Quiz 1 (chapters 1, 4, 11, 17, 18, 23, 29, & 30)

The Neutropenic Precaution sign was posted outside the client's room. Which subsequent nursing action supports this set-up?

eliminating vegetable salads from the diet.

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.

exposure to the pathogen nonspecific symptoms positive laboratory tests return of appetite

Airborne precautions are being followed for a client in a health care facility. Which disease would require the nurse to follow airborne precautions?

measles

A nurse educates student nurses on recommended skin care practices for their clients. Which statement accurately describes one of these guidelines?

Avoid using soap and water.

A nurse is performing wound care on the chronic pressure ulcer on a client's coccyx. What should be used during this procedure?

Clean technique

A nurse is preparing to provide care to a client, prioritizing and organizing the care using Maslow's hierarchy of human needs. Place the following needs in the order in which the nurse would prioritize them.

Elimination Predictable routine Avoidance of loneliness Respect Maximizing potential

A client tells the nurse that the only thing that helps him sleep is a glass of warm milk. The nurse caring for the client insists that this practice is a myth and tries to convince the client that reading a book will help make him sleepy. What is the nurse demonstrating?

Ethnocentrism

How do people of Canadian Indian descent prefer to be identified?

First Nations

A nurse is preparing to remove personal protective equipment. Place the personal protective equipment below in the order that the nurse would remove them from first to last.

Gloves Goggles Gown Mask

A group of nursing students is reviewing information about the various nursing theorists in preparation for a class exam. The students demonstrate understanding of the material when they identify which theorist as emphasizing the interpersonal interaction between the client and nurse?

Hildegard Peplau

What is a recommended guideline for maintaining a sterile field?

If the client touches the sterile field, the nurse should discard the supplies and prepare a new sterile field.

Which national nursing organization serves as a primary source of research data about nursing education, and is the professional organization for nurse educators?

National League for Nursing (NLN)

Of all possible nursing interventions to break the chain of infection, which is the most effective?

Practicing hand hygiene

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Recognize that this is ischemia, followed by reactive hyperemia.

During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when the skin is which color during the application of light pressure?

Red

The nurse determines the need for an interpreter when providing care for a client. What would the nurse do first?

Talk with the interpreter before meeting with the client.

The nurse is caring for a client who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

Although all of the following are nursing responsibilities, which one would be expected of a nurse with a baccalaureate degree?

using research findings to improve practice

A client is discharged from the hospital and will need to change his left leg dressing using sterile technique twice per day. To prevent the development of further infection, the client will need to:

wash hands for 1 minute, apply nonsterile gloves, remove the dressing, apply antibacterial waterless soap, and sterile gloves.

Nursing students are reviewing information about physical variations among cultural groups. The students demonstrate understanding of this information when they state:

• "Asian Americans do not metabolize alcohol as quickly as African Americans do."

The student nurse is discussing the use of massage with the instructor. Which statement by the student indicates the need for further instruction? Select all that apply.

• "The benefits of massage may last up to 5 days." • "Massage should be avoided on clients who are not able to move independently." • "Massage may result in increased blood pressure and heart rate in a client recovering from a stroke."

Which education points would the nurse use to explain the development of pressure ulcers to clients and how to prevent them? Select all that apply.

• "The skin can tolerate considerable pressure without cell death, but for short periods only." • "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." • "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation."

Which question should the nurse include in a cultural assessment? Select all that apply.

• "What religion do you belong to?" • "What do you do to promote good health?" • "Do have a particular name for this illness?" • "What do you think is causing your illness?"

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

• 38-year-old man • Height: 6' (1.82 m) • Weight: 195 lb (89 kg)

A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply.

• Bathing can improve appearance and self-image. • Bathing removes organisms from the skin, reducing infection. • Bathing can stimulate circulation.

What are basic principles of surgical asepsis? Select all that apply.

• Consider the outer 1 inch of a sterile field to be contaminated. • Avoid talking, coughing, sneezing, or reaching over a sterile field. • Only a sterile object can touch another sterile object. • The nurse should never turn her back on a sterile field. • Hold sterile objects above waist level.

A group of nursing students is preparing for a class discussion on culture and has been assigned the task of creating a slide presentation describing the characteristics of culture. The students demonstrate understanding of the concept when they include which characteristic in their slide presentation? Select all that apply.

• Dynamic • Ritualistic • Shared

A nurse is assessing a client with an infection and suspects that the client may be developing systemic inflammatory response syndrome. What would support the nurse's suspicions? Select all that apply.

• Heart rate 110 beats/minute • Respiratory rate of 26/minute • Chills

The nurse is developing a plan of care for a client. Which of the following is a nursing care activity/intervention? Select all that apply.

• Holding the client's hand • Starting an IV • Educating clients

While nursing can and has been described in many different ways, the focus of all nursing interventions can be described by which statement?

• Nursing focuses on the human experience and responses of individuals, families, and groups.

Which is part of the graded criteria for predicting pressure ulcers using the Braden Scale? Select all that apply.

• Nutrition • Friction • Ability • Sensory perception

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What would alert the nurse to the possibility that the client's circulation is impaired? Select all that apply.

• Pale, cool hand • Reports of finger numbness • Decreased radial pulse

The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.

• Slide the fingers of the ungloved hand between the remaining glove and the wrist. • Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene. • Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. • Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area.

Which are considered vital signs? Select all that apply.

• Temperature • Pulse • Respiratory rate • Blood pressure

An operating room nurse is putting on sterile gloves to assist with client surgery. Which actions are performed correctly in this procedure? Select all that apply.

• The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. • The nurse opens the outside wrapper by carefully peeling the top layer back. • The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove.

A nurse practitioner is setting up a sterile field to perform a biopsy on a client. Which actions follow recommended guidelines for this procedure? Select all that apply.

• The nurse discards a sterile field when a portion of it becomes contaminated. • The nurse calls for help when realizing a supply is missing. • The nurse considers the outer 1-inch edge of the sterile field to be contaminated.

A nurse is implementing transcultural nursing care. Which attribute would be most important? Select all that apply.

• being aware of the health care system culture • recognizing personal aspects of nurse's own culture • understanding the culture of the clients receiving care

How is the nursing profession becoming more culturally diverse? Select all that apply.

• by the increased number of male nurses in the profession • by the increased number of foreign-born nurses in the profession

In which population should the nurse recognize an increased risk for infection? Select all that apply.

• older adults • debilitated clients • clients with impaired skin integrity

The nurse is explaining to a nursing colleague why there should be only one entry into the profession. What is the best statement by the explaining nurse?

"Multiple methods of preparation are confusing to consumers."