FON 2 quiz

a nurse in an acute care mental health facility is caring for a client who begins to yell and scream at staff members which of the following actions is the nurse priority

ask the client to talk about his feelings

complete the following sentence by using the option

assess the area where the restraint is to be placed on the client, attach the restraints to the movable parts of bed-frame

a nurse applies wrists restraints to client who is confused and attempting to pull out the chest tube which of the following actions should nurse take

document what less restrictive intervention she tried

a nurse is assisting with the development of a plan of care for an older adult who is risk for falls which of the following actions should the nurse contribute to the plan

keep a night light on in the clients room and bathroom, lock the wheel on beds and wheelchairs during transfer, place the bedside table within the clients reach

a nurse is preparing to lift a box of supplies in the supply room which of the following body mechanics should the nurse plan to use

keeping the box close to his body as he lift it

a. nurse is removing a wound dressing that is saturated with blood and purulent drainage which of the following methods should the nurse when disposing of the soiled dressing

place the dressing in biohazards waste container

a nurse is caring for an older adult client who Is at risk for skin breakdown which of the following interventions should the nurse use to help maintain the client skin integrity

provide the client with a diet high in protein

a nurse is reinforcing discharge teaching with client who has AIDS which of the following statement should the nurse make regarding home infection control

soak sponges used for cleaning in a black solution after use

a nurse is caring for a client who has clostridium difficile infection which of the following cleansing agents should the nurse use for hand hygiene

soap and water

a nurse is caring for a client who had an IV pump that begins to alarm which of the following should nurse take

tag the pump and notify engineering

a nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot the nurse enters the room to discover the client hopped on one foot to the bathroom using IV pole for support which of the following actions should the nurse take

tell the client to remain in the bathroom after toileting and obtain a wheelchair

a nurse is caring for a client in long term care facility who is receiving enteral feeding via an NG tube which of the following actions should the nurse take prior to administering the tube feeding

test the pH of gastric aspirate

a nurse is reinforcing discharge teaching for a client who requires home oxygen therapy which of the following statement should the nurse identify as an indication that the client needs further teaching

I will wear synthetic clothing and woolen socks when using my oxygen

a nurse is caring for a client who recently had surgery for insertion of permanent pacemaker which of the following prescriptions should the nurse questions

MRI of the chest

a nurse is walking down the until hall and sees a blood spill on the flood which of the agent should the nurse use to sanitize the floor

chlorine

a charge nurse is planning to admit several client to medial unit which of the following client should nurse assign to a private room

a client who had neutropenia

a nurse is collecting data form client who has diabetes mellitus and reports foot pain the nurse should evaluate the client for which of the following allegations as an indication that the client had an infections.

an increase in neutrophils, localized edema

a nurse is and urgent care center for a client who fell and injured her ankle the ankle appears swollen and eccumotic while the clients waits for the x ray technician when the following actions should the nurse take

apply ice, apply a compression bandage, elevate the foot

a nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

as long as I change my gloves between clients it is not necessary to wash my hands

a nurse is caring for a client who is HIV positive and is 1 day postoperative following an appendectomy which of the following actions requires the nurse to wear a gown as PPE

changing a wound dressing

a nurse is preparing to administer an enema when the client states my doctor didn't tell me I was supposed to receive an enema which of the following actions should the nurse take

check the clients medical record for the providers prescriptions

a nurse is caring for a client who has hemophilia and has developed hemarthrosis of left knee which of the following actions should the nurse take

elevate the knee

a nurse is caring for group of client for which of the following nurse should wear gloves

emptying urine, providing oral care, changing an stony pouch

a nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms which of the following dietary elements should the nurse instruct the client to limit

fat

donning PPE

gloves, eyewear, gown, mask, perform hand hygiene

a nurse inserts an indwelling urinary catheter for a client who is preoperative three days later the client develops a urinary tract infection the nurse should identify that the client has which of the following typer of infections

health care associated

a nurse is preparing to help with transferring a Client who can partially assist to a gurney which of the fowling actions should the nurse take

lower the head of the bed

a nurse receiving a cleansing enema reports mild cramping after a few minutes he asks the nurse to stop the enema and allow him to go to bathroom which of the following actions should the nurse take

lower the height of the solution bag

a nurse is caring for a client who ingested a poison and is now having seizures which of the following is the priority actions the nurse should take

maintain the potency of clients airway

a nurse is caring for client require droplet precautions which of the following PPE is should the nurse wear when setting up clients meal tray

mask

a nurse is caring for a client when the safety on the bed plug's electrical outlet pops and begins to smoke which of the following actions is nurse priority

move any client in immediate vicinity

a nurse is caring for a child who is having a tonic clonic seizure and vomiting which of the following actions is nurse priority

move the child into a side. lying position

after reviewing the data the nurse determines that which of the following findings places the client at risk for fall

muscular degeneration, osteoarthritis, throw rugs in kitchen, blood pressure

a client receives the wrong emaciation in error the nurse who made the medication error should do which of the following first

observe the client

what is sequence of actions the nurse should following

obtain vital signs, client to bed, inform the provider, notify unit manager, complete the incident report

a nurse is caring who is postoperative following a cholecystectomy and reports pain which of the following actions should the nurse take

offer the client a back rub, remind the client to use incisional splinting, identify the clients pain level, change the client position

a nurse is caring for a client who is immunocompromised which of the following actions should the nurse take first

perform hand hygiene before and after care

a nurse is preparing to transfer a client from a bed to a chair which of the following actions should the nurse take

place a transfer belt on the client

a nurse is preparing to transfer a client from lying in bed to sitting in a chair when identifying the safest method of transfer which of the following is most important for the nurse to determine

the client current weight bearing status

a nurse is providing change of shift report to the oncoming nurse which of the following information should the nurse include in the report

the client in room 108 has been prescribed a new pain medication

a nurse is collecting data from a client who has a wrist restrain in place which of the fowling findings should the nurse identify as an indication of complication of restrain

the clients hand is cool and pale

A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

they will improve your circulation keep blood fro pooling in your legs

a nurse on a medical unit is reinforcing teaching with a group go assistive personnel about handling client bed linens safely which of the following instructions should the nurse include

tie linen bags securely at the top

a nurse is caring for a client who receives intermitted internal feeding through NG tube before administering a feeding the nurse should measure the gastric residual for which of the following purposes

to identify delayed gastric emptying

a nurse is removing an isolation gown that has waist ties in the front after caring for a client who requires contact precautions which of the following steps should the nurse take

untie the front waist ties, remove the gloves and untie the neck ties

which of the following actions should nurse take

wear a mask when caring for the client, place client in private room, increase fluids intake,

an assistive personnel ask a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia which of the fowling responses should the nurse make

wear a mask when entering the clients room

a nurse is assisting with a admission of client who requires droplet precautions due to pertussis which of the fowling isolation precautions should. the nurse take while caring for his client

wear a mask when giving the client care

a nurse is caring for a group of client for which nurse plan to wear eye equipment

withdrawing cord blood from a neonate, suctioning secretion from a child placed tracheostomy tube

a nurse is assisting with planning an in service for staff nurses about disaster management and triage which of the fowling color tag should the nurse include as identifying a client who require treatment within 30 to 2 hr

yellow