Intro to Nursing Clinical midterm

Which action would the nurse take for a client whos right radial pulse is weak and thready? select all that apply

-Assessing all peripheral pulses-Assessing and comparing both radial pulses -Asking a second nurse to assess the client's pulses -Assessing for edema or other issues that may be restricting peripheral blood flow -Observing for pallor/skin temperature differences distal to the weak pulse

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.

1. Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist 2. Apply either a surgical mask or a respirator around the mouth and nose 3. Apply eyewear or goggles snugly around the face and eyes 4.Apply clean gloves within the gown 5. Bring the glove cuffs over the edge of the gown sleeves

Which product would the nurse instruct IDUs to use for cleaning needles and syringes between uses?

Bleach

The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct

"Wash your hands before and after any client care."

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client?

Bradypnea

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

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

Which reaction is an example of a type I hypersensitivity reaction?

Anaphylaxis

Which component of hand washing would the nurse include that is most effective for removing microorganisms?

Friction

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is:

Full

When preparing to assess a client with C. diff, which piece of protective equipment is necessary for the nurse before entering the client room?

Full plastic gown

Which manifestation indicates tertiary syphilis?

Gummas

Which STI causes condylomata acuminate?

HPV

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?

Kussmaul's respiration

The nurse is caring for a client diagnosed with MRSA in the urine. The health care provider orders an in dwelling urinary catheter to be inserted. Which safeguard would the nurse take during this procedure?

Surgical asepsis

when a client expresses anxiety about an upcoming surgical procedure, which action would the nurse take first?

Take the client's vital signs and ask questions about the source of anxiety.

A client with a MRSA infected wound is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse would implement which precaution?

Cover the infected site with a dressing

Which term describes the practice of placing clients with the same infection in a semi-private room?

Cohorting

Which category of isolation would the nurse implement for a client who is positive for C.diff?

Contact

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection?

To the client from outside sources

Which action should the nurse take to maintain sterility when performing a dressing change?

Remove the sterile drape from its package by lifting it by the corners.

Which definition is correct to explain the nursing process?

Sequence of steps used to meet the clients needs

The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source?

Severity of pain

Which should the nurse include when teaching a client with C. diff about decreasing the risk of transmission to family members?

Soap and water for hand washing

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection, which teaching would be priority?

Hand washing

Which antibody forms first after exposure to an antigen?

IgM

Which action would the nurse take to decrease the risk of transmission of VRE?

Move the client to a private room

When preparing to assess a client with active TB, which piece of protective equipment is necessary for the nurse before entering the client room?

N95

Which client assessment finding should the nurse document as subjective data?

Pain

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply.

Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors

A client asks about the purpose of a pulse oximeter. Which measurement is it used for?

Percentage of oxygen carrying hemoglobin

Which site should be monitored for a pulse to assess the status of circulation to the foot? Select all that apply.

Dorsalis pedis arteryPosterior tibial artery

Which finding during assessment prompts the nurse to don a protective gown?

Excessive wound drainage

Which piece of equipment must the nurse ensure remains sterile during care of the patient?

Suction catheter

Which is the causative organism for syphilis?

T. pallidum

The nursing student under the supervision of the registered nurse (RN) is performing a pulse assessment. While preparing to assess the client, the RN asks the nursing student to check the apical pulse after assessing the radial pulse. Which would be the reason behind this change?

The client may have dysrhythmia

A client with AIDs states "I'm not worried because they have a cure for AIDs". Which response would the nurse use?

There is no cure for AIDs, just medicine that can slow down the virus.

Why are the faucet handles on the sink in a clients room considered contaminated?

Touched by dirty hands

Figure of assessing ulnar pulse

evaluating arterial insufficiency

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to?

nosocomial

The nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis?

Keeps the area free of microorganisms

Which step in the nursing process involves the nurse interviewing a client about a current health problem and taking the client's vital signs?

Assessment

The registered nurse is teaching the student nurse about various sites for assessing body temperature. Which statements made by the student nurse is/are correct?

Axilla unconscious patient Tympanic for infants temporal for rapid rapid changes in core

While caring for different clients with respiratory problems, the nurse assesses the different alterations in the breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration?

Client 3

Arrange in order the items of personal protection equipment removed after seeing a client in droplet

Gloves Face shield Gown Mask

The nurse is providing colostomy care to a client with MRSA. Which personal protective equipment would the nurse use?

Gloves Gown Goggles

The registered nurse is evaluating the statements of a new nurse about wound dressings. Which statement made by the new nurse is incorrect?

I should use the cotton swab on the table

Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm3 be classified?

Stage 2

A client is being treated for flu A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to other. Which statement by the client indicates a need for further instruction?

"I should obtain a pneumococcal vaccination each year"

Which technique would the nurse use to maintain surgical asepsis?

Change the sterile field after sterile water is spilled on it.

Which STI is more commonly reported?

Chlamydia

The nurse is changing the soiled bed linens of a client with a wound that is draining seropurulent exudate. Which ppe would the nurse wear?

Clean gloves

A 50-year-old client is diagnosed with chronic obstructive pulmonary disease. The clinical data on admission are as follows: a heart rate of 100 beats/min, a blood pressure of 138/82 mm Hg, a respiratory rate of 32 breaths/min, a tympanic temperature 98.2, and an oxygen saturation of 80%. Which vital signs obtained by the nurse indicates a positive outcome? (select all that apply)

RR BP Oxygenation saturation

While caring for a postoperative patient, the nurse observed a pulse deficit during physical assessment. What pulses are used to assess a pulse deficit?

Radial and apical