with DID hearing voices does not indicate a psychotic episode.
The home health nurse has several clients to see during the day. What is the most important action the nurse can take to prevent the spread of infection between these patients? A. Use hand sanitizer in the car B. Thoroughly wash hands on entering and leaving each home C. Wear gloves while providing client care D. Use separate shoe covers for each home
B. Thoroughly wash hands on entering and leaving each home
The health care practitioner uses nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes are ruptured, the nurse expects the paper will turn which color? A. pink B. blue C. yellow D. green
B. blue Explanation: Nitrazine paper turns blue on contact with alkaline substances such as amniotic fluid. Normal vaginal discharge and urine are acidic and cause nitrazine paper to turn pink.
A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus? A. sputum B. feces C. blood D. urine
B. feces Explanation: The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.
A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to A. bananas. B. latex. C. kiwi fruit. D. color dyes.
B. latex. Explanation: If a child is sensitive to bananas, kiwi fruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.
A nurse is reviewing information about immunizations with a new mother. The nurse determines that the woman has an understanding of the information based on which client statement about active immunity? A. "Although it is only temporary, this immunity develops rapidly." B. "Antibodies in my blood are transmitted to my baby." C. "Direct exposure by a vaccine or disease leads to this type of immunity." D. "I can give it to my baby when I give him my breast milk."
C. "Direct exposure by a vaccine or disease leads to this type of immunity." Explanation: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but is temporary. Passive immunity may be transferred from mother to neonate.
After completing a course on infection control, a licensed practical nurse (LPN) demonstrates knowledge of the use of standard precautions based on which statement? A. "Standard precautions should be implemented at the nurse's discretion, as the need arises." B. "Routine care activities may transmit human immunodeficiency virus (HIV), regardless of precautions." C. "Standard precautions are mandatory for use with all client care." D. "Standard precautions include measures related to transmission-based precautions.
C. "Standard precautions are mandatory for use with all client care." Explanation: The Centers for Disease Control and Prevention requires the use of standard precautions, which protect against blood and body fluid transmission of potential infective organisms, for all client care, and are not at the nurse's discretion. Routine care activities do not facilitate transmission of HIV. Transmission-based precautions, such as airborne precautions or droplet precautions, are used in addition to standard precautions against the spread of highly transmissible pathogens.
The LVN/LPN is supervising a nursing assistant working in a long-term care facility. What task may be assigned to the nursing assistant by the LVN/LPN? A. Administer prescribed medication to a client. B. Change a sterile dressing. C. Assist with feeding a client. D. Insert a nasogastric tube in a client.
C. Assist with feeding a client.
An 8-year-old client has tested positive for West Nile virus infection. The nurse suspects the client has the severe form of the disease when she recognizes which signs and symptoms? A. Fever, rash, and malaise B. Anorexia, nausea, and vomiting C. Fever, muscle weakness, and change in mental status D. Fever, lymphadenopathy, and rash
C. Fever, muscle weakness, and change in mental status Explanation: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, muscle weakness or paralysis, changes in mental status, and seizures. Such signs and symptoms as fever, rash, malaise, anorexia, nausea and vomiting, and lymphadenopathy suggest the mild form of West Nile virus infection.
A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention? A. Have the parent give the child syrup of ipecac. B. Tell the parent to get the child to drink a glass of milk. C. Give the parent instructions on how to call poison control. D. Determine whether the parent knows cardiopulmonary resuscitation (CPR).
C. Give the parent instructions on how to call poison control. Explanation: The parent should call poison control and ask what immediate steps should be taken to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.
A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution? A. Ask if the client is really allergic to the medication. B. Give the medication as ordered by the NP. C. Hold the medication until speaking with the NP. D. Call the pharmacist and discuss a substitution for the medication.
C. Hold the medication until speaking with the NP. Explanation: The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.
A client that is homebound requires long-term intravenous antibiotic therapy. The insurance company refuses to keep the client in the hospital during this treatment regimen. Which services would best meet the needs of the client? A. Hospice B. Respite care C. Home healthcare D. Telehealth
C. Home healthcare
A client is infected with the fungal infection tinea capitus. Which objective data would the nurse document for this client? A. Green, foul-smelling discharge from the vagina B. A white patch on the mouth and tongue C. Lesions on the scalp D. Lesions on the feet
C. Lesions on the scalp
Given the tenets of Florence Nightingale's Natural Healing Theory, which nursing activity would be a priority? A. Administering a medication B. Notifying the physician of a client's worsening condition C. Making sure that a patient was served a balanced diet D. Preparing a client for surgery
C. Making sure that a patient was served a balanced diet
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? A. Chickenpox B. Impetigo C. Measles D. Cholera
C. Measles Explanation: Measles warrants respiratory isolation, which aims to prevent disease transmission primarily over short distances through the air (droplet transmission). Other infections necessitating respiratory isolation include epiglottitis or pneumonia caused by Haemophilus influenzae, erythema infectiosum, meningitis caused by H. influenzae or meningococci, meningococcal pneumonia, meningococcemia, mumps, and pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and cholera, enteric isolation.
Florence Nightingale believed that: A. Doctors heal B. Surgery heals C. Nature heals D. In cleaning away germs to prevent infection
C. Nature heals
A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse? A. Break the transfer down into smaller steps. B. Apply a back belt before beginning the transfer. C. Obtain an assistive device to help with the transfer. D. Recommend the client remain in bed until strength returns.
C. Obtain an assistive device to help with the transfer. Explanation: If any healthcare provider is required to lift more than 35 pounds (16 kg) of a client's weight, the client should be considered fully dependent and assistive devices should be used for the transfer. Breaking the transfer down into smaller steps will not help if the client is unable to assist. A back belt has not been proven effective in preventing injuries. Additional bedrest will cause the client to become further weak and debilitated.
The CNA informs the nurse that a confused client keeps removing the covers and exposing themselves. Which intervention can the nurse suggest to the CNA to protect the client's privacy? A. Use soft wrist restraints so the client cannot remove the covers. B. Use safety pins to fasten the gown to the bed sheets. C. Obtain pajamas for the client to wear. D. Tie the covers to the side rails.
C. Obtain pajamas for the client to wear.
The nurse is preparing to administer medication to a client in contact precautions. What is the proper procedure? A. Take the paper MAR into the room B. Take the med cart into the room C. Open the medications outside the room, then don gown and gloves and bring the med cup into the room along with the single-dose packages D. Bring any used syringes out of the room to dispose of them in the medication room
C. Open the medications outside the room, then don gown and gloves and bring the med cup into the room along with the single-dose packages
A provider orders transmission precautions be instituted for a client with a draining wound. What should the nurse do? A. Pull the curtain between the two beds in the room B. Place a sign on the door, and leave a box of masks for use in the room C. Place a sign on the door, and leave a cart outside the room with gowns and gloves D. Remove non-essential belonging s from the room and store them at the nurses' station.
C. Place a sign on the door, and leave a cart outside the room with gowns and gloves
A client begins to experience alcoholic hallucinosis. Which appropriate nursing intervention does the nurse implement at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes
C. Providing a quiet environment and administering medication as needed and prescribed Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or herself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.
While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action? A. Administer the medication immediately and chart it as given on time. B. Report the error and request a private meeting with the unit manager. C. Report the error, complete the proper paperwork, and meet with the unit manager. D. Contact the physician and follow their instructions.
C. Report the error, complete the proper paperwork, and meet with the unit manager. Explanation: Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, the nurse must still report the error and complete the proper paperwork. The nurse should contact the physician and follow their instructions, but shouldn't bypass proper protocol.
When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next? A. Rinse their eyes with water, record the incident on the client's chart, and see Employee Health. B. Wash their hands, complete an incident report, and see a physician as soon as possible. C. Rinse their eyes with water, report the incident, and go to Employee Health. D. Rinse their eyes, contact Employee Health and document their findings.
C. Rinse their eyes with water, report the incident, and go to Employee Health. Explanation: Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their eyes may allow viral transmission through contact with the mucous membranes.
A clinical instructor is reinforcing a student's knowledge of medical asepsis. Which statement by the student indicates correct understanding of Standard Precautions? A. Standard precautions can be implemented at a nurse's discretion B. Routine can can transmit HIV regardless of precautions observed C. Standard precautions should be observed by all caregivers whenever providing care. D. Should be used whenever a client's medical history is unknown
C. Standard precautions should be observed by all caregivers whenever providing care.
A nurse is reinforcing education with parents on how to reduce the spread of impetigo. What should the nurse encourage the parents to do? A. Teach children to cover mouths and noses when they sneeze. B. Arrange for their children to be immunized against impetigo. C. Teach children the importance of proper hand washing. D. Isolate a child with impetigo from other members of the family.
C. Teach children the importance of proper hand washing. Explanation: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing will not prevent its spread. Currently, no vaccine exists to prevent a child from contracting impetigo. Isolating a child with impetigo is unnecessary
The RN is developing the plan of care for a client with pneumonia. Who should the nurse include in the development of the care plan? A. Unit secretary B. Dietary C. The client D. Administration
C. The client
A nurse has a license in Oregon and wants to practice in Washington as well, of what should the nurse be aware? A. The nurse may only practice in their state of residence B. The nurse needs to take the Washington licensing exam C. The nurse must obtain a Washington license by endorsement D. Oregon and Washington have reciprocity, so if a nurse lives and is licensed in one of the states, they can also practice in the other
C. The nurse must obtain a Washington license by endorsement
A nursing student in the final term is working with a preceptor. What action by the student would require the preceptor to intervene? A. The student nurse engages the safety device after injecting the client B. The student places the whole syringe as well as the needle in the sharps container C. The student recaps the needle after injecting the clientto carry it across the room to the sharps container D. The student safely re-caps the needle after drawing up the medication to carry the syringe to the client's room for administration
C. The student recaps the needle after injecting the client to carry it across the room to the sharps container
The nurse is preparing to administer medication to a client who is in isolation. What action would the nurse take? A. Take the original medication administration record (MAR) into the room. B. Obtain a computer for documentation and take it into the room. C. Unwrap medications and take them into the room in their packages. D. Take needles and syringes out of the room and dispose of them in the medication room.
C. Unwrap medications and take them into the room in their packages.
A client is suspected of having a urinary tract infection. Which specimen does the nurse obtain to determine which bacteria is present as well as which antibiotic to use? A. White blood cell count B. Urinalysis C. Urine for culture and sensitivity D. Hemoglobin
C. Urine for culture and sensitivity
Which of the following precautions would the nurse observe as part of standard precautions? A. Wear gown and gloves while obtaining vital signs B. Administer an antibiotic if the client has a fever C. Use PPE as needed to protect from blood and body fluids D. Place a client with any sort of infection in a private room.
C. Use PPE as needed to protect from blood and body fluids
A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority? A. Have three staff members present, one to restrain each side of the client's body and one for the head. B. Tie restraints securely to the side rails. C. Use an organized, efficient team approach to apply and secure the restraints. D. Secure restraints to the bed with knots to prevent the client from escaping.
C. Use an organized, efficient team approach to apply and secure the restraints. Explanation: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots.
The nurse is providing care to a group of clients. Which priority action by the nurse can help decrease the spread of infection to this client group? A. Have the client wear a mask whenever care is delivered. B. Administer prophylactic antibiotics to all clients. C. Wash hands when entering and leaving client rooms. D. Wear gloves whenever delivering client care.
C. Wash hands when entering and leaving client rooms.
A client was out enjoying the warm weather, and stepped barefoot on some broken glass shards, getting a deep puncture wound on the sole of the foot. What is the nurse's PRIORITY question? A. Was the glass dirty? B. What kind of soap was used to wash the foot? C. When was your last tetanus shot? D. Was an antibiotic cream applied?
C. When was your last tetanus shot?
A provider states that they suspect a client to have "Thrush" what signs might the nurse see that would be evidence for this diagnosis? A. Very sore throat that looks like raw beef B. Red eyes and conjunctiva C. White "cottage cheese" looking patches in the client's mouth/ throat D. Purulent drainage from the nose
C. White "cottage cheese" looking patches in the client's mouth/ throat
The nurse is preparing to do a wound irrigation and dressing change on a client with a draining wound. The wound infection is not from a resistant organism. What PPE should the nurse wear? (select all that apply) A. N95 mask B. sterile gloves C. gown D. face shield E. procedure mask F. clean gloves
C. gown D. face shield E. procedure mask F. clean gloves
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: A. develops rapidly and is temporary. B. occurs by antibody transmission. C. results from exposure of an antigen through immunization or disease contact. D. may be transferred by mother to neonate.
C. results from exposure of an antigen through immunization or disease contact. Explanation: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission and occurs rapidly but it's temporary. Passive immunity may be transferred by mother to neonate.
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? A. ineffective coping B. hopelessness C. risk for injury D. disturbed personal identity
C. risk of injury Explanation: This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation. Although ineffective coping, hopelessness, and disturbed personal identity also are appropriate diagnoses, the client's safety takes highest priority. The nurse should take immediate action to protect the client from injury.
Which communicable disease requires isolating infected children from pregnant women? A. pertussis B. roseola C. rubella D. varicella
C. rubella Explanation: Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Pertussis, roseola, and varicella don't have any teratogenic effects on a fetus.
A nurse is assisting a patient in a healthcare facility. Which therapeutic communication technique helps to communicate to the patient that the nurse has understood the patient's problem? A. clarification B. reflection C. summarization D. paraphrasing
C. summarization
The mother of a child with chickenpox (varicella) asks the nurse when her child may return to school. The nurse responds correctly by telling the mother that the child can return: A. when the fever has resolved. B. 24 hours after the appearance of the rash. C. when all of the lesions are crusted over. D. after the child receives the first dose of diphenhydramine.
C. when all of the lesions are crusted over. Explanation: The period of communicability for chickenpox begins 1 to 2 days before the appearance of the body rash and continues until all skin lesions have crusted over. The child may return to school after this period.
A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? A. "You could have gotten it by using I.V. drugs." B. "You must have received an infected blood transfusion." C. "You probably got it by engaging in unprotected sex." D. "You may have eaten contaminated restaurant food."
D. "You may have eaten contaminated restaurant food." Explanation: Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.
A "portal of entry" for an infection could include any of the following except A. Ingestion of contaminated food or water B. A contaminated hand touching the mucous membranes of the face C. A needle stick D. A bad dream
D. A bad dream
Which client requires a negative pressure room? A. client with pneumonia B. A client with pharyngitis C. A client with a draining leg wound D. A client with pulmonary tuberculosis
D. A client with pulmonary tuberculosis
A client is placed on neutropenic precautions. Which observation made by the nurse requires immediate intervention? A. Housekeeping personnel don a mask before entering the client's room. B. The physician uses strict handwashing prior to entering the room. C. Dietary dons gown, mask, and gloves when bringing in the lunch tray. D. A family member brings a basket of fresh fruit into the client's room.
D. A family member brings a basket of fresh fruit into the client's room.
If you are providing health care, what must you always wear on the job? A. A nursing pin B. Clean scrubs C. White shoes D. A name tag
D. A name tag
A patient has been admitted to the healthcare facility under an alias. What care should the nurse take with respect to this patient? A. Address the patient by his or her actual name only when alone. B. Use the patient's actual name for records and address the patient by his or her alias. C. Use the patient's alias on the facility's records only. D. Address the patient by his or her alias at all times.
D. Address the patient by his or her alias at all times.
An LPN is assigned care for a client at the healthcare facility. Which of the following is the role of the LPN? A. Notify the healthcare provider of the clients arrival. B. Check the healthcare providers orders for the clients diet. C. Confirm the clients diet order has been placed. D. Assess the vital signs of the client.
D. Assess the vital signs of the client.
According to the "Miasmal" theory of disease causation, infectious diseases were caused by what? A. Poor diet B. Evil spirits C. Drinking and debauchery D. Bad air (bad smells)
D. Bad air (bad smells)
A client requests that the nurse increase the heat in the room. The temperature is presently 72 °F. Which is the priority action by the nurse? A. Tell the client to put more clothing on. B. Inform the client that it is warm in the room. C. Tell the client that you cannot comply with that request. D. Bring the client a blanket from the warmer.
D. Bring the client a blanket from the warmer.
An LVN/LPN is moving to another state to practice nursing. After receiving a license to practice there, what is most important that the LPN do? A. Determine what the standards of practice are in that state. B. Take another NCLEX exam for that state. C. Sign up at the local community college to take review classes. D. Call the state Board of Nursing to let them know they are going to practice in that state.
D. Call the state Board of Nursing to let them know they are going to practice in that state.
A nurse working in a mental healthcare facility understands that the clients are to be treated respectfully and their rights maintained. Which nurse was an advocate for the humane treatment of the mentally ill? A. Florence Nightingale B. Melinda Richards C. Isabel Robb D. Dorothea Dix
D. Dorothea Dix
The nurse caring for a client must be attentive to the client's emotions, lifestyles, physical changes, spiritual needs, and individual challenges. When the nurse attends to these needs, the nurse is providing which type of care? A. Behavioral healthcare B. Specialized healthcare C. Caring healthcare D. Holistic healthcare
D. Holistic healthcare
The nurse is caring for a terminally ill client that is to be discharged. Which referral should the nurse make with the client's and family's approval? A. Extended care B. Telehealth C. Respite care D. Hospice
D. Hospice
Which intervention is appropriate for a client under contact precautions? A. Dispose of B/P cuff after each blood pressure check B. Keep a set of vital signs equipment for use with any clients under isolation precautions C. Wear gloves whenever removing equipment from the room D. Keep a dedicated set of vital signs equipment in the client's room
D. Keep a dedicated set of vital signs equipment in the client's room
According to CDC guidelines regarding Standard Precautions, what action must a nurse always perform? A. Re-cap needles to prevent needlesticks while carrying syringes to the sharps container B. Wear a gown whenever changing bed linens C. Wear gloves whenever administering medications D. Perform hand hygiene after removing gloves.
D. Perform hand hygiene after removing gloves.
A nurse is assisting with planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety? A. Apply a restraining vest to keep the client from getting out of bed. B. Orient the client to the room so the client can find the way to the bathroom. C. Lower the side rails so the client can get out of bed more easily. D. Place the call bell within the client's reach and ensure the client knows how to use it.
D. Place the call bell within the client's reach and ensure the client knows how to use it. Explanation: To reduce the risk of injury and falls in a client with both eyes patched, the nurse should place the call bell within reach and instruct the client how to use it. Because the client is alert and oriented, applying a restraint to keep the client in bed is inappropriate. If activity prescriptions allow limited ambulation, such as to the bathroom, the nurse should explain the importance of calling for assistance when getting out of bed. When the client is in bed, the side rails should be raised for safety.
The nurse observes the CNA provide assistance to a client. Which observation made by the nurse regarding the care administered by the CNA requires intervention? A. Wearing gloves when providing perineal care. B. Cleaning a water spill from the floor. C. Wiping the bedside table with antimicrobial wipes. D. Placing linens on the floor after taking them off of the bed.
D. Placing linens on the floor after taking them off of the bed.
A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? A. Report the incident to the nursing regulatory agency. B. Complete an adverse drug reaction (ADR) report. C. Anticipate suspension from the facility due to the error. D. Report the incident to risk management.
D. Report the incident to risk management. Explanation: The incident should be reported to risk management in order to evaluate care, and determine potential risks or system problems that contributed to the error. This type of error will not be reported to the nursing regulatory agency, or result in the nurse's suspension. Some facilities track the number of errors made by a nurse, or that occur on a particular unit, in order to provide appropriate education, and to improve the nursing process. Adverse drug reaction forms are used to report a client's reaction to a medication, not errors.
The nurse is caring for a preschool child just diagnosed with impetigo. What is the most important action the nurse should take to prevent the spread of impetigo to others? A. Cover the area. B. Isolate the child at home. C. Apply an antibacterial ointment. D. Teach child and family good handwashing techniques.
D. Teach child and family good handwashing techniques. Explanation: Handwashing is the most important action that a nurse or client can take to prevent the spread of infection. Covering the area or applying an antibacterial ointment does not stop the spread of infection, nor does isolating the child.
The nurse enters a client's hospital room to administer medication. Which observation made by the nurse would be of greatest concern? A. The overbed table has a telephone on it. B. The call light is attached to the bed within the client's reach. C. The head of the bed is elevated to 45°. D. The bed is elevated to a high position and the side rails are down.
D. The bed is elevated to a high position and the side rails are down.
Since hospital stays are becoming shorter and shorter, new nurses should be aware that: A. There will be fewer job openings B. All nurses should seek a BSN to be employable C. There will be more hospital openings since patients are sicker D. There will be proportionately more job openings in community-based and long term care.
D. There will be proportionately more job openings in community-based and long term care.
A client is suspected of having a chronic urinary tract infection. What test will best determine what organism is involved and what drug will best treat it? A. Urinalysis with microscopy B. Blood culture C. 24 hour urine screen D. Urine culture and sensitivity
D. Urine culture and sensitivity
A nurse must obtain the blood pressure of a client in airborne isolation. Which method is best to prevent transmission of infection to other clients by the equipment? A. dispose of the equipment after each use B. wear gloves while handling the equipment C. use the equipment only with other clients in airborne isolation D. leave the equipment in the room for use only with that client
D. leave the equipment in the room for use only with that client
What is the difference in infection causing potential between parasites and saprophytes?
Saprophytes live off the organic remains of dead plants and animals, therefore don't usually cause infections in humans. Parasites are microorganisms that live on or within the host, taking nutrients from and releasing toxins into the host, therefore capable of causing infection.
When caring for the client with urinary catheter, how can the nurse prevent the transmission of infectious diseases? a. Ensure the urine bag is placed at client level. b. Disinfect tubes and ports when collecting specimen. c. Wear a protective gown when caring for the client. d. Avoid changing the client's position. e. Always apply moisturizers to client's skin.
b. Disinfect tubes and ports when collecting specimen. The nurse should ensure that urine collection bags are positioned lower than the client to prevent backflow. A protective gown is worn only when there is danger of splashing or spraying body substances. The client should be repositioned frequently to prevent occurrence of bedsore or injury to the skin. Moisturizer is applied to dry skin or lips to prevent cracking.
