3130 first 3 quizzes- study set for 1st test

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gown, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the appropriate nursing response?

"These barriers help prevent the transmission of infection."

After taking vital signs, the nurse writes down findings as T = 98.6 (37), P =66, R = 18, BP = 124/82. Which number represents the systolic blood pressure?

124

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

A nurse drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication?

Ask the care provider to come and assess the client.

When assessing a client's respiratory rate, the nurse should take which action?

Do it immediately after the pulse assessment so the client is unaware of it.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?

Healthcare-associated infection

A man runs into the emergency room with an 18-month-old boy in his arms. The man screams, "Help, my son is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?

High priority

A new nurse is caring for a client who has a prescription for a stool specimen analysis. As the nurse performs the procedure in the image, the charge nurse walks in to the client's bathroom and observes the new nurse obtaining the specimen. What is next priority action by the charge nurse?

Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids

All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

Meeting the care needs of clients.

Recently the United States and Canada have seen the development of West Nile virus. It is carried to humans by:

Mosquitoes

After receiving ibuprofen (Motrin) 800 mg orally for right hip pain two hours ago, the patient states that his pain is 8/10. The order states the patient may have the ibuprofen Q 6 hrs. Which action should the nurse take?

Notify the prescriber that the current pain management plan is ineffective.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. What is the appropriate nursing intervention?

Offer the family member a mask, explaining its use.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital.

When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. What is the appropriate action by the nurse?

Perform hand hygiene after removing the glove

A nurse caring for a client in a long-term health care facility measures the client's intake and output and weighs the client to assess water balance. These actions help to meet which type of need in Maslow's hierarchy of needs?

Physiologic

A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field?

Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.

The nurse is assessing an adult who has a pulse rate of 180 beats/min. Which condition would the nurse document?

Tachycardia

Which is an example of a long-term goal for a client with asthma?

The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

In conjunction with the client, the nurse has set the following client outcomes. Which client outcome reflects Maslow's level of self-esteem needs?

The client will verbalize feelings of increased confidence in performing a finger-stick blood sugar.

Which factor should the nurse most consider when determining which interventions would best meet the needs of a client?

The client's response to health and illness.

The certified nursing assistant (CNA) tells the nurse: "I can help you with your assessment."

"If you will obtain the vital signs and place them in the chart then that would be a big help."

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 ft (30 m) without the use of mobility aids by 12DEC." Several nurses have evaluated the client's progression towards this outcome at various points during care. Which evaluative statement is most appropriate?

"12DEC - Outcome partially met. Client ambulated 75 ft (22.5 m) without the use of mobility aids."

Clients demonstrating apnea have what?

a temporary cessation of breathing

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?

apical

Which term describes a heart rate that is below the expected norm?

bradycardia

The nurse is beginning an assessment on a nonverbal client. The nurse must first:

establish eye contact prior to assessing, touching, and interacting with the client.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

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

An overweight middle-aged client has had hypertension for 15 years. The pathologic event the client is most at risk for is:

stroke.

When performing hand hygiene, the nurse prefers to use an alcohol-based hand sanitizer. For which situation should the nurse use a different method?

visibly soiled hands