EAQ 1

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means?

Blood Semen

A nurse is changing the dressing of a postoperative client. The nursing assistant informs the nurse that another client has fallen down near the nursing station after losing consciousness. What is the best nursing action in this situation?

Attend to the client who lost consciousness.

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next?

Bending and then straightening their knees

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? .

Bringing equipment to the client's room Transporting the client to a diagnostic test

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions

A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning?

"I should examine the client in noise-free areas." "I should wear eye shields while examining a client with excessive drainage."

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms?

Friction

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction?

To the client from outside sources

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions?

Airborne Standard Contact

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?

Instruct the client to dangle the legs.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client's condition every hour.

A nurse is caring for a client whose mobility is restricted to a wheelchair following a motor vehicle accident. The client has been prescribed physiotherapy as a part of rehabilitation care. What interventions should the nurse consider when the client is discharged from the healthcare facility?

Assist the family in identifying community support systems Encourage the primary caregiver to set a routine time for respite Consider the primary caregiver's experience in the discharge plan

Which nursing interventions would be beneficial for providing safe oxygen therapy?

Check tubing for kinks Post "no smoking" signs in the clients' rooms

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?

Clean gloves

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an N95 respirator mask before entering the room.

A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do?

Explain the transfer procedure step by step.

The nurse is caring for a nonambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included in the client's plan of care?

Impaired skin integrity, related to the effects of pressure and shearing force

While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take?

Initiate an agency incident report.

Which positioning should be avoided while assessing a client with a history of asthma?

Lateral recumbent

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what?

Moves the walker no more than 12 inches (30.5 cm) in front of the client during use

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where?

On the hands

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?

Place a surgical mask on the client.

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what?

Remove loose rugs from the environment.

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker?

Strong upper arm strength and non-weight bearing on the affected extremity

What does the nurse recognize as the reason the faucet handles on the sinks in a client's room are considered contaminated?

They are touched by dirty hands when turning the water on.

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason?

To reduce edema at the operative site

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

Use draw sheets to pull up, transfer and position the client.

Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?

Prevent an adult client from getting up at night when there is insufficient staffing on the unit.