chapter 16,23,24

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload." "This client has a medical history of heart failure." "I am calling because the client receiving blood has developed dyspnea and had crackles." Submit Answer Exit quiz

"I think the client would benefit from intravenous furosemide."

A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? "This client has a medical history of heart failure." "I am calling because the client receiving blood has developed dyspnea and had crackles." "I think the client would benefit from intravenous furosemide." "It seems like this client has fluid volume overload."

"I think the client would benefit from intravenous furosemide."

Following insertion of a foley catheter, the nurse instructs the unlicensed assistive personnel (UAP) to remove the sterile gloves by inverting one glove into the other. The UAP states, "Why is that important?" Which response by the nurse is most appropriate? "Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms." "Inverting gloves makes it easier to get them off throw away." "Inverting gloves prevents any soil on the outside from getting on your uniform." "Inverting gloves after inserting a foley prevents the potential for client infection."

"Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms." Explanation:

A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? "This antibiotic is the best choice since the causative organism is not known." "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." "Drug resistance can develop when the wrong antibiotic is used for pneumonia." "Pneumonia is usually caused by multiple organisms."

"This antibiotic is the best choice since the causative organism is not known."

nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

. a client who is homebound and needs skilled nursing care

When assessing an infant's axillary temperature, it will be: 1 degree lower than an oral temperature. 1 degree higher than a rectal temperature. 1 degree higher than an oral temperature. The same as the tympanic temperature.

1 degree higher than an oral temperature.

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1 p.m. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? 3 p.m. 12 noon 8 p.m. Wait until day 5 of treatment.

3 p.m.

A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding? 12 to 20 breaths per minute 30 to 60 breaths per minute 60 to 80 breaths per minute 80 to 100 breaths per minute

30 to 60 breaths per minute

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? 40% of the circumference of the limb to be used 50% of the circumference of the limb to be used 60% of the circumference of the limb to be used 70% of the circumference of the limb to be used

40% of the circumference of the limb to be used

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/min. What number would the nurse document for this assessment? 5,000 mL 5,550 mL 5,850 mL 6,000 mL

5,850 mL

A nursing instructor is discussing a nursing student's Facebook post about a very interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? "All aspects of the clinical experience are confidential and should not be discussed." "Any information that can identify a person is considered a breach of client privacy." "You may continue to post about client you cared for during clinicals, as long as you do not use the client's name." "The information being posted on Facebook is inappropriate. Make sure to discuss information about client's privately with friends and family." Submit Answer Exit quiz

Any information that can identify a person is considered a breach of client privacy."

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Wear a protective gown and gloves with any direct contact. Apply a non-particulate (N-95) respirator when entering the room. Have the client wear a mask during care. Wear a mask with face shield during invasive procedures.

Apply a non-particulate (N-95) respirator when entering the room.

The nurse is preparing to measure an adult's radial pulse using a Doppler device. Arrange the following steps of the procedure in the correct order. 1 Apply conducting gel to the site where the pulse will be auscultated. 2 Place the Doppler probe tip in the gel. 3 Adjust the volume of the device, as needed. 4 Maneuver the tip of the Doppler probe over the area until the pulse is heard. 5 Count the number of heartbeats for 1 full minute. 6 Wipe the gel off of the client's skin.

Apply conducting gel to the site where the pulse will be auscultated. Place the Doppler probe tip in the gel. Adjust the volume of the device, as needed. Maneuver the tip of the Doppler probe over the area until the pulse is heard. Count the number of heartbeats for 1 full minute. Wipe the gel off of the client's skin.

The parent of a 33 year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate?

Ask the client if information can be given to the parent.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene? Decontaminate hands using an alcohol-based hand rub. Do not wash hands; apply clean gloves. Wash hands with soap and hot water. Wash hands with soap and water, followed by an alcohol-based hand rub.

Decontaminate hands using an alcohol-based hand rub.

Unbeknown to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur. 1 Incubation period 2 Prodromal stage 3 Full stage of illness 4 Convalescent period

Incubation period Prodromal stage Full stage of illness Convalescent period

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients? Indwelling catheter Bath blanket Face shields Specimen containers

Indwelling catheter

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart? Listen for heart sounds. Count the heartbeat for 2 minutes. Count each "lub-dub" as two beats. Palpate the space between the fifth and sixth ribs.

Listen for heart sounds

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? Let the family member know that the client cannot be visited. Welcome the family member into the client's room. Offer the family member a mask, explaining its use. Allow the family member to visit, but only for 5 minutes.

Offer the family member a mask, explaining its use.

Which principle should guide the nurse's documentation of entries on the client's medical record? Correcting fluid is used rather than erasing errors. Documentation does not include photographs. Nurses should not refer to the names of physicians. Precise measurements should be used rather than approximations.

Precise measurements should be used rather than approximations.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement? All new residents are prescribed antibiotics. Review the current infection control protocols. Culture all residents and staff. Restrict visitors to public places.

Review the current infection control protocols.

When documenting information in a client's medical record, what should the nurse do consistently for each entry?

Sign each entry by name and title.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? Surgical asepsis technique Medical asepsis technique Droplet precautions Strict reverse isolation

Surgical asepsis technique

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? There is a nonauscultatory gap. There is a widening in the diameter of the artery. There is an auscultatory gap. There is an adult diastolic pressure.

There is an auscultatory gap.

The nurse is preparing to perform hand washing. Arrange the steps in the correct order. You Selected: Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Turn the faucet off with a paper towel. Pat hands dry with a paper towel.

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrist areas. Apply soap product. Wash the palms and back of the hands for at least 15 seconds. Pat hands dry with a paper towel. Turn the faucet off with a paper towel.

A nurse is caring for a 55-year-old post-operative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? Urinary catheter PICC line Salem sump nasogastric tube Endotracheal tube

Urinary catheter

Which documentation by the nurse best supports the PIE charting system? Vomiting 250 mL undigested food, antiemetic given, no further vomiting Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea

Vomiting 250 mL undigested food, antiemetic given, no further vomiting

A physician is in a hurry to leave the unit and tells the nurse to give a morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

a written order is needed

Surgical asepsis is defined as: absence of all virulent microorganisms. absence of all microorganisms. slowed growth of microorganisms. use of hand washing, gowning, and gloving.

absence of all microorganisms.

What does the nurse recognize as the purpose of the electronic medical record? (Select all that apply.)

documenting continuity of care qualifying healthcare providers for government funds ensuring client safety facilitating health education and research

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts? infectious microorganism exit route susceptible host vehicle of transmission

exit route

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts? infectious microorganism exit route susceptible host vehicle of transmission .

exit route

A nurse is caring for four clients. Which client has the highest risk of infection? older male with an enlarged prostate toddler with a benign heart murmur woman in second trimester of pregnancy young woman with a history of scoliosis

older male with an enlarged prostate

Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records?

response: "The clients' medical records are obstruction to research and education."

Before and after doing aseptic techniques with a client, the nurse should: sterilize equipment. apply clean gloves. replace equipment. wash hands.

wash hands

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 client care and interaction wearing a face mask when entering and staying at a distance from the client wearing protective eye wear for all client contact placing the client in a regular, private room

wearing a particulate respirator for all client care and interaction

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? "Any staff that enters my room will be wearing personal protective equipment (PPE)." "I can leave my room any time I want as long as I wear a mask." "I will tell my visitors to keep a 3-foot distance from me." "My personal belongings should remain in the room until I am discharged."

"I can leave my room any time I want as long as I wear a mask."

A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate? "It will give me a better sense of what my workload will be today." "It will let me see everything that has been done and things that need to be done." "It will allow for us to see the client and possibly increase client participation in care." "It makes our client feel like we care, especially if we start the day off with a clean room."

"It will allow for us to see the client and possibly increase client participation in care."

The student nurse is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor? "You don't have to worry about trying to read poor handwriting." "You save time because you don't have to look for the physical chart." "The computer reminds the nurse to enter information and inhibits omissions." "You can make extra money with overtime pay with end-of-shift charting." Submit Answer Exit quiz

"You can make extra money with overtime pay with end-of-shift charting."

What is the pulse pressure of a client whose blood pressure is 132/82 mm Hg? 100 1.6 214 50

50

Which practice is a correct application of infection control practices? A nurse performs hand washing each time the nurse removes a pair of gloves. A nurse dons a pair of gloves prior to any client contact. A nurse ensures that the nurse rinses the hands thoroughly after the application of an alcohol-based handrub. A nurse uses an alcohol-based handrub each time that the nurse's hands are visibly soiled

A nurse performs hand washing each time the nurse removes a pair of gloves.

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. Palpate the client's apical pulse. Arrange for cardiac monitoring. Auscultate the client's brachial artery.

Auscultate the client's apical pulse

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Calling the client information desk to find out the room number of the family member Asking the emergency department nurse for information on the family member Accessing the electronic medical record of the family member to find out extent of injury Finding the emergency medical technicians that transported the family members about the injuries Submit Answer Exit

Calling the client information desk to find out the room number of the family member

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse? Discard the sphygmomanometer in the trash Cleanse and disinfect the sphygmomanometer Send the sphygmomanometer for sterilization Use the sphygmomanometer

Cleanse and disinfect the sphygmomanometer

What is the primary purpose of the client record? Advocacy Education Communication Research

Communication

A nurse is providing care to a client diagnosed with impetigo. The nurse would institute which type of infection control? Airborne precautions Droplet precautions Contact precautions Protective isolation

Contact precautions

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? (Select all that apply.)

Conversations about clients must take place in private places where they cannot be overheard. Documentation must be kept of personnel who have accessed a client's record. Light boxes for examining X-rays with the client's name must be in private areas.

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. Don a second pair of sterile gloves over the first pair. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field.

Correct response: Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection? Exogenous healthcare-associated Endogenous healthcare-associated Iatrogenic Antibiotic-resistant

Exogenous healthcare-associated

Two nurses are working together on the medical unit. One nurse goes to the other nurse and informs of an injury from a scalpel left on a procedure tray. Without knowing anything about the client's or the other nurse's history, for which infectious disease would the nurse be most at risk? Hepatitis B Hepatitis C HIV Methicillin-resistant Staphylococcus aureus (MRSA

Hepatitis B

To eliminate needlesticks as potential hazards to nurses, the nurse should: Place the uncapped needle on a tray and carry it to the medicine room for disposal. Immediately deposit uncapped needles into puncture-proof plastic container. Stick the uncapped needle into a Styrofoam block and deposit in a plastic container. Slide the needle into the cap and deposit it in a puncture-proof plastic container.

Immediately deposit uncapped needles into puncture-proof plastic container.

The nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns, and potentially to initiate in-service programs. This is an example of which type of report?

Incident report

A nurse changing the linens of a client bed is exposed to urine and performs hand hygiene. Which is a guideline for performing this skill properly following this client encounter? Remove all jewelry, including wedding bands before hand washing. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. Use an alcohol-based hand rub to decontaminate hands. Keep hands lower than elbows to allow water to flow toward fingertips.

Keep hands lower than elbows to allow water to flow toward fingertips.

Nurses and other health care workers play a key role in reducing the spread of disease, minimizing complications, and reducing adverse outcomes for their clients. Which statement accurately describes this process? Select all that apply. Nurses perform surgical asepsis, which includes practices used to render and keep objects and areas free from microorganisms. Nurses use medical asepsis, which involves procedures and practices that reduce the number and transfer of microorganisms. Nurses practice asepsis, which includes all activities to prevent infection. Nurses use PPE, which is the most effective way to help prevent the spread of organisms. Nurses limit the spread of microorganisms by completing the chain of infection. Nurses use standard precautions and transmission-based precautions as an important part of preventing infectio

Nurses practice asepsis, which includes all activities to prevent infection. Nurses use medical asepsis, which involves procedures and practices that reduce the number and transfer of microorganisms. Nurses perform surgical asepsis, which includes practices used to render and keep objects and areas free from microorganisms. Nurses use standard precautions and transmission-based precautions as an important part of preventing infection.

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur? Orthostatic hypotension Dyspnea Primary hypertension Secondary hypertension Dyspnea

Orthostatic hypotension

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumonia, which is particularly prone to cause infections, also referred to as what? Virulent Pathogenic Specific Source

Pathogenic

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. Redness Swelling Pain Coolness Exudate

Redness Swelling Pain Exudate

The nurse hears a nursing assistant discussing a client's allergic reaction to a medication with another nursing assistant in the cafeteria. What is the highest priority nursing action? Report the nursing assistant to the nurse manager. Remind the nursing assistant about the client's right to privacy. Notify the client relations department about the breech of privacy. Document the nursing assistant's conversation

Remind the nursing assistant about the client's right to privacy.

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? Allow many family members to visit at once. Deliver flowers and balloons to the room. Remove fresh fruit from the room. No special precautions are required.

Remove fresh fruit from the room.

Which of the following is the best example of a nurse donning/removing protective equipment properly? Removing respirator after leaving client's room Removing gown after leaving client's room Donning gown after entering client's room Donning respirator inside of client's room

Removing gown after leaving client's room

What is an accurate guideline for the use of PPE? Put on PPE after entering the client's room. Substitute personal glasses for protective eyewear, if desired. Replace gloves if they are visibly soiled. When wearing gloves, work from "dirty" areas to "clean" ones.

Replace gloves if they are visibly soiled

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper- wrapped sterile items to the sterile field? While wearing sterile gloves, unwrap the package and add to the field. Separate the sealed flaps and drop contents onto field. Open the package away from the field. Set up another sterile field for the additional items.

Separate the sealed flaps and drop contents onto field.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? Objective data is what the client states about the problem. Subjective data should be included when documenting. The plan includes interventions, evaluation, and response. Abnormal laboratory values are common items that are documented

Subjective data should be included when documenting.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? Surgical asepsis Increased T cells Decreased antibiotics Increased vitamin C

Surgical asepsis

The nurse is aware that many products in the hospital have the potential to contain latex. Which piece of protective equipment is most likely to contain latex? Surgical masks Goggles Pillows Gowns

Surgical masks

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? The new nurse touches 1.5 inches from the outer edges. The sterile field is set up at waist level. Direct visualization of the sterile field is maintained. The top flap of the package is opened away from the new nurse's body.

The new nurse touches 1.5 inches from the outer edges

Which finding from a nursing audit reflects high standards for client safety and institutional health care? The nurse fails to identify the nursing diagnoses or clients' needs. The nurse records inappropriate nursing interventions. The nurse fails to adequately complete data on clients' health history and discharge planning. The nurse documents clients' responses to nursing interventions.

The nurse documents clients' responses to nursing interventions

A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? The nurse is caring for a client with a C. difficile infection. The nurse performs routine care and is moving to another patient. The nurse finishes cleaning a patient's table. The nurse finishes patient care and hands are not visibly soiled

The nurse is caring for a client with a C. difficile infection.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? The nurse sends or directs someone to take action in a specific nursing care problem. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

A client was recently hospitalized. In order to process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? Release the full medical record to expedite payment. Refer the insurance agency directly to the client. Do not release any information to the insurance company. Use minimum disclosure policy to release the information

Use minimum disclosure policy to release the information

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 handrub is appropriate in which of the following situations? After completing a wound dressing Before direct contact with clients After direct contact with clients When hands are visibly soiled

When hands are visibly soiled

A nurse recognizes an error in documentation regarding the site of a wound. What actions by the nurse are appropriate? (Select all that apply.) Write the words "mistaken entry" above the incorrect entry. Put a single line through the incorrect entry. Have the charge nurse co-sign the incorrect entry. Make a different entry explaining the incorrect entry. Use correction fluid to cover the incorrect entry.

Write the words "mistaken entry" above the incorrect entry. Put a single line through the incorrect entry.

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? notifying the nursing team of the client's condition accurately documenting client care on the client record keeping an accurate medication record documenting client data on the flow sheet Submit Answer Exit quiz

accurately documenting client care on the client record

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client? standard airborne droplet contact

airborne

Which client would require a negative flow room? a 21-year-old man with latent tuberculosis who is postoperative following repair of a femoral fracture a 4-year-old boy with meningitis an 81-year-old man with active tuberculosis and a productive cough a 3-year-old with influenza A and a productive cough

an 81-year-old man with active tuberculosis and a productive cough

An ultrasonic Doppler is used for: auscultating a pulse that is difficult to palpate. auscultating diastolic blood pressure. aiding palpation of pulse and rhythm. aiding palpation of diastolic blood pressure.

auscultating a pulse that is difficult to palpate.

Which peripheral pulse site is generally used in emergency situations? Carotid Apical Radial Temporal

carotid

Question 1 of 10 A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside her bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting her into bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up the incident with other members of the care team

identifying risks and ensuring future safety for clients

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. relevant data. interpretation of data. important information.

interpretation of data.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation

omitting client's response to nursing interventions

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? firm placement of thumb on the inner wrist of the opposite arm palpation of the radial pulse on the thumb side of the inner aspect of the wrist. light palpation of the femoral pulse below the inguinal area firm palpation of bilateral carotid artery for one minute

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature? Ear Rectum Axilla Mouth

rectum

The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? removes gloves and walks out of the room asks the client to state name and date of birth applies a mask with face shield performs hand hygiene before donning gloves

removes gloves and walks out of the room

Which nursing assessments should the nurse take into consideration before making entry into clients' record? (Select all that apply.) reviewing the agency's list of approved abbreviations checking that the clients' names cannot be identified with the chart forms locating the clients' files within an electronic recording system ignoring the agency's policy for the charting format it uses identifying the paper form appropriate to be used for documenting

reviewing the agency's list of approved abbreviations locating the clients' files within an electronic recording system identifying the paper form appropriate to be used for documenting

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How will the nurse listen to the client's heart? stethoscope belonging to the nurse stethoscope that remains in the client's room stethoscope that hangs outside the client's room stethoscope that has been purchased by the client

stethoscope that remains in the client's room

A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the priority nursing action the nurse must perform before leaving the client's room? thorough handwashing spraying of disinfectant placing one bag of contaminated items within another removing personal protective equipment that is most contaminated first

thorough handwashing

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? to release the entire health record for research to inform family and others concerned about the client's care to investigate the quality of care in the agency to transmit health records between insurance companies Submit Answer Equiz

to investigate the quality of care in the agency

While assessing a client admitted with a transmissible spongiform encephalopathy, what finding might the nurse observe? difficulty breathing distended abdomen unsteady gait redden, circular rash

unsteady gait

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?

urine output 100 ml