Exam III
A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?
"I think there is a better way to handle this."
A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?
"I understand you have four kids; how many times have you actually been pregnant?"
The nurse is caring for a client that has multiple dental caries and wants to understand the cause. Which statement by the client indicates that additional teaching is warranted?
"I will brush once every day and floss every other day."
The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?
"I will start an IV that will add fluids directly to the blood stream."
The parents of 3 young children have discussed the dental health needs of their children with the nurse. Which statement indicates the need for further instruction?
"If my children do not have cavities by the age of 10, fluoride treatments can be discontinued."
A parent reports that their home water is not fluoridated and questions the nurse whether it would be benefitial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate?
"In the absence of fluoridated water supplies, supplementation is often recommended."
A client who has been reluctant to have his or her hair shampooed for a week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." The client's hair is very greasy, the scalp is irritated, and it has begun to smell. What is the appropriate nursing response?
"Let's talk about what might be bothering you about your hair."
A nurse is calling a physician to communicate a change in the client's condition. According to the I-SBAR-R format for hand-off communication among healthcare personnel, which is the most appropriate way to begin the conversation?
"My name is Sue Smith, RN and I am calling regarding Mrs. Jones in room 356 at Jefferson hospital."
A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response?
"Share with me the advantages and disadvantages of your options as you see them."
The nurse is discussing antiviral medication with a client diagnosed with human immunodeficiency virus (HIV) which client statement indicates a need for further teaching?
"The antiviral medication will cure the virus from my body."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."
A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response?
"Advertised remedies that promise a cure may be a scam."
Paramedics arrive in the emergency department with a victim of a motor vehicle collision. The paramedic reports the driver was restrained, the car was traveling about 30 miles per hour (48 Km/hour) , and the air bags were not deployed. The paramedic continues to report the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?
"All of the victims got themselves out of the car?"
During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:
"Can you tell me why your physician sent you here to be admitted?"
The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?
"Could you tell me more about how you are feeling right now?"
The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement made by the newly hired nurse would indicate to the nurse educator that intervention is needed?
"Do you have any questions about your cholecystectomy?"
A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which of the following statements conveys empathy on part of the nurse?
"I know this is hard for you. Is there any way I can help?"
Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?
"These brown spots are senile lentigines and are common when you get older."
The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?
"We reviewed your plans for your new diet and medications. Do you have any other questions?"
A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:
"Were you tired and depressed before starting the new medication?"
A 70-year-old female client had a cholecystectomy four days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask in order to assess the client's orientation?
"What day of the week is it?"
The nurse faculty is observing a student nurse gather data from a client. Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions?
"Why did the health care provider prescribe this medication for you?"
A nurse is having problems communicating with a client. Which statement by the nurse would open up the most dialogue with the client?
"You are back from therapy; tell me about it."
The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?
"You are hoping to figure out the cause of your extreme fatigue during this hospital stay."
A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?
"You said that you do not smoke, but you have an open package of cigarettes in your pocket."
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing?
-Use of a tub/shower seat may be necessary if balance problems are present. -Water temperature should be monitored carefully due to decreased temperature sensation. -Use a long-handled shower brush or attachment to help with limited mobility.
Which practice is a correct application of infection control practices?
A nurse performs hand washing each time the nurse removes a pair of gloves.
Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. What is an example of the proper use of social media by a nurse?
A nurse uses a disclaimer to verify that any views expressed on Facebook are his or hers alone and not the employer's.
Which of the following nurses most likely is the best communicator?
A nurse who easily developed a rapport with clients.
A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure?
ANSWER: A A. Apply gentle pressure on the lower eyelid to center the lens prior to removing it. B. Move the eyelids toward one another to cause the lens to slide out between the eyelids. C. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. D. Have the patient look forward, retract the lower lid, and move the lens down on the sclera.
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply.
ANSWER: A,B,C A. It promotes the patient's sense of well-being. B. It prevents deterioration of the oral cavity. C. It contributes to decreased incidence of aspiration pneumonia. D. It eliminates the need for flossing. E. It decreases oropharyngeal secretions. F. It helps to compensate for an inadequate diet.
A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply.
ANSWER: A,C,E A. Bathe the feet thoroughly in a mild soap and tepid water solution. B. Soak the feet in warm water and bath oil. C. Dry feet thoroughly, including the area between the toes. D. Use an alcohol rub if the feet are dry. E. Use an antifungal foot powder if necessary to prevent fungal infections. F. Cut the toenails at the lateral corners when trimming the nail.
Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply.
ANSWER: A,C,F A. Compare bilateral parts for symmetry. B. Proceed in a toe-to-head systematic manner. C. Use standard terminology to report and record findings. D. Do not allow data from the nursing history to direct the assessment. E. Document only skin abnormalities on the patient record. F. Perform the appropriate skin assessment when risk factors are identified.
A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply.
ANSWER: A,D,E A. For male and female patients, wash the groin area with a small amount of soap and water and rinse. B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. C. For male and female patients, always proceed from the most contaminated area to the least contaminated area. D. For male and female patients, use a clean portion of the washcloth for each stroke. E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. F. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis.
A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.
ANSWER: A,E,F A. Wash the skin twice a day with a mild cleanser and warm water. B. Use cosmetics liberally to cover blackheads. C. Use emollients on the area. D. Squeeze blackheads as they appear. E. Keep hair off the face and wash hair daily. F. Avoid sun-tanning booth exposure and use sunscreen.
A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response?
ANSWER: B A. Bathe the patient more frequently. B. Use an emollient on the dry skin. C. Massage the skin with alcohol. D. Discourage fluid intake.
A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply.
ANSWER: B,D,C,F A. A patient who is taking antibiotics for chronic bronchitis B. A patient diagnosed with type II diabetes C. A patient who is obese D. A patient who has a nervous habit of biting his nails E. A patient diagnosed with prostate cancer F. A patient whose job involves frequent handwashing
A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure?
ANSWER: C A. Shift the focus of the interaction to the "process of bathing." B. Wash the face and hair at the beginning of the bath. C. Consider using music to soothe anxiety and agitation. D. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.
A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action?
ANSWER: C A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. B. Cut the gown with scissors to allow arm movement. C. Thread the bag and tubing through the gown sleeve, keeping the line intact. D. Temporarily disconnect the tubing from the IV container, threading it through the gown.
A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?
ANSWER: C A. Add bath oil to the water to prevent dry skin. B. Allow the patient to lock the door to guarantee privacy. C. Assist the patient in and out of the tub to prevent falling. D. Keep the water temperature very warm because older adults chill easily.
A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action?
ANSWER: D A. Make a recommendation for the patient to see an oral surgeon. B. Report the condition to the primary care provider. C. Gently scrape the oral cavity with a tongue depressor. D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.
A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes?
ANSWER: D A. Use hydrogen peroxide on a clean washcloth to wipe the eyes. B. Wipe the eye from the outer canthus to the inner canthus. C. Position the patient on the opposite side of the eye to be cleansed. D. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.
A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings?
ANSWER:B A. Do not remove or wash the piercings without permission from the patient. B. Rinse the sites with warm water and remove crusts with a cotton swab. C. Wash the sites with alcohol and apply an antibiotic ointment. D. Remove the jewelry and allow the sites to heal over
A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene?
ANSWER:B A. When the patient had his or her most recent bath B. The patient's usual hygiene practices and preferences C. Where the bathing fits in the nurse's schedule D. The time that is convenient for the patient care assistant
The nurse is caring for an older client with pulmonary tuberculosis. Which precautions will the nurse begin?
Airborne
A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?
All visitors who enter the room must wear special masks
A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?
Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.
A nurse caring for the skin of clients of different age groups should consider which accurately described condition?
An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a non-particulate (N-95) respirator when entering the room.
A nurse is planning care for an adult client with severe hearing impairment that uses sign language and lip reading for communication that has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care?
Arrange for a sign language interpreter when discussing treatment.
A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?
Avoid touching the outer surfaces of the gown
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. What is the appropriate nursing action?
Change to airborne precaution
A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?
Check that the bathroom has a nonskid floor.
The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care?
Check the nursing care plan for hygiene directives.
When preparing to take a client's blood pressure, the nurse notes that the spygmomanometer is visibly soiled. What is the correct action by the nurse?
Cleanse and disinfect the sphygmomanometer
A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An outcome goal is for the client to participate in self-care measures by the end of the week. Which documentation by the nurse shows the outcome was met?
Client demonstrated bathing independently while seated in the bathroom. Client experienced no difficulty with the procedure and experienced no pain.
The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?
Contact
The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?
Contact a podiatrist to care for toenails.
A client with diabetes has been admitted to a long-term care facility. Upon assessment, the nurse noticed that the client's toenails are very thick, and pedal pulses are diminished. What nursing interventions are appropriate?
Contact health care provider regarding diminished pedal pulses. Contact a podiatrist.
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is appropriate?
Continue to don the glove, then use the other gloves hand to carefully insert the finger into the proper hole.
The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?
Decontaminate hands using an alcohol-based hand rub
The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?
Disinfect it with alcohol swabs
he nurse is planning hygiene care for a client with self-care bathing deficit related to weakness. Which nursing intervention is appropriate?
Encourage the client to wash own face and hands.
The nurse is visiting a hospice client in his home. He is explaining the difficulties he is having with his home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is utilizing which therapeutic nurse-client communication technique?
Encouraging elaboration
Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?
Escherichia coli in the intestinal tract
The nurse is discussing hygiene with a client. The client states that not understanding the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse?
Excessive perspiration will result in potentially offensive odor. Bacteria can flourish in the presence of excessive perspiration. Perspiration promotes skin breakdown.
A nurse is making the bed of a client whose limited mobility prevents her from leaving the bed. What should the nurse do when performing this procedure?
Fan-fold soiled linens as close to the client as possible.
Foot care is an essential part of routine hygiene. What is an important nursing consideration when planning foot care for clients with diabetes?
Foot care should not include soaking the feet.
A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation?
Gently slide the hard lens over the cornea and remove it with gloved fingers.
Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?
Gown and gloves
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the client?
Hand hygiene is needed after contact with objects near client
The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?
Heat the entire package in the microwave, following the manufacturer's recommendation.
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
Help me understand your thoughts about vaccinations
A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?
Hold sterile objects above waist level to prevent accidental contamination
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
Hold sterile objects above waist level to prevent inadvertent contamination
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
Hold sterile objects above waist level to prevent inadvertent contamination.
Which nursing actions are recommended guidelines when performing oral care?
Ideally, brush teeth immediately after eating or drinking. If desired, use an automatic toothbrush to remove debris and plaque from teeth. If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.
Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure?
If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair
To eliminate needlesticks as potential hazards to nurses, the nurse should?
Immediately deposit uncapped needles into puncture-proof plastic container
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?
Incentivizing health care workers to utilize hand hygiene
The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?
Keep hair off the face and wash hair daily.
A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?
Keep hands lower than elbows to allow water to flow toward fingertips
When caring for a client with dentures, what should the nurse teach the client?
Keeping dentures out for long periods of time permits the gum line to change, affecting denture fit
The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?
Launder gowns, linens, and towels separate from other clients' items
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?
MRSA in the wound
A ________ ________ is caused by food or environmental toxin
Noncommunicable disease
The nurse is asked to check the unit's supply of personal protective equipment (PPE) to see if additional equipment needs to be ordered from central supply. The nurse should assess the level of which type of equipment?
Nonsterile gloves, masks, gowns, and protective eyewear
When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do?
Obtain a new bottle of sterile saline
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?
One that remains in the client's room
A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?
Orientation phase
When caring for a psychiatric client, a formal contract is made with the client during which phase of the nurse-client relationship?
Orientation phase
A nurse is going to bathe a client who is confined to bed. What does the nurse do first?
Perform hand hygiene.
The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
A nurse has finished providing morning care for the client. Which safety measures should the nurse employ prior to leaving the client's room?
Place the bed in the lowest position. Test the functioning of the bed and bed controls. Place the call light near the client within reach. Ensure the bed is locked.
A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?
Place the specimens into plastic biohazard bags
A nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client?
Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position.
Nurses working in bed management are assessing clients from the emergency room to semiprivate rooms. Client's with which two diagnoses are appropriate to room together, based on safety and infection control standards?
Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)
An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from
Recapping the needle
The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?
Remind the student that a fitted N95 respirator is required
A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use?
Remove and discard the cap after one use and dry the client's hair with a towel.
The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?
Remove fresh fruit from the room.
What is an accurate guideline for PPE?
Replace gloves if they are visibly soiled
The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?
Review the current infection protocols
Which nursing action is appropriate when providing foot care for a client?
Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.
The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?
Speak directly to the client.
The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?
Staff education on utilizing hand hygiene
A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?
Store dentures in cold water when not in use.
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?
Surgical asepsis
A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of?
Survival adaptation
Standard precautions do not apply to ______ or _______ ______
Sweat, intact skin
Which documentation note regarding an assessment of eroding tooth enamel is most appropriate?
The client is at risk for caries due to eroding tooth enamel.
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?
The client's immune system was further weakened
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 in (4 cm) from the outer edges.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure
Which best describes an element of the nurse-client relationship?
The nurse self-discloses only what is necessary for the client's benefit.
A nurse and an older adult patient with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?
The nurse will be sensitive to the patient's emotional barriers.
The student nurse is studying the concepts of communication. Which description demonstrates the student understands the concept of feedback?
The sender and the receiver use one another's reactions to produce further messages.
In order to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?
Therapeutic communication
Disinfectants are used?
To clean room between clients
Personal protective equipment (PPE) is used in health care facilities for primarily which reason?
To protect both the staff and clients from becoming infected by one another
Personal Protective Equipment (PPE) is used in health care facilities to protect the staff from potentially infected client's
True
Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes
True
Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes.
True
A nurse is caring for a 55-year-old postoperative 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
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?
Use an electric razor for shaving purposes.
The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention?
Use bath oil in the tub to decrease dry skin.
The nursing student is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which teaching provided by the nursing student requires nursing instructor intervention?
Use soap daily when bathing to remove debris and keep skin moist.
An older adult client has been admitted to the hospital and the nurse is preparing to provide hygiene to the client. The nurse brings a soft toothbrush and toothpaste to the bedside and the client's daughter begins to laugh, stating, "She doesn't actually have a single tooth left!" What should the nurse do?
Use the toothbrush as planned, despite the client having no teeth.
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
Vehicle
A nurse is providing oral care to children on a pediatric unit. Which guideline should the nurse follow for providing care in special situations?
Water should be used to clean an infant's teeth.
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 hand rub is appropriate in which situation?
When hands are visibly soiled
In which situation would it be appropriate to shave the beard of an unconscious client without his permission?
When inserting an endotracheal tube
In which situation is an alcohol-based rub an inappropriate option for hand hygiene?
When the nurse's hands are visibly soiled
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate response?
When your sputum culture is negative
A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time." The nurse responds
You may have infection in your birth canal that you are unaware of
Surgical asepsis is defined as?
absence of all microorganisms
A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:
aggressive
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
airborne
A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:
allow the client to set the pace.
Which client presents the most significant risk factors for the development of clostridium difficile infection?
an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
Which client would require a negative flow room?
an 81-year-old man with active tuberculosis and a productive cough
A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:
an audiologist
An older adult client who has had a colostomy for over 10 years states, "I won't need any teaching about colostomies. I understand how to change the bag and care for my colostomy, but I'm not sure how to best clean my stoma." What does this statement indicate?
an incongruent relationship
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?
an older adult client with a history of heart failure
A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information?
are you allergic to any medications?
An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse she is afraid of waking up during surgery. The best response by the nurse is to:
ask the client why she thinks she will wake up during surgery.
A nurse is on his lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. The nurse recognizes one of the physicians as being in charge of his clients. The nurse witnesses the physician point at the nurse and state, "That guy needs to get fired." The best response by the nurse would be to:
ask to speak to the physician in private and address any disrespectful remarks or behaviors.
A client arrives at the emergency department after experiencing several black, tarry stools. The nurse will develop a cause and effect by:
asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate.
A female nurse states the following to another nurse who is constantly forgetting to wash her hands between patients: "It looks like you keep forgetting to wash your hands between patients. It's really not safe for your patients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech?
assertive
A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?
back massage
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an)?
bacteria
A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?
be silent and allow the client to continue speaking when ready
A nurse is selecting a product to provide a complete bed bath to a client who is on bed rest. Which product would be best to use in this manner?
body foam
A nurse anticipates collaborating with the nurse aide, physical therapist, surgeon, and respiratory therapist in which circumstance?
caring for a client following a total hip replacement
During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "How many times have you been hospitalized this year for your back pain?" This is an example of which type of question?
closed question
The nurse is caring for a client. When does the nurse determine that nursing care will be most effective related to nurse-client communication?
common understanding
A nurse touches the client's hand while discussing his diagnosis. This action is a(an):
communication channel
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?
contact
When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is:
conveying information.
The nurse caring for a client with a recent head injury asks the client to raise his left arm as high as possible. The client repeatedly raises his right arm. What does this indicate?
difficulty with decoding messages
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?
diligent handwashing practices
A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with the diagnosis include:
easy wrinkling of the skin and sunken eyes.
A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:
eliminate as many distractions as possible
A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?
empathy
Which qualities in a nurse help the nurse to become effective in providing for a client's needs while remaining compassionately detached?
empathy
When assessing a client's nonverbal communication, the nurse will assess which characteristic as the most expressive part of the body?
facial expression
A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?
giving false reassurance
The mother of a toddler is deciding if she wants to allow her child to receive the recommended immunizations. The clinic nurse responds, "If you don't immunize your child you are jeopardizing the health of other children." What type of approach does this response indicate?
guilt inducement or approval/disapproval
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing
A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:
have group members confront the dominant member to promote the needed team work.
An older adult client is reporting dry, itching skin. The nurse should assess:
how often the client is bathing.
It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy?
identifying with the client's feelings
A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an)
incongruent relationship
The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist?
interpersonal
the term meta communication is best defined as:
interpersonal bridge between verbal and nonverbal communication
The nurse observing an interaction between a mother and her daughter appropriately identifies the interaction as which communication zone?
intimate
The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?
into a private room
A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:
involve the child's stuffed animal in the educational session
Several nurses on the same hospital unit communicate on the same social networking site. A nurse posts the following statement to the social networking page, "The lady in room 34 with heart failure was a train wreck!" This statement:
is unacceptable and breaches the client's confidentiality rights.
The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client to avoid that is on the dietary tray?
jelly to go on the toast
The client is talking to the nurse about recent health problems of immediate family members and the strain she has been under trying to care for them. She begins to cry between sentences. What response by the nurse demonstrates the most empathy?
just take your time. I am listening
The nurse is communicating with a client who begins to cry. The nurse places a hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client?
kinesthetic
When communicating with clients nurses need to be very careful in their approach. This is particularly true when communicating using:
medical terminology
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?
medications listed on the client's medication administration record (MAR)
A nurse gives a speech on nutrition to a group of pregnant women. What is the speech itself known as?
message
The nurse notices multiple caries upon inspecting a client's mouth. When asked if the client has dental pain, the client responds, "No, my teeth and gums never hurt." Which structural damage does the nurse anticipate?
nerve
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?
noncommunicable disease
The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?
noncommunicable disease
A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques?
open ended question
The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship?
orientation phase
Any microorganism capable of disrupting normal physiologic body processes is a?
pathogen
The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?
pulling the razor against the direction of hair growth
A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?
reaches down to the bed to pick up a sterile drape
An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:
recommend 40 mg of furosemide be administered because the client had improvement with past administration.
The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurolgoical checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed?
recommendation
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug abuser. To foster effective communication, the nurse should:
remain honest, open, and frank.
A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out?
reviewing health changes
A nurse is caring for a client who suffered a spinal cord injury and has paraplegia. The client is frustrated, crying, and tells the nurse, "I just want to die." The nurse best displays empathy when she:
says, "I can only imagine how hard this is on you. How can I help you?"
A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. The nurse is the:
sender
A nurse enters a client's room to complete an admission history. The nurse will convey interest in the client's story if the nurse:
sits at the clients bedside and faces the client
A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach?
surgery is your only option. You need this operation
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
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
A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:
swaddling the child and gently stroking its head.
A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:
tell herself to "remain calm" and remember that she was trained to perform this skill
A nurse has been caring for a client who suffered a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how he feels. Which scenario warrants further investigation?
the client stares at the floor and states "I feel fine"
When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?
the client's tone of voice
A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply?
the physician want to monitor you and control your pain
When the preoperative client tells the nurse that he cannot sleep because he keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:
the thought of having surgery is keeping you awake
A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?
the working phase
A nurse has developed strong rapport with the wife of a client who has been receiving rehabilitation following a debilitating stroke. The wife has just been informed that her husband will be unlikely to return home and will require care that can only be provided in a facility with constant nursing care. The client's wife tells the nurse, "I can't believe it's come to this." How should the nurse best respond?
this must be difficult for you to hear. how do you feel right now?
What quality do clients most value in nurses?
trustworthiness
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:
understand that his culture may influence his hygiene and ask him his preference.
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
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?
working phase
A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?
youre worried about how you will tolerate the pain associated with labor
