NURS 208 Exam 1 (PerpU ?'s)
Place the following stages of infection in the sequence in which they will occur.
- Incubation period - Prodromal stage - Full stage of illness - Convalescent period
The experienced nurse teaching a student to measure an apical pulse includes which critical information? Select all that apply.
- The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. - To determine the apical pulse, count the heartbeats for 1 full minute.
A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply.
- The nurse's back is facing the sterile field. - The nurse touches an unsterile object to the instrument tray. - The nurse is talking with the scrub nurse over the sterile field.
There have been an increase of needlestick injuries in the intensive care unit. When preparing to address this occurrence in a staff meeting, what should the nurse manager include in an education presentation to prevent needlestick injuries? Select all that apply.
- disposing of used needles in sharps container - using self-retracting safety needles - sing needleless adapters for medication administration
The nurse is talking to an older adult client who performs home blood pressure monitoring (HBPM) and finds that recently her BP measurements have consistently been low. Which factors may contribute to causing this client's BP to be falsely decreased? Select all that apply.
- applying too wide a cuff - releasing the valve rapidly - using a cracked or kinked tubing
A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.
1. exposure to the pathogen 2. nonspecific symptoms 3. positive laboratory tests 4. return of appetite
The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?
"Avoid touching the outside of your gown when removing it."
A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding?
30 to 60 breaths/min
After meeting with the family to give an update on the surgical client, the nurse shakes their hands before leaving. Which method of hand hygiene is most appropriate following this encounter?
Alcohol-based hand rub
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag
A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?
Apply oxygen as prescribed
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?
Incentivizing health care workers to utilize hand hygiene
Which of the following are considered the building blocks of the immune system?
T lymphocytes
A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?
The radial pulse is difficult to obtain
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria.
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?
contact
A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?
low prealbumin levels
The client has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:
within normal limits (normal is 8,000)
The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first?
Assess client's pain level and manage pain accordingly.
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
Assess when client generally eats meals.
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?
Auscultate the client's apical heart rate.
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
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?
Give the client a bath in tepid water. Correct
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?
Hand hygiene is needed after contact with objects near the client.
A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?
Inform the physician about this finding
A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?
It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.
The nurse is assessing an adult who has a pulse rate of 150 beats/min. Which action should the nurse take next?
Notify the health care provider of tachycardia
What is an accurate guideline for the use of PPE?
Replace gloves if they are visibly soiled.
The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching?
The client sits in the chair with feet flat on the floor and arm below the level of the heart.
A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?
The client's most recent temperature
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?
WBC of 25,000 mcL
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
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
airborne
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?
an older adult client with a history of heart failure
Which term describes foreign particles that enter a host and stimulate the body's immune response?
antigen
Prior to allowing a client to eat, which action is most important for the nurse to take?
assess the client's level of consciousness. Correct response:
An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?
auscultate the client's apical pulse
A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?
clear mucus
The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:
fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.
The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?
flow meter set at 5 liters of oxygen
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:
hemoglobin level.
hyperpyrexia
high fever
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
increased temperature.
The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?
inserting an arm within each sleeve while touching the outer surface of the gown
The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
into a private room
A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?
older adult
Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?
peripheral vascular disease
The most common infection in children is:
respiratory
The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?
speak to the client but limit the need for the client to respond verbally while chewing and swallowing.
The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect?
the bathroom is highly contaminated with the Clostridium difficile bacteria.
Gram-negative organisms are the most common cause of:
urinary infections
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
A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.
- increased respiratory rate - lymph node enlargement - fever
The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?
placing the client's arm at heart level
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
poor tissue perfusion
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
the client who is 48-hours postsurgical procedure