Exam 1 Funds / 2

Which client would be at highest risk for injury to the skin and mucous membranes?

77-year-old with diabetes

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen when the client rises in the morning

The ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning?

Ask the client to list foods to include in their diet.

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting.

A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include?

Dry mouth is common for older adults.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client?

Encourage the client to communicate their thoughts and feelings.

A nurse has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the nurse do?

Provide supplies and orient the client to the bathroom

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. What is an appropriate consideration when assisting the client with morning hygiene?

Provide the client with an electric shaver

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

Remove the antiembolisum stockings during the bath

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session

A nurse is shaving the facial hair of a client confined to bed. What is a recommended guideline for this procedure?

Shave with the direction of hair growth in a downward direction,..

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

Sit at eye level with the child.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field?

The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound."

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer?

"All of this equipment can be frightening."

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?

"Can you explain the concerns you're having right now?"

The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn?

"Can you tell me about how long the surgery will take?"

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart?

"Client normally bathes and washes hair every other day; applies moisturizer to dry areas."

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you."

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed."

A nurse is admitting a client who has major depressive disorder. The client states, "This has been the worst day of my life." Which of the following responses should the nurse offer?

"Please take a seat and talk to me about your feelings."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands."

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide?

"What worries you about being without your teeth?"

A college-aged student has influenza. At what stage of the infection is the student most infectious?

prodromal stage

Before a long-term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water?

to prevent drying and warping of the plastic

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.)

Gown and Gloves

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning?

Have the client demonstrates the procedure

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body

A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching?

Kosher diets have restrictions regarding how the food must be prepared.

How to store dentures

In water to prevent warping

A nurse is making a bed occupied by a client. What is a recommended step for this procedure?

Fan-fold soiled linens as close to the client as possible

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should outer edge of the sterile field. the nurse take when preparing the sterile field?

Place a mask on the client to limit the spread of micro-organisms into the surgical wound.

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in elicting information about personal hygiene?

Tell me about what you do to take care of your skin

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature?

Temporal

4. The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the following actions by the client indicates that psychomotor learning has taken place?

The client demonstrates emptying the ostomy pouch. The client writes the steps of how to empty the ostomy pouch on a piece of paper.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

The flap farthest from the body

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique?

The inner wrapping of an item on the sterile field

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures.

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take?

Turn the client's head to the side.

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

A nurse is providing denture care for a client. Which of the following actions should the nurse take?

Using a gauze pad to grasp and pull forward and downward to remove the upper denture

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing?

Wash the hands with soap and water for at least 15 seconds.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?

Wear a gown when in the client's room

A nurse is contributing to a plan of care for a client who is being admitted to a facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest?

Wear a mask when providing care within 3ft of the client.

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?

partial care

A nurse is providing oral care to a client with dentures. What action would the nurse perform first?

don gloves