NURS 302 - ATIs and study guide questions

The nurse manager is talking to the unit staff about importance of EBP. Which statements will the nurse expect to hear? (Select all that apply) 1. Goal is improving safety 2. A problem-solving approach 3. Use of best evidence 4. It's the way it's always been done 5. Related to increasing medical errors

1, 2, 3

A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer 3. Everyone coming into the room must be wearing a gown and gloves 4. While the patient is in Contact Precautions, he cannot leave the room 5. C. difficile dies quickly once outside the body

1, 2, 3 Clostridium difficile is transmitted through the oral-fecal route and spread through contact with contaminated feces or surfaces touched by hands not appropriately cleaned after providing care to a patient infected with C. difficile. The organism develops a hard spore and can live for long periods of time on surfaces, making it very hard to eradicate. As long as patient is continent of stool and first cleans hands and changes gown, a patient with C. difficile may leave the room.

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

1, 2, 3, 4

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures

1, 2, 4 Proper cleaning and disinfection are processes that occur prior to sterilization, with cleaning always done from dirty to clean to decrease the risk of further infection and contamination

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves

1, 2, 5 Chicken pox is an airborne organism that can travel great distances, so it is important that the air breathed by the nurse is filtered, and hands and clothes are covered, as required for airborne precautions

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) 1. Use antimicrobial toothpaste 2. Brush teeth 4 times a day 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses 4. Use a soft toothbrush for oral care 5. Avoid cleaning the gums and tongue

1, 3, 4 The ADA guidelines (2018) for effective oral hygiene include brushing the teeth at least twice a day with an American Dental Association-approved fluoride toothpaste. Use anti-microbial toothpastes and 0.12% CHG oral rinses for microbial toothpastes and 0.12% CHG oral rinses for patients at increased risk for poor oral hygiene (e.g., older adults and patients with cognitive impairments and who are immunocompromised). Rounded soft bristles stimulate the gums without causing abrasion and bleeding. Patients should clean the gums and the surface of the tongue

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Rase head of bed 30 degrees when patient positioned supine

1, 3, 5 A transfer device can pick up a patient and prevent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position causes patient to slide down, causing shear.

Put the following steps for removal of protective barriers after leaving an isolation room in order 1. Remove and dispose of gloves 2. Perform hand hygiene 3. Remove eyewear or goggles 4. Untie top and then bottom mask strings and remove from face 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side

1, 3, 5, 4, 2 Removing isolation PPE correctly decreases the risk of self-contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they interfere with removal of other PPE. The gown is third, followed by the mask or respirator

After surgery, the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply) 1. Notify the health care provider 2. Allow the area to be exposed to air until all drainage has stopped 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately 5. Cover the area with sterile gauze and apply an abdominal binder

1, 4 If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; these sterile towels that are hoisted with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

1, 4, 5 Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure injuries

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative pressure wound therapy 4. Sanitization

1. Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing

During an EBP committee meeting, a nurse discussed two systematic integrative reviews related to the use of prepackaged bath kits versus the standard use of bath basins. What level of evidence is the nurse presenting? 1. Level I 2. Level II 3. Level IV 4. Level VI

1. Level I Level I evidence is the strongest level of evidence. It is comprised of systematic integrative reviews or meta-analyses of randomized and unrandomized clinical trials.

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1. The front and sides of the sterile gown are considered sterile from the waist up 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5cm (1 inch) of the sterile field as contaminated 4. Only health care personnel within the sterile field must wear personal protective equipment 5. After cleansing the hands with antiseptic rub, apply clean disposable gloves

2, 3 Maintaining sterility throughout the procedure requires constant vigilance and strict rules to ensure sterility, such as keeping the sterile field in sight at all times, making sure everyone in the room is in protective clothing like gowns, masks, eyewear and gloves, and considering anything beyond the front or below the waist of the gown to be contaminated. To make sure the sides of the sterile field are not contaminated, there is an outer one-inch border not considered sterile

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) 1. Prone position 2. Sims' position 3. Semi-Fowler's position with head to side 4. Trendelenburg positon 5. Supine position

2, 3 Place the unconscious patient in semi-Fowler's position with head to the side or use the Sims' position to help avoid aspiration while performing oral care. The supine and Trendelenburg positions would make it easier for a patient to aspirate. The prone position would not be suitable for accessing the oral cavity

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) 1. Cut nails frequently 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care 4. Apply lotion to feet daily 5. Clean toes after bathing

2, 4, 5 Because of a patient's risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes because this may create skin breakdown and open sores, leading to skin breakdown or infection.

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions

2. Droplet precautions Because the patient is diagnosed with meningitis, which can be spread when the patient coughs or sneezes, droplet precautions are most appropriate

Patient-to-patient transmission of infection cannot occur if gloves are routinely used 1. True 2. False

2. False Although gloves are an additional tool to decrease the spread of infection from patient to patient, touching gloves with unclean hands as you put them on contaminates the gloves so that they are no longer clean

When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure (Select all that apply.) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

3, 4 Check a patient's respirations and whether there is a gag reflex present to determine risk for aspiration and to establish a baseline for the patient's condition

While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? 1. A patient who just returned to the nursing unit from a diagnostic test 2. A patient who prefers a bath in the evening when his wife visits and can help him 3. A patient who is experiencing frequent incontinent diarrheal stools and urine 4. A patient who has been awake all night because of pain 8/10

3. A patient who is experiencing frequent incontinent diarrheal stools and urine Urine and fecal material contain substances that can injure a patient's skin and increase the risk for pressure injury and skin damage. Prompt and frequent perineal hygiene is a priority in incontinent patients

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3. Explain the reasons for isolation procedures and provide meaningful stimulation. By providing a rationale for the isolation, the patient is able to better understand the safety risks and cooperate with care. Providing reading material or other distractions for the patient will also help with times when alone in the room.

A nurse is reading a research article discussing a new practice to decrease the incidence of catheter-associated urinary tract infections. One section of the article describes who was studied and how the data were collected to answer the research questions and hypotheses. What section of the research article is currently being read? 1. The literature review 2. The data analysis 3. The methods 4. The implications for practice

3. The methods The methods section of a study describes the study designs, subjects being studied, and how the researcher collets and organizes the data to answer the research question and hypotheses. The methods section also tells you where the study was conducted, how many subjects participated in the study, and what instruments were used to collect the data.

The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: 1. Obsessive-compulsive behavior 2. Personal preferences 3. The patient's cultural norm 4. Controlling behaviors

3. The patient's cultural norm Cultural beliefs often influence patients' hygiene practices. Middle Eastern practices encourage one hand to be kept clean at all times

9. Nurses in a community clinic are conducting an EBP project focused on improving the outcomes of children with asthma. The PICO question asked by the nurses is "In school-aged children, does the use of an electronic gaming education module versus educational book improve the usage of inhalers?" In the question, what is the "O"? 1. School-aged children 2. Educational book 3. Use of inhalers 4. Electronic gaming education

3. Use of inhalers The question is "In school-aged children, does the use of an electronic gaming education module versus educational book improve the usage of inhalers?" The "I" would be an electronic gaming education, the "C" would be educational book, and the "O" would be use of inhalers.

The nurse on a medical/surgical unit has been assigned to care for four clients. Which of the following client's needs may be assigned to the Unlicensed assistive personnel (UAP) or CNA? 1. Feeding a client who was just admitted with a stroke and has dysphagia. 2. Teaching a client how to assess his radial pulse 3. Performing a sterile dressing change on a post-operative client 4. Taking and recording vital signs on a client who is 3 days post-operative

4 is correct 1. Patient was JUST admitted. RN needs to see this patient because they are unstable and assessment needs to be done first. Dysphagia is concerning too because they are an aspiration risk 2. UAP cannot do teaching. Only RN. UAP can reinforce teaching but cannot do actual teaching. 3. Sterile technique needs to be done by RN 4. UAP can do this one

A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take. (Move the steps of the process into the box on the right, placing them in the selected order of performance. All steps will be used.) 1. Attach a syringe to the collection portion of the indwelling catheter 2. Transfer the urine to a sterile specimen container 3. Withdraw 3 to 30 mL of urine 4. Wipe the port with an alcohol swab or agency specified antiseptic 5. Transport the specimen to the laboratory

4, 1, 3, 2, 5

A nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse should perform the following steps (Use all the steps.) 1. Open the side flaps 2. Open the flap closest to body 3. Open the flap furthest from body 4. Position the tray so that the top flap is farthest away from the body

4, 3, 1, 2 The nurse should first position the package on table so that the top flap is farthest away from their body. The surface should be clean and flat and above waist level. The first package flap the nurse should open is the one that is furthest away from their body. This will prevent the nurse from reaching across the opened package and contaminating the sterile field. Next, the nurse should open the side flaps of the package. The nurse should keep their arm to the side of the package and allow the side flap to open onto the table. The nurse should then repeat this process with the other side flap. Finally, the nurse should open the flap closest to their body. The nurse should pull the flap toward their body, stepping back and away from the package as needed to avoid contaminating the sterile field.

A nurse is preparing to assist a client with a tub bath. Identify the sequence of steps then nurse should take. 1. Instruct the client on using safety bars when getting in and out of the tub 2. Instruct the client to remain in the tub for no longer than 20 minutes 3. Place a rubber mat on the tub floor. 4. Gather all the necessary supplies 5. Assist the client into the bathroom

4, 3, 5, 1, 2 ...I don't really know what to say about this one tbh, the rationale is just repeating the steps

A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female patient who has had removal of a breast lesion and is having her menstrual period 2. A 56-year-old patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line 3. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool

4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool The 70-year-old patient has reduced circulation, which increases risk for infection, and is likely unaware of skin problems because of dementia. The presence of stool will also irritate the skin. The 44-year-old female patient needs good perineal hygiene. The 56-year-old patient is at risk for drying and fragility of the skin. The 60-year-old patient has reduced sensation and mobility and thus is unaware of skin problems or pressure areas

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; if the integrity of the vessel is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

A nurse implements an EBP change that teaches patients the importance of taking their diabetes medications correctly and regularly on time using videos streamed on the Internet. The nurse measures the patients behavioral outcome from the practice change using which type of measurement? 1. Measuring the patient's weight 2. Chart auditing teaching sessions 3. Observing patents viewing the videos 4. Checking patients' blood sugars

4. Checking patients' blood sugars The desired behavioral outcome is the patient's blood sugars, which will show the patients' adherence to taking medications as prescribed. Measuring the patients' weight is a desirable physical outcome but not a measure of the effects of the teaching program. Charting auditing teaching sessions is a process measure to track teaching sessions. Observing the patients viewing the DVD is also a process measure.

Place the steps of the EBP process in the appropriate order 1. Critically appraise the evidence you gather 2. Ask the clinical question in PICOT format 3. Evaluate the outcomes of the practice decision or change 4. Search for the most relevant and best evidence 5. Cultivate a spirit of inquiry 6. Integrate the evidence 7. Communicate the outcomes of the EBP change

5, 2, 4, 1, 6, 3, 7 The process starts with a spirit of inquiry and the final step is sustaining the EBP change.

The use of hot water is not recommended in surgical asepsis for which of the following reasons (Select all that apply.) A. Hot water is hard on the skin because it has a drying effect that can result in cracking. B. Hot water makes it too uncomfortable to wash for the recommended amount of time C. Hot water minimizes the effectiveness of soap because it keeps soap from lathering effectively

A & B B is correct because it is especially true for hands that are washed frequently C is incorrect because cold water keeps soap from lathering properly and prevents the effective removal of soil and microorganisms

The patient is a 26-year-old male who arrived at the emergency department (ED) with reports of nausea and vomiting over the past 24 hours. Vital signs: Temperature = 36.8 C (98.2 F), blood pressure = 124/76 mm Hg, pulse = 88/min, RR = 16/min. The client reports abdominal fullness and burning pain in the upper abdomen that they rate as 7 out of 10 on a 0-10 pain scale. The client says that they have been "drinking a lot" since losing their job 4 months ago. The client is to be admitted to rule out gastritis. Which of the following components of standard precautions are required in this case? (Select all that apply.) A. Wash hands after client contact B. Wear clean disposable gloves when handling the client's emesis basin C. Place emesis-soiled linen on the floor, well away from the client and any visitors

A, B A. Handwashing is considered the most effective way to prevent the spread of micro-organisms and is a component of standard (tier-one) precautions. B. Standard precautions require the use of clean, non sterile gloves whenever there is actual or potential touching of body fluids, blood, secretions, excretions, or any object that might be contaminated with such materials C. Linen that has been soiled with body fluids must be handled, transported, and processed in a manner that prevents the contamination of other people or objects. This action would have contaminated the floor and added to the potential for transmitting infectious micro-organisms.

The nurse is completing an assessment on a new admission. Which findings are objective data? (Select all that apply) A. Wound appearance B. Pacing in the hallway C. Temperature result D. Patient states they feel nauseas

A, B, C

Which of the following nursing actions are appropriate when caring for a client whose cultural background is different from the nurse's? (Select all that apply) A. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures B. Respect the client's cultural beliefs. C. Ask the client if there are cultural or religious requirements that should be considered when planning care. D. Explain the nurse's beliefs to that the client will understand the differences.

A, B, C Nonverbal cues may have different meanings in different cultures. In one culture, eye contact is a sign of disrespect; in another, eye contact shows respect and attentiveness. The nurse should always respect the client's cultural beliefs and ask if he has cultural requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture; it is not the client's responsibility to understand the nurse's culture. The nurse should never impose her own beliefs on her clients. Culture influences a client's experience with pain. For example, in one culture pain may be only expressed whereas in another culture it may be quietly endured.

A charge nurse is reviewing organizational structure with a group of newly licensed nurses. Which of the following should she include in her discussion? (Select all that apply.) A. Lines of authority B. Organizational size C. Formal structures D. Informal structures E. Interprofessional relationships

A, B, C, D Choice E is incorrect because inter professional relationships are a component of collaborative relationships, not organized structure.

Which of the following should be included in an interprofessional interdisciplinary team? (Select all that apply.) A. Respiratory therapist B. Provider C. Nurses D. Family members E. Dietitian

A, B, C, E Interprofessional relationships are a group of various disciplines who utilize their own individual professional theories to promote health care.

Which of the following factors are risk factors for the formation of a stage 1 pressure injury? (Select all that apply.) A. Incontinence B. Previous history of pressure injuries healed by scar formation. C. Impaired cognitive ability D. Serum pre albumin level 19.6 mg/dL E. Darkly pigmented skin F. Braden score less than 16

A, B, C, F A. Both fecal and urinary incontinence increase the risk for pressure injury formation. Skin exposed continually to moisture leads to maceration, and fecal bacteria can cause infection, irritation, and breakdown B. Areas of skin that have previously had to heal by scar formation are typically not as strong and cannot tolerate pressure as well as areas of undamaged skin C. Clients who have cognitive impairment cannot always sense when they need to change positions and often cannot change position independently. This also applies to clients who are heavily sedated D. A pre albumin level of LESS than 19.5 mg/dL would indicate inadequate nutrition, which is a potential risk factor for pressure injury development. While serum protein levels are influenced by other factors, a level of 19.6 mg/dL in itself does not indicate pressure injury risk due to malnutrition E. Sometimes, darkly pigmented skin requires a different assessment technique for pressure injury formation. However, it is not a risk factor for skin breakdown. F. The Braden Scale determines pressure-injury risk via six sub scales: sensory perception, moisture, activity, mobility, friction, and shear. Scores range from 6 to 23; the lower the score, the greater the risk for pressure injury formation. For adults, a score less than 18 indicates increased risk.

A client with a history of vomiting states, "I feel really sick. I'm going to throw up," and then projectile vomits approximately 150 mL of green emesis that appears to be blood-tinged into an emesis basin and onto their shirt. Both the nurse and the ED technician quickly don PPE before continuing to provide care to the client. Which of the following PPE are appropriate to use when caring for this client? (Select all that apply.) A. Single-use, disposable gown B. Disposable mask C. Surgical gloves D. Goggles

A, B, D A. This is appropriate for standard precautions when the potential for contact with bloody fluids is significant B. This is appropriate for standard precautions when the potential for contact with bloody body fluids projected out into the environment is significant, as it is with projectile vomiting. This situation poses a risk for the transfer of micro-organisms through the mucus membranes of the mouth and nose. C. These are not appropriate since the concern is not the possibility of transmitting microorganisms to the client but rather being contaminated by microorganisms transferred from the client D. These are appropriate for standard precautions when the potential for contact with bloody body fluids projected out into the environment is significant, as it is with projectile vomiting. This situation poses a risk for the transfer of microorganisms through he mucous membranes of the eye.

Today, you are working on an orthopedic surgery unit. You make rounds on your assigned clients, introducing yourself and sharing with each client the plan of care for the day. You stop to see a client who had arthroplasty on her left knee yesterday. You ask the client how she is feeling and explain that her care plan calls for her to get out of bed to a chair today for the first time. The client responds as follows: "I guess I am doing as well as can be expected, but I really don't think I am doing well enough to get out of bed. I am sure it will be very painful." You communicate with the client and she agrees to her care plan. Which of the following nursing actions will help improve the client's tolerance of getting out of bed? (Select all that apply.) A. Administer the prescribed oral pain medication to the client about 20 minutes before they get out of bed B. Have the client dangle their legs at the side of the bed first for a few minutes before getting out of bed C. Assign the nursing assistant on the team to help the client get out of bed D. Explain the steps involved in getting out of bed to the client prior to the procedure E. Have the client use crutches to help them get out of bed

A, B, D A. oral medication typically has a time of onset of about 20 minutes, so the client will have the benefit of pain relief while moving -- the most difficult and painful aspect of getting up B. Dangling allows the client's circulation to equilibrate and helps prevent episodes of dizziness due to orthostatic hypotension and, therefore, injuries from falling C. If your assessment tells you that the client might need two people to help them get out of bed, you may ask the nursing assistant to provide that additional support. However, since this is the client's first time out of bed, you should be there to assist. D. Teaching and demonstrating the techniques to be used enhance the client's understanding, reduce anxiety, and encourage the client to cooperate with the procedure E. Getting from the bed to the chair requires that the client stand and bear weight on the nonoperative (right) leg and pivot into the chair. With you standing there to help them maintain stability, there is no need for crutches. They may be prescribed when the client begins to ambulate, however.

A nurse is reviewing the current protocol for documenting the medication record. Which guidelines are appropriate for legally documenting in the medication record? (Select all that apply.) A. All dates and times recorded B. Information that protects the hospital from lawsuits C. Short, concise, objective sentences D. Only factual evidence (objective and subjective)

A, C, D

The nurse is trying to meet the needs of culturally diverse clients. What are the most appropriate actions of the nurse? (Select all that apply.) A. Avoid stereotyping B. Explain to the patient why your course of care is correct C. Establish culturally appropriate goals and healing modalities for clients D. Bridge cultural gap by providing meaningful and supportive care

A, C, D

The provider assess the wound of your patient as prescribes a wound vacuum-assisted closure (VAC). You explain the procedure to the client and obtain the supplies. When you return to the client's room with the supplies, the client has another question for you. In answering the client, you explain the nursing action that help maintain an airtight seal for the wound VAC device or the negative pressure wound therapy (NPWT). Which of the following information should you include? (Select all that apply.) A. Clip the hair along the wound borders B. Cut the transparent film to extend 1 to 2 cm beyond the wound borders C. Use strips of transparent film to patch any leaks. D. Use adhesive remover to help remove the transparent dressing E. Avoid wrinkling the transparent film while applying it to the foam

A, C, D, E A. Any debris such as hair and moisture can interfere with the ability of the transparent dressing to form an airtight seal B. The transparent film must extend AT LEAST 3 to 5 cm beyond the wound borders for an effective seal. If the film is too small, the negative pressure generated by the wound VAC device may cause the edges of the film to peel back, thus creating air leaks. C. Once you apply the foam and transparent tape and turn the wound VAC device, you can identify small air leaks by listening with a stethoscope or feeling around the edges. You can patch small leaks using strips of transparent film along the edges to maintain the airtight seal D. There are two advantages to using adhesive remover to help remove the transparent dressing; it maintains the surrounding skin intact and decreases the client's pain during removal of the dressing E. When applying the transparent film, it is important to avoid wrinkling the film. Wrinkles in the film interfere with the ability of the transparent dressing to form an airtight seal

A client with a history of vomiting states, "I feel really sick. I'm going to throw up," and then projectile vomits approximately 150 mL of green emesis that appears to be blood-tinged into an emesis basin and onto their shirt. Considering the previous history, which of the following information is vital to determining how the staff should protect themselves? (Select all that apply.) A. The client is experiencing projective vomiting. B. The client is alert and able to use an emesis basin C. The client's vital signs do not support the presence of an infective process. D. The emesis appears to be blood-tinged

A, D A. Projectile vomit forcefully transports body fluid and any infectious microorganisms it may contain out into the environment, where it has the added potential for cross-contamination of other people and objects. B. The fact that the client is capable of rational through does not minimize the risk of transmission of infections microorganisms in their body fluids. C. Standard precautions are used in the care of all hospitalized clients regardless of their actual or potential infection status. D. The presence of blood in the vomitus adds another infectious component of the body fluid.

A nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field? (Select all that apply.) A. A cotton ball dampened with sterile normal saline is placed on the field B. A contaminated instrument touches the outer edge of the sterile field C. A sterile instrument is dropped onto the near side of the sterile field D. The nurse turns to address the client's question concerning the procedure E. The procedure is postponed for 30 min to accommodate the client F. A liquid is poured into a sterile container from a distance of 25 cm (10 in)

A, D, E, F A. Principles of surgical asepsis state that a sterile field becomes contaminated by capillary action when it comes into contact with moisture B. A 2.5 cm (1 in) border around a sterile field is considered contaminated C. The near side of the field is an appropriate location for introducing items onto the field without reaching over the field itself D. Principles of surgical asepsis state that a sterile field becomes contaminated when it is out of visual range E. Principles of surgical asepsis state that a sterile field becomes contaminated when it is exposed to air for prolonged periods F. The recommended pouring distance is between 10 to 16 cm (4 to 6 in) to decrease the risk of contaminating the sterile field by touching or reaching over it

A nurse is preparing an educational program for a group of staff nurses about Transmission Precautions. Which of the following instructions should the nurse include? A. "A nurse should use airborne precautions when caring for a client who has tuberculosis." B. "A nurse should use contact precautions when caring for a client following stem cell transplantation." C. "A nurse should use a protective environment when caring for a client who has streptococcal pharyngitis." D. "A nurse should use droplet precautions when caring for a client who has herpes simplex virus."

A. "A nurse should use airborne precautions when caring for a client who has tuberculosis." The nurse should use airborne precautions when caring for clients who have tuberculosis or other infections that can be transmitted by small droplets in the air, which remain present for a long period of time. Airborne precautions include a private room with negative air pressure that exchanges air 6 to 12 times per hour. People who enter the client's room must wear an N95 mask.

A nurse is educating new staff on Evidence Based Practice (EBP). What should they include? A. "EBP is based on client's values/expectations." B. "This is how we've always done it." C. "Some parts of EBP are more important than others." D. "EBP is based only on integration of best available evidence and clinical expertise."

A. "EBP is based on client's values/expectations." Evidence-based practice includes the integration of best available evidence, clinical expertise, and patient values and circumstances related to patient and client management, practice management, and health policy decision-making. All three elements are equally important.

A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI? A. A Salmonella infection that occurs after eating contaminated food from the cafeteria B. An infection that occurs during a therapeutic procedure C. A yeast infection that occurs while receiving broad spectrum antibiotics D. A urinary tract infection that occurs after a sterile catheter insertion

A. A Salmonella infection that occurs after eating contaminated food from the cafeteria An exogenous HAI is an infection acquired from pathogens found outside of the client's body, such as in contaminated food

A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital signs hereafter. What phase of the nursing process is being implemented by the nurse? A. Assessment B. Diagnosis C. Planning D. Implementation

A. Assessment Anything done to gather information is part of assessment

A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury? A. Barrier creams B. Antifungal ointment C. Chemical debridement agent D. Antibiotic agent

A. Barrier creams Barrier creams and ointments are used for clients that are prone to skin breakdown from pressure, shear, or incontinence. Therefore, the nurse should plan to apply barrier creams fro a client who has a stage 1 pressure injury.

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? A. Bear down B. Take deep breaths C. Sip water D. Tighten the perineum

A. Bear down The nurse should instruct the client to bear down as if to void because this relaxes the external sphincter and aids in the insertion procedure.

While observing your client's sacral area while repositioning her, you document the following: intact skin over the sacral area with a well-defined area of redness 2 cm in width and 3 cm in length. When palpated, the area feels boggy and is nonblanching. Which of the following is appropriate to add to your documentation of the client's skin in the sacral area? A. Client has a stage 1 pressure injury B. Client has a stage 2 pressure injury C. Client has partial thickness skin loss

A. Client has a stage 1 pressure injury A stage 1 pressure injury is an observable alteration seen in intact skin over an area of pressure as compared with the surrounding or adjacent skin. These changes may include alterations in skin color or temperature or tissue consistency or sensation. Your description of intact skin with a well-defined area of redness that is boggy and nonblanchable meets the criteria for a stage 1 pressure injury.

At this time, you must secure the Jackson-Pratt drainage device. To maintain your client's safety and to prevent dislodgment of the drain, you secure the Jackson-Pratt drainage system to which of the following? A. Client's gown B. Surgical dressing C. Bed frame

A. Client's gown The bulb portion of the Jackson-Pratt drain has a small hanger that you can use to secure it to the client's gown with a small safety pin. Securing the device on the gown in an accessible area near the surgical dressing helps prevent pulling on (and possible dislodgment of) the drain when the client moves in bed and ambulates

What is the primary purpose of the medical record (client chart)? A. Communication B. Advocacy C. Research D. Education

A. Communication The client's medical record is a valuable source of data for all members of the health-care team, so communication is the primary purpose of the client record. Other purposes include education and research, but not all client records serve these purposes. All client records serve as a communication record.

During assessment of a client's vital signs, the nurse notes a pulse rate of 120 beats per minute. Which nursing action is priority when interpreting and analyzing this client's pulse rate? A. Compare the client's pulse rate to the standard range. B. Notify the client's healthcare provider immediately. C. Document the pulse rate on the appropriate graphic form in the client's medical record. D. Ask another nurse to verity the pulse rate.

A. Compare the client's pulse rate to the standard range. It is important to know normal range of vital signs, but also normal range for a specific client. A pulse rate outside the normal range may be normal for a client. It is appropriate to first check the chart to determine the client's normal range. The question is asking about interpreting and analyzing the client's pulse rate.

To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? A. Drying provides the full antiseptic effect. B. Residual alcohol can easily stain clothing C. Excess gel could transfer to the client D. Slippery gel can make the nurse drop supplies

A. Drying provides the full antiseptic effect. A dry environment offers better protection against the proliferation of pathogens than a moist environment does. The bactericidal alcohol components of these gels further enhance their superior antiseptic effect

While assessing a postoperative client's abdomen, you note that their Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time? A. Empty the reservoir B. Notify the surgeon about the blood loss. C. Remove the drain

A. Empty the reservoir The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half-full, the suction pressure is diminished. It is appropriate to empty it and record the amount of drainage you discard.

Which of the following types of communication is informal, becomes distorted, and typically involves three or four individuals? A. Grapevine B. Horizontal C. Upward

A. Grapevine Grapevine communication is informal and generally involves three or four people at one time. The message often contains errors as it is communicated because the sender bears little accountability for the message.

Which action is appropriate when transferring a client to a gurney using a side board and three team members? A. Have one person hold the slide board steady while the other two pull the client onto the gurney. B. Position the slide board under the client and over the draw sheet. C. Adjust the height of the gurney so it is slightly higher than the height of the bed.

A. Have one person hold the slide board steady while the other two pull the client onto the gurney. Using this method, the slide board remains stationary as two team members pull the draw sheet and move the client. This slippery surface reduces friction and makes it easier for the staff to pull the client onto the gurney.

A nurse manager is discussing aggressive communication with a nurse who is having conflicts with peers due to her ineffective communication patterns. Which of the following should the nurse manager identify as a characteristic of aggressive communication? A. Infringes on the rights of others B. Says no without guilt C. Congruent facial expressions

A. Infringes on the rights of others Individuals who infringe on the rights of others are using aggressive communication patterns.

Which intervention by the hospital nurse can help prevent falls? A. Insisting the patient wear non-slip socks before ambulating B. Keeping four side rails up so the patient doesn't fall out of bed C. Keeping the wheelchair unlocked so the client can move around D. Placing a high-risk client away from the nurse's station where it's quiet

A. Insisting the patient wear non-slip socks before ambulating Falls are preventable, and nurses can play a role in assessing for and recognizing fall risks. Some of those include improper footwear and leaving beds/wheelchairs unlocked. Some nursing interventions for prevention include fall risk assessments, hourly rounding, bed alarms, equipment modifications (e.g., bedside commode, low beds), evaluating medications, and assisting with transfers

Which of the following is an advantage of using alcohol-based gel? A. It takes less time to use than washing with soap and water B. It removes gross contamination better than soap and water does C. Its protective nature reduces the need for frequent handwashing D. It provides adequate protection before surgical applications

A. It takes less time to use than washing with soap and water During an 8 hour shift, an estimated 1 hour of an intensive care unit nurse's time is saved by performing hand hygiene with an alcohol-based gel

When checking the dressing, you note that the patient's Jackson-Pratt drain is intact and draining and that there is a quarter-sized area of fresh red bloody drainage noticeable on the dressing. Which of the following is the appropriate action for you to take at this time? A. Mark the edges of the area of drainage with tape. B. Replace the dressing with a fresh sterile dressing C. Apply another dressing on top of the dressing

A. Mark the edges of the area of drainage with tape. Mark the drainage by circling the outer perimeter of the drainage and note the date and time you marked the dressing in the client's record. This way everyone caring for the client can monitor the dressing for increasing drainage or signs of hemorrghage

A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes? A. Moisture from excessive diaphoresis can cause skin breakdown B. Moisture on the sheets can cause discomfort to the client C. It provides an opportunity to frequently evaluate the skin on the client's back side D. It provides an opportunity to turn client from side to side to facilitate clearing potential fluid from the lungs

A. Moisture from excessive diaphoresis can cause skin breakdown The greatest risk to the client is skin breakdown, which can result from increased contact with the moist sheets. Increased contact with moist sheets can cause skin irritation and promote bacteria growth. Therefore, the linens should be changed frequently

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? A. Move their leg behind their body B. Move their leg forward and up C. Move their leg medially toward their other leg. D. Turn their foot and leg away from their other leg.

A. Move their leg behind their body This movement demonstrates hyperextension of the hip

You perform a tracheal suctioning procedure on your client while wearing all the proper PPE. You suction your client successfully. Airway clearance has the desired effect; they no longer display any signs of respiratory difficulty. You remove your mask, goggles, and then your gloves, being careful to remove the gloves by turning them inside out and enclosing them together to prevent contaminating your hands. You dispose of the gloves in the proper receptacle, wash your hands, make sure the client is safe, and leave the room. Have you removed and disposed of the PPE, including the sterile gloves, in the proper manner? A. No B. Yes

A. No You should have removed your gloves first (in the manner described) to prevent contamination of your mask and goggles and thus minimizing the possibility of contaminating yourself as well.

Lucy responds to Francine's aggressive request to cover for her during her break. Which of the following communication styles did Lucy use? A. Passive B. Shaming C. Dismissive

A. Passive Lucy used a passive communication style when responding to Francine. Passive or submissive communication is ineffective and inappropriate to use because the nurse avoids confrontation by permitting others to make decisions. Shaming and dismissive communication styles are ineffective forms of communication with negative consequences. The nurse did not respond when using these styles.

Using the nursing process to plan client care, which statement describes the goal? A. Patients wound will heal by 5 days B. Wound depth and circumference C. How patient is feeling about their care D. Patient's wound could heal in a day

A. Patients wound will heal by 5 days SMART, this is Time-limit framed

A nurse manager is conducting an in-service on ineffective communication patterns. Which of the following should she include when discussing components of passive communication? (Select all that apply.) A. Puts others' needs and wants ahead of self B. Avoids conflicts C. Difficult time saying "no" D. Uses "I" or "me" statements E. Intimidating

A. Puts others' needs and wants ahead of self B. Avoids conflicts C. Difficult time saying "no" Choice D is a component of assertive communication. Choice E is a component of aggressive communication.

A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take? A. Raise the room temperature B. Completely remove the linens C. Add soap to the water in the basin before beginning the bath D. Bathe one side of the body at a time

A. Raise the room temperature The nurse should raise the temperature of the room to help keep the client warm while various parts of the body are exposed and washed.

A nurse is contributing to the plan of care for a client who has a wound infection and requires contact precautions. Which of the following actions should the nurse include in the plan of care? A. Remove the isolation gown before leaving the client's room after providing direct care to the client. B. Place the client in a room with a negative-airflow pressure of at least six exchanges per hour. C. Limit the visitation of family members to 30 min per day. D. Instruct the client to remain in bed.

A. Remove the isolation gown before leaving the client's room after providing direct care. The nurse should remove the isolation gown before leaving the client's room to minimize the spread of infectious materials to other areas of the environment.

A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage? A. Serosanguineous B. Sanguienous C. Serous D. Purulent

A. Serosanguineous This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for the irrigation. Which of the following positions is appropriate for the wound irrigation? A. Side-lying B. High-Fowler's C. Supine

A. Side-lying With the client lying on his side, the irrigating solution can flow from one end of the horizontal wound to the other and into a basin placed perpendicular to (below) the wound.

Categorize/Stage the description of the wound based off this description: A reddened area is seen on the right lateral foot from pressure. The skin surface is intact. The area of redness does not blanch when compressed A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

A. Stage 1 pressure injury Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Categorize/Stage the description of the wound based off this description: This 80 year old male has a localized area of reddened skin over his right sacrum. No blistering of the skin or loss of epidermis is noted. The reddened area does not blanch with lightly applied pressure. No area of purple or maroon skin discoloration is noted. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

A. Stage 1 pressure injury Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Categorize/Stage the description of the wound based off this description: This 80-year old patient was on the operating room table for a 10-hour ENT operation. The following day he has a non-blanchable redness on his sacrococcygeal area. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

A. Stage 1 pressure injury Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? A. The gloves B. The gown C. The face shield D. The N95 respirator

A. The gloves Gloves are considered the most contaminated and should be removed first, followed by face/eye protection, gown, and mask/respirator

A nurse should identify that which of the following is the goal of surgical asepsis? A. To create and maintain a micro-organism free environment B. To kill all microorganisms on all instruments involved in a procedure C. To reduce the presence of pathogenic organisms in the environment D. To minimize exposure to the clients blood during an invasive procedure?

A. To create and maintain a micro-organism free environment Surgical asepsis consists of methods and practices directed toward keeping an area or object free of all microorganisms

While waiting for a sterile procedure to begin, how should a nurse position their hands and arms? A. With hands clasped together in front of the body above waist level B. At the sides of the body with hands pointing downward C. Folded across the chest with hands on the shoulders D. With hands clasped together in the back of the body at waist level

A. With hands clasped together in front of the body above waist level Holding their hands and arms this way keeps them from coming into contact with non sterile items

The patient is a 74 year old male who was seen in the emergency department (ED) where he reported nausea, severe abdominal cramping, and diarrhea for the past couple of days. He was admitted to the unit with a diagnosis of dehydration. Vital signs: Temperature = 38.4 C (101.2 F), bp = 114/76 mm Hg, pulse= 104/min, RR = 16/min The patient reports weakness and syncope, especially when standing. Skin turgor is fair, and oral mucous membranes appear pale and dry. The client experienced a cerebrovascular accident 2 years ago that has left them with left-sided paralysis. The client requires assistance to reposition in bed, transfer to a chair, and perform self-hygiene care. The client reports, "The last thing I ate before the diarrhea started was a salad with grilled chicken." Do you have concerns about infection control for this client? A. Yes B. No

A. Yes Vomiting and diarrhea are often the result of an infectious process, and the client has signs of infection and dehydration: elevated temperature, tachycardia, poor skin turgor, altered oral mucous membranes, and orthostatic hypotension.

The nurse has several patients to triage from a warehouse fire. Which patient will she see first? The patient with A. Blistering over his arms and scapula B. Hoarseness and coughing up dark sputum C. Bilateral burns to the feet complaining of pain 10/10 on a 0/10 scale D. Superficial burns on the thighs and abdomen

B is correct answer A. Blistering is a third degree burn (not called that anymore). Worried, but not first priority. All patients have burns B. Based off symptoms probably has smoke inhalation (hoarseness or stridor indicated airway issue). Stridor means airway is closing and turbulence is coming through. Airway and Breathing issue C. Pain never killed nobody — should address second after hack-up man D. Superficial burns nbd in grand scheme of things

Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items should a nurse don? (Select all that apply.) A. Gown B. Protective eyewear C. Hair cover D. Mask E. Shoe covers

B, C, D, E A. A gown used for a sterile procedure is considered sterile and is not donned until the surgical hand scrub has been completed and the hands have been dried B. Protective eyewear is worn to protect mucous membranes from splashes or sprays of blood and body fluids C. Hair is covered to prevent hair and dander from contaminating the sterile field D. A mask is worn to protect mucous membranes from splashes or sprays of blood and body fluids E. Shoe covers are worn to facilitate sanitation whenever splashes or spills are anticipated

Which of the following should a nurse include in the verbal SBAR report to a provider? (Select all that apply.) A. Introduction B. Background C. Assessment D. Situation E. Recommendation

B, C, D, E Introduction is included in ISBAR

A nurse manager is reviewing concepts related to organizational communication with a group of charge nurses. Which of the following statements made by a charge nurse requires additional teaching? A. "Managers should not provide overwhelming amounts of information to subordinates." B. "Information should be informally distributed." C. "Information should be unaffected by perceptions, values, and emotions."

B. "Information should be informally distributed." Information SHOULD be distributed formally.

A nurse is preparing to provide oral care for a client who is NPO. The client tells the nurse, "I don't need oral care because I haven't eaten anything." Which of the following responses should the nurse make? A. "Since you are not eating, we can wait and do it before bedtime." B. "Oral care is still important even though you are not eating." C. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out." D. "We will wait until your family gets here to help."

B. "Oral care is still important even though you are not eating." The nurse should identify that bacteria are still present in the oral cavity regardless of a client NPO status. Therefore, it is important to perform oral care to help reduce oral bacteria and keep the oral cavity moist

When teaching a client how to ambulate with a cane, which of the following should you say? A. "When properly fitted, the cane length is twice the distance between the greater trochanter and the floor." B. "Place the cane on your stronger side for support." C. "After moving the cane, bear weight on the stronger side and swing yourself forward."

B. "Place the cane on your stronger side for support." A client who use a cane should place the cane in the and on the stronger side so that the cane and the stronger leg provide support and balance when ambulating. A is incorrect because the cane length should be equal to the distance between the greater trochanter and the floor. C is incorrect because the client should move the cane forward, followed by moving the weaker leg so that body weight is divided between the cane and stronger leg

A nurse is implementing priority-based interventions for a group of clients. Which of the following clients should the nurse see first? A. A client who is saturating dressings with serous drainage every 2 hours B. A client who has a cast on a compound fracture and has SaO2 of 88% C. A client who has emphysema and is coughing up thick, yellow secretions D. A client who has a kidney stone and reports a pain of 8 on the numerical pain scale

B. A client who has a cast on a compound fracture and has SaO2 of 88% When using the airway, breathing, circulation approach to client care, the nurse should determine that the finding of SaO2 of 88% indicates hypoxia and requires priority-based interventions.

A nurse is admitting a client who reports increased thirst and fatigue. Which of the following actions should the nurse include in the assessment step of the nursing process? A. Take action to restore the client's health B. Ask the client when the condition started C. Reach a conclusion about the client's health status D. Set goals for the client's recovery

B. Ask the client when the condition started. Assessment is the first step of the nursing process, where the nurse gathers subjective and objective information about the client's condition.

A nurse is reviewing professional communication skills with a newly licensed nurse. Which of the following is a form of effective communication? A. Passive B. Assertive C. Passive-aggressive

B. Assertive Assertive communication is the most effective communication technique that is used to convey information in an informative and professional manner.

Which body alignment will reduce strain on the nurse's back? A. Keep knees and hips straight B. Bring center of gravity close to base C. Bend primarily at the waist D. Keep feet close together

B. Bring center of gravity close to base Nurses rely on balance to maintain proper body alignment and posture when providing patient care. This reduces strain on musculoskeletal structures and maintains adequate muscle tone. To achieve balance and alignment follow these steps: Widen your base of support by separating the feet to a comfortable distance, bring the center of gravity closer to your base of support to increase balance, bend your knees and flex the hips until squatting, and maintain proper back alignment to keep the trunk erect

A nurse is following the steps of the nursing process when caring for a group of clients. Which of the following actions by the nurse demonstrates the evaluation step of the nursing process? A. Draw a conclusion after noting a client has a 4+ pitting edema of the lower extremities and decreased urine output. B. Check and document a client's pain level 30 minutes after administering pain medication. C. Review the results of blood glucose drawn before a client ate breakfast. D. Administer an antibiotic to a client who has an infected wound.

B. Check and document a client's pain level 30 min after administering pain medication. The nurse is evaluating, which is the final step of the nursing process, to determine if the pain medication administered to the client is effective. Evaluation is the same as assessment; however, to determine the client's status and progress, evaluation is performed. Choice C is assessing or gathering data, which is the first step of the nursing process

You empty 60 mL of bright-red bloody drainage from the Jackson-Pratt's reservoir and record this on the client's output record. To reactivate the Jackson-Pratt drain, you should do which of the following? A. Attach the device to a wall suction unit and set to low suction. B. Collapse the drainage bulb fully and secure the seal. C. Fully expand the bulb and allow it to drain by gravity

B. Collapse the drainage bulb fully and secure the seal. Each time you empty a Jackson-Pratt drain, you must re-establish its suction. To do so, squeeze the bulb to let out as much air as possible. When it is fully collapsed, seal the drainage sprout to allow negative pressure within the device to continue to draw drainage from the wound.

The correct steps for obtaining a urine sample from a closed catheter system are which of the following? A. Disconnect the collection bag from the drainage tubing, cleanse the end of the tube with an aseptic solution, and allow urine to flow from the tube into a specimen bottle B. Collect 5 to 10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode C. Allow all the urine to collect in the bag and then empty the bag and collect urine from the collection port

B. Collect 5 to 10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode When the collection bag is new, it is still sterile and uncontaminated. For the first sample, the nurse can collect the sample from the collection bag. Any other samples will need to be obtained from the collection tube.

A nurse is caring for a client who has multiple sclerosis and a chronic non healing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? A. Tricyclic antidepressants B. Corticosteroids C. Beta blockers D. Anticholinergics

B. Corticosteroids Corticosteroids suppress the immune system and can therefore delay wound healing.

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take first? A. Pull the catheter out as quickly as possible B. Deflate the balloon completely before removal C. Cut the inflation port to deflate the balloon D. Tell the client to expect to feel a tugging sensation on removal

B. Deflate the balloon completely before removal Removing an indwelling urinary catheter while inflation solution remains in the balloon is likely too cause trauma to the urethral canal. Therefore, the nurse should deflate the balloon completely prior to removing an indwelling urinary catheter.

Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair? A. Bend at the waist and place arms under the client's arms and lift B. Face the client, bend knees and place hands on client's forearm and lift C. Spread his or her feet apart D. Tighten his or her pelvic muscles

B. Face the client, bend knees and place hands on client's forearm and lift Bending at the knees is the proper body mechanics for a solid center of gravity

During assessment of a 48 year old client, the nurse recognizes which of the following as one of the first physical signs of aging? A. Experiencing more frequent aches and pains B. Failing eyesight, especially close vision C. Increasing loss of muscle tone D. Accepting limitations while developing assets

B. Failing eyesight, especially close vision Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization evelopment act occurs in adulthood (ages 31 to 45)

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side position to a 180 degree angle C. Abducting the arm to a 90 degree angle from the side of the body D. Circumducting the shoulder in a 180 degree half circle

B. Flexing the shoulder by raising the arm from a side position to a 180 degree angle This demonstrates full range of motion of the shoulder. The client's fingers should be pointing directly upward.

A nurse in full personal protective equipment (PPE) is preparing to leave the room of a client who is in isolation. Which of the following items of PPE should the nurse remove first? A. Face shield B. Gloves C. Gown D. Mask

B. Gloves The gloves are the most contaminated item of PPE; therefore, the nurse should remove them first.

You position the client comfortably on his side and remove the old dressing using the appropriate technique. You note that the horizontal wound has an opening approximately 10 cm long and 5 cm across at the widest point. The wound base is red in color, moist, and has a rough (not smooth) surface. When charting the description of the wound, you should document the presence of which of the following? A. Exudate B. Granulation C. Slough

B. Granulation This describes granulation tissue, the presence of which indicates a healthy, healing wound.

When opening a sterile pack, which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack? A. Allowing movement of team members around the field B. Holding the sterile pack below waist or table level C. Keeping sterile items away from the edge of the table D. Opening the sterile pack just prior to the procedure

B. Holding the sterile pack below waist or table level The top of the table or sterile field is the ONLY area that is considered sterile. Anything below the waist or table level is considered nonsterile

Lucy used the SBAR format while calling Dr. Higgins. Which of the following is the purpose of SBAR? A. Provides a permanent client documentation record B. Improves communication among health care workers C. Tool used to evaluate a client's risk potential

B. Improves communication among health care workers SBAR, which stands for Situation, Background, Assessment, and Recommendation, is used to decrease communication errors and improve client safety by standardizing how communication is exchanged between health care workers. SBAR is not a permanent part of the client record, nor is it an evaluation tool.

Which of the following is a disadvantage of a hydrocolloid dressing for a stage 1 pressure injury? A. It must be changed several times a day. B. It does not allow visualization of the wound. C. It must be secured with the use of tape.

B. It does not allow visualization of the wound. Although hydrocolloid dressing can be used to treat stage 1 pressure injuries, they do not allow visualization of the wound and reduces the exchange of oxygen between the wound and atmosphere. Not visually observing the wound might be acceptable in settings where a provider does not see the client daily (such as home care), but it is not a good choice in an inpatient setting where daily monitoring of a new pressure injury is essential.

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene? A. Places a removable cover over the sling B. Leaves the bed in the lowest position throughout the procedure C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before transfer

B. Leaves the bed in the lowest position throughout the procedure The bed should be raised to a comfortable working position in order to prevent injury to nursing staff and to properly position the lift under the client's bed.

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A. Grasp the penis at its base B. Lift the penis perpendicular to the body C. Hold the penis parallel to the client's body D. Lift the penis to a 45 degree angel to the client's body

B. Lift the penis perpendicular to the body Lifting the penis to a position perpendicular to the body, or at a 90 degree angle, while applying light traction straightens the urethral canal to facilitate catheter insertion

You are caring for a client who has a new tracheotomy. The client's respiratory rate has increased to 22/min. He is restless, and his oxygen saturation has dropped from 96% to 92%. You determine that tracheal secretions are posing a threat to this client's oxygenation, so you prepare to suction the client. First, you assemble the necessary equipment and explain to the client his need for suctioning. You test the wall suction, wash your hands, cover the client's chest with a protective pad, and place him in a semi-Fowler's position. You are now ready to begin the process of suctioning your client. You apply a disposable gown and goggles. Suctioning the trachea requires the use of specific personal protection equipment (PPE). Have you selected all the appropriate PPE? A. Yes B. No

B. No Tracheal suctioning requires the use of a mask in addition to the goggles, although you could use a face shield in place of the mask and goggles. This procedure requires surgical asepsis and so it will require the use of sterile gloves as well

It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group and community A. Assessment B. Nursing process C. Diagnosis D. Implementation

B. Nursing process A, C, and D are all parts of the nursing process

A nurse is caring for a client who has Mycoplasma pneumonia. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? A. Wear a respirator B. Protect their eyes C. Put on clean gloves D. Wear shoe covers

B. Protect their eyes Droplet transmission involves contact of infectious, large-particle droplets with the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person. Droplets are generated by the client during coughing, sneezing, or talking and during procedures such as suctioning and bronchoscopy.

A nurse is preparing to exit the isolation room of a client who has disseminated varicella zoster virus which requires airborne precautions. Which of the following actions should the nurse take? A. Keep the client's door open to prevent a feeling of loneliness. B. Remove the first glove by grasping the lower portion of the glove with the opposite hand and pulling it off inside out. C. Remove the mask by holding the front of the mask with one hand while untying the top and bottom ties with the other hand. D. Fold the contaminated side outward when removing the gown.

B. Remove the first glove by grasping the lower portion of the glove with the opposite hand and pulling it off inside out. The nurse should use a gloved hand to grasp the first glove and pull it inside out to prevent infectious material from touching the nurse's skin.

Immobilized clients frequently have hypercalcemia, placing them at risk for which of the following conditions? A. Osteoporosis B. Renal calculi C. Pressure ulcers D. Thrombus formation

B. Renal calculi Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized clients are at risk for calculi because they frequently have hypercalcemia. Osteoporosis is caused by accelerated bone loss. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel

A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is: A. Fowler's position B. Side lying C. Supine D. Trendelenburg

B. Side lying This decreases the chance of the patient aspirating. The rest do not decrease the risk of aspiration

A nurse is documenting data about a deep necrotic wound on client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document? A. Keloid B. Slough C. Granulation D. Eschar

B. Slough Slough is a stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed. The nurse should document this finding for the client.

Categorize/Stage the description of the wound based off this description: Mr. H is a 73 year old male who is chair bound. A pressure injury is observed on the right ischial tuberosity. The wound is shallow with a red wound bed. No slough is observed. Tissue loss extends into the dermis. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

B. Stage 2 pressure injury Partial thickness loss with exposed dermis. The wound is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present.

Categorize/Stage the description of the wound based off this description: Pressure injury is located over the right buttox. Areas of tissue loss extend to dermis. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

B. Stage 2 pressure injury Partial thickness loss with exposed dermis. The wound is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present.

A nurse should identify that which of the following areas of the hands requires special attention during the prescrub wash? A. The area between each finger B. The area under each fingernail C. The palm of each hand D. The back of the hands

B. The area under each fingernail The area under the fingernails, called the subungual area, harbors micro-organisms. The nurse should clean it thoroughly during the first scrub of the day and whenever visibly soiled

When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand? A. Slipping the fingers beneath the cuff maintains the gloves sterility B. The inner edge of the cuff will lie against the skin and thus will not be sterile C. Gloving the dominant hand first allows for better control over the process D. The hand has been surgically scrubbed and is considered uncontaminated

B. The inner edge of the cuff will lie against the skin and thus will not be sterile Direct contact with the skin makes the inner edge of the cuff non sterile. Thus, touching the inner edge of the cuff to don the glove does not contaminate the glove.

A nurse is washing their hands with soap and water prior to reposition a client in bed during the handwasing procedure, it is important to take which of the following action? A. Make sure that the water is hot. B. Wash for at least 20 seconds. C. Use a liquid soap preparation. D. Remove rings and watches first.

B. Wash for at least 20 seconds. Handwashing with nonantimicrobial soap and water for at least 20 seconds reduces bacterial counts and can remove loosely adherent transient flora. The CDC recommends rubbing hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take? A. Cleanse their hands with an alcohol based gel. B. Wash their hands with soap and water. C. Brush off the soil against a cloth surface. D. Use a wet paper towel to remove the soil

B. Wash their hands with soap and water. The CDC recommends washing with soap and water whenever hands are visibly dirty. In this case, it is the combination of friction, running water, and the properties of soap that remove the soil from the hands.

The patient is a 26-year-old male who arrived at the emergency department (ED) with reports of nausea and vomiting over the past 24 hours. Vital signs: Temperature = 36.8 C (98.2 F), blood pressure = 124/76 mm Hg, pulse = 88/min, RR = 16/min. The client reports abdominal fullness and burning pain in the upper abdomen that they rate as 7 out of 10 on a 0-10 pain scale. The client says that they have been "drinking a lot" since losing their job 4 months ago. The client is to be admitted to rule out gastritis. Do you have any concerns about infection control for this client? A. No B. Yes

B. Yes While standard precautions are used in the care of all hospitalized clients, a history of vomiting is of particular concern because it makes direct contact with the client's body fluids especially likely.

A nurse notices a client's sacrum skin is red and non-blancheable. What is the proper course of action? (Select all that apply.) A. Nothing needs to be done, non-blancheable skin is a normal assessment finding B. Make sure the patient is properly hydrating C. Apply a transparent dressing D. Keep the area clean

C, D Red, non-blancheable skin is a Stage 1 pressure ulcer

Match the components of PICO using the question "Does the use of guided imagery compared with standard care decrease the post-operative pain in hospitalized adolescents? A. Adolescents receiving standard care B. Decreased postoperative pain C. Hospitalized adolescents D. Guided imagery

C, D, A, B This question includes the four PICO elements of patient/population (hospitalized adolescents who had surgery), intervention (guided imagery), comparison group (adolescents receiving standard care), and outcome (decreased postoperative pain)

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? A. "Lean on the crutches to support your body weight when standing." B. "Fully extend your arms when holding onto the hand grips." C. "Hold the crutches on your unaffected side when preparing to sit in a chair." D. "Hold the crutches 9 inches in front of and to the side of each foot."

C. "Hold the crutches on your unaffected side when preparing to sit in a chair." The crutches should be held on the unaffected side when preparing to sit in a chair.

A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I'll swab the clients mouth with lemon-glycerin swabs." B. "I'll swab the client's mouth with mouthwash." C. "I'll swab the client's mouth with chlorhexidine." D. "I'll swab the client's lips with a very small amount of mineral oil."

C. "I'll swab the client's mouth with chlorhexidine." The nurse should use chlorhexidine for daily oral care for unconscious client's because evidence-based practice indicates that it improves client outcomes by preventing microbial build-up.

A nurse manager is discussing formal and informal structures or processes with a newly licensed nurse. Which of the following statements made by the newly licensed nurse requires further teaching? A. "Formal structures are generally highly planned." B. "A written policy is a type of formal structure." C. "Informal structures are visible."

C. "Informal structures are visible." Informal structures or processes tend to be hidden and unplanned. Informal processes are not usually discussed or written.

The nurse is collecting information from Mr. Smith who has dementia; Mr. Smith's daughter Susan is at the bedside. Which of the following statements by the nurse recognizes the client's value as an individual? A. "Susan, can you tell me how long your father has been this way?" B. "Susan, I have to go and read your father's old charts before we talk." C. "Mr. Smith, tell me what you do to take care of yourself." D. "Mr. Smith, I know you can't answer my questions, but it's okay."

C. "Mr. Smith, tell me what you do to take care of yourself." The client is usually your best source of information. The nurse should initially direct questions to clients, even clients who are cognitively impaired. Clients should be included in data collection and planning care. By asking the client questions, the nurse can determine the degree of cognitive impairment and a client's ability to care for himself/herself. Begin with the client, and then move to family members if the client is unable to respond or the client asks family to respond. Remember that the client is always at the center of care.

A nurse manager is discussing organizational concepts in a charge nurse meeting. Which of the following statements by a charge nurse indicates a need for further teaching? A. "Organizations are formed due to a large number of workers requiring a supervisor to oversee work efforts." B. "Organizational size will impact interactions, communication, and decision-making within the organization structure." C. "Smaller organizations find communication more difficult due to size and complex processes."

C. "Smaller organizations find communication more difficult due to size and complex processes." Larger organizations, not smaller ones, find communication difficult due to size and complex processes.

Which is the fluid of choice to correct isotonic dehydration? A. Dextrose 5% in 0.45% sodium chloride B. 0.45% sodium chloride C. 0.9% sodium chloride D. 3% sodium chloride

C. 0.9% sodium chloride 0.9% sodium chloride (normal saline) is an isotonic fluid that increases the intravascular supply. This is especially important for this client's kidneys and will help resolve his electrolyte imbalance.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? A. A client who has a persistent urinary tract infection B. A client who has urge incontinence C. A client who is in the ICU for a gastrointestinal bleed D. A client who has incontinence due to cognitive decline

C. A client who is in the ICU for a gastrointestinal bleed The nurse should expect an order for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill

A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear? A. A sterile gown B. Goggles C. A face shield D. An N95 respirator

C. A face shield A face shield protects the face, mouth, nose, and eyes from any potential splashes of blood or other body fluids. Irrigating a wound has the potential for splashing irrigating fluid containing blood, body fluids, and tissue particles onto the nurse's face

You determine that a client performs the prescribed three-point gait appropriately when using his crutches when he does which of the following? A. Positions each upper crutch pad centered in the axilla B. Leans his torso forward slightly in the tripod position C. Advances the crutches first, followed by the unaffected leg

C. Advances the crutches first, followed by the unaffected leg When performing a three-point gait, the correct procedure is to advance the crutches while bringing the affected leg forward. The client then advances the unaffected leg.

A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? A. Transparent B. Hydrogel C. Alginate D. Dry gauze

C. Alginate Alginate dressings help establish hemostasis while providing a moist environment for healing and absorption of exudate. They do not adhere to the wound, so removal is unlikely to cause further bleeding.

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed B. Placing the client's left leg in front of the right leg just prior to the transfer C. Aligning the nurse's knees with the client's knees just before the transfer D. Grasping the client under the axillae to assist them to their feet

C. Aligning the nurse's knees with the client's knees just before the transfer This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position

Clients on bed rest and otherwise immobile are at risk for which of the following? A. Increased metabolic rate B. Increased diarrhea (peristalsis) C. Altered metabolic function D. Increased appetite

C. Altered metabolic function Immobility disrupts normal metabolic functioning: decreasing metabolic rate, altering the metabolism of carbohydrates, fats, and proteins (nutritional function); causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis

A nurse is planning morning hygiene care for a postoperative client. Which of the following actions should the nurse take? A. Inform the client when morning hygiene care is provided at the hospital B. Schedule the client's morning hygiene care at the same time as their roommate C. Ask the client in what order they typically perform their morning routine D. Plan to provide care before the next scheduled dose of pain medication

C. Ask the client in what order they typically perform their morning routine The nurse should ask the client to describe their morning routine so that they can tailor care to the individual client

You have a patient that is newly admitted to the unit after kidney surgery that has bloody urine output. You enter the room, and immediately the client reports severe abdominal pain. Which of the following nursing assessments should you perform? A. Obtain orthostatic blood pressures B. Palpate bilateral pedal pulses C. Auscultate and palpate the abdomen D. Measure the client's jugular venous pressure

C. Auscultate and palpate the abdomen The client reports severe abdominal pain and may be hemorrhaging. For this client, the hemorrhage is most likely in the abdominal cavity where the surgery took place, so auscultate the abdomen immediately for decreased bowel sounds and palpate it for increased firmness and discomfort. You might not find other objective signs of hemorrhage, such as tachycardia, hypotension, decreased urine output, agitation, and pale or diaphoretic skin until the client's hemoglobin is well below 10.0 gm/dL

Which of the following statements is true about communication? A. Cultures and lifestyle do not influence the communication process. B. Younger and older adults require the same communication techniques. C. Communication is a powerful therapeutic tool and an essential nursing skill that influences others and achieves positive health. D. When caring for clients, in order to effectively communicate, the nurse's message to the client is the most important one.

C. Communication is a powerful therapeutic tool and an essential nursing skill that influences others and achieves positive health. A. is incorrect. Culture and lifestyle do not influence the communication process. B. is incorrect. Older adults with sensory, motor, or cognitive impairments require the adaptation of communication techniques to compensate for their loss of function and special needs. D is incorrect. Effective interdisciplinary communication is essential to provide safe transitions and care

A nurse has a prescription for wrist restrains. The client says that they don't want them. What action should the nurse take? A. Continue with the order B. Contact the charge nurse C. Consider alternative measures D. Contact the provider

C. Consider alternative measures

What should the nurse do to maintain standard precautions? A. Rinse gloves that become visibly soiled during use B. Use an antimicrobial soap for routine handwashing C. Disinfect hands immediately after removing gloves D. Keep gloves on when touching environmental surfaces

C. Disinfect hands immediately after removing gloves It is an essential component of standard precautions to disinfect hands immediately after glove removal, which often occurs at the end of a client-care procedure, and hand hygiene is mandated between client contacts. Hand hygiene is required in case the integrity of each glove has been breached, power or other residue remains not he nurse's hands, or the nurse's hands have been contaminated during glove removal

A nurse is preparing a plan of care for a client who is experiencing pain after surgery. Which of the following components should the nurse identify as part of the planning step of the nursing process? A. Organize client information B. Compare client data with outcomes to draw a conclusion C. Formulate client goals for prioritized problem D. Supervise delegated client care to the assistive personnel

C. Formulate client goals for prioritized problem. Formulating client goals for prioritized problems is a component of planning, which is the third step in the nursing process.

Which behavior by a 40 year old client indicates adult cognitive development? A. Has perceptions based on reality B. Assumes responsibility for actions C. Generates new levels of awareness D. Has maximum ability to solve problems and learn new skills

C. Generates new levels of awareness Adults 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development - not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30.

Immobility is a major risk factor for pressure ulcers. When caring for the client who is immobilized, the nurse needs to understand which of the following? A. Breaks in skin integrity are easy to heal B. Preventing a pressure ulcer is more expensive than treating one C. Immobilized clients can develop skin breakdown within 3 hours D. Pressure ulcers are caused by a sudden influx of oxygen to the tissue

C. Immobilized clients can develop skin breakdown within 3 hours Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore, preventing nursing interventions are imperative. An older adult who is immobilized can develop skin breakdown within 3 hours. Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation.

Which of the following assessment findings in a client who has a wound VAC would alert to you to a potential wound infection? A. Increased redness of the base of the wound B. Increased pain after applying the wound VAC dressing C. Increased exudate in the drainage chamber

C. Increased exudate in the drainage chamber Drainage is expected with a wound VAC, but the drainage is typically minimal and serosanguineous. Manifestations associated with a wound infection include tenderness, inflammation, increased drainage, and malodorous drainage

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? A. Stretch the sheath portion of the condom catheter along the length of the penis B. Secure the sheath portion with adhesive tape C. Leave a space between the penis and sheath portion tip D. Reposition the foreskin after application

C. Leave a space between the penis and sheath portion tip The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine

Which of the following products can affect the permeability of latex gloves? A. Antimicrobial soap and water B. Alcohol-based antiseptic gel C. Petroleum-based hand lotion D. Water-based hand lotion

C. Petroleum-based hand lotion The use of petroleum-based hand lotions or creams can impair the integrity of latex gloves, weakening them and increasing their permeability.

To assess an adult's developmental stage, which of the following should the nurse consider? A. Height and weight B. Blood pressure C. Previous problem-solving strategies D. Pulse rate

C. Previous problem-solving strategies The nurse can use previous problem-solving strategies to assess an adult's developmental stage as it relates to intellectual functioning. The other choices are related to physiological attributes.

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive? A. Placing a transparent dressing over the pressure injury B. Applying hydrocolloids to the wound bed C. Pulsating lavage D. Using a topical enzyme solution in the wound bed

C. Pulsating lavage Pulsating lavage or irrigations provides mechanical debridement by dislodging exudate, debris, and necrotic tissue in the wound bed.

Now that you have assessed the wound and properly positioned the client, you perform an irrigation using a slow continuous flush of warmed 0.9% sodium chloride. You monitor the client for the duration of the irrigation for increased pain and observe the solution that returns in the basin for clarity and for any debris. You notice that the solution begins to have a slightly pink color and observe that the wound base is bleeding. Which of the following actions is appropriate for you to take at this time? A. Apply pressure to the bleeding area of the wound B. Change to a pulsatile flush until the returns are clear. C. Reduce the force you are using to flush the wound.

C. Reduce the force you are using to flush the wound. Using too much force while irrigating a wound can cause tissue trauma and lead to bleeding. Decreasing the irrigation pressure helps prevent further tissue injury and allows the bleeding to stop. Notify the client's provider that the wound bled during irrigation.

You reassess your patient and find their Jackson-Pratt drainage reservoir is half-full. You remove 60 mL of pale, blood-tinged, watery yellow drainage from the Jackson-Pratt's reservoir. When documenting the wound drainage in the client's medical record, you describe it as which of the following? A. Serous B. Purulent C. Serosanguineous

C. Serosanguineous Serosanguineous drainage is plasma mixed with blood. It is thinner and more watery than blood, often yellowish in color, and blood-tinged, rather than bright red and bloody (sanguineous drainage).

Categorize/Stage the description of the wound based off this description: Area of tissue loss extends into subcutaneous tissue. Wound is 5 cm in length, 3 cm in width and 0.6 cm in depth. Wound bed contains granulation tissue. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

C. Stage 3 pressure injury During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. At stage 4, the pressure injury is very deep, reaching into muscle and bone and causing extensive damage.

Categorize/Stage the description of the wound based off this description: Area of tissue loss is noted over the coccyx. Subcutaneous tissue is visible in the wound bed. No muscle, tendon or bone is exposed. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

C. Stage 3 pressure injury During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. At stage 4, the pressure injury is very deep, reaching into muscle and bone and causing extensive damage.

Which of the following wound dressings is the best choice for a patient with a stage 1 pressure injury? A. Hydrogel B. Wet-to-dry C. Transparent

C. Transparent Because the skin is intact with a stage 1 pressure injury, a dressing is not always required. However, a transparent dressing is an appropriate choice because it protects the skin from shearing forces and allows easy visualization of the wound.

A nurse is evaluating an assistive personnel's (AP) understanding of isolation precautions. Which of the following actions by the AP indicates an understanding of isolation precautions? A. Covering her uniform with a client hospital gown when emptying the bed pan for a client who has Clostridium difficile infection B. Wearing clean gloves when providing a back massage for a client who is postoperative following an appendectomy C. Using a separate urinary measuring container to empty a client's urinary catheter drainage bag D. Holding her hands higher than her elbows when performing hand hygiene at the beginning of the shift

C. Using a separate urinary measuring container to empty a client's urinary catheter drainage bag. To prevent the spread of microorganisms from one client's room to another, the nurse should use a separate urinary measuring container for each client.

Your client is a 57-year-old male with aspiration pneumonia. He has been living in a metropolitan subsidized housing facility with no significant support system. This client has a history of type 2 diabetes mellitus, coronary artery disease, and a cerebrovascular accident. He smokes about one pack of cigarettes per day and also has a history of significant alcohol use. While assisting the client with a bath, you notice that he has mild edema on the lower extremities. Which of the following will encourage venous return? A. Massaging the leg tissue deeply while washing the skin B. Applying firm pressure to the calves with a kneading motion C. Washing the legs using a long, gentle, distal-to-proximal strokes

C. Washing the legs using a long, gentle, distal-to-proximal strokes A. Deep pressure can cause tissue injury while also contributing to skin breakdown B. Calf pressure can cause any thrombi present to dislodge and become emboli C. Using this technique while the client is supine encourages blood return to the heart while applying minimal pressure

A nurse is providing teaching to an assistive personnel (AP) about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give? A. "ask another team member to assist with donning gloves" B. "Choose a pair of gloves at least one size smaller than usual." C. "Grasp only the underside of the cuff with your ungloved hand." D. "Grasp only the inside of the glove with your ungloved hand."

D. "Grasp only the inside of the glove with your ungloved hand." The inside of the glove is considered non sterile and will be placed against the skin of the hand, which is also considered nonsterile. When donning gloves using the open-gloving method, the nurse should use a skin-to-skin and glove-to-glove technique

The ED nurse is caring for the following clients. Which client will the nurse see first? The client with A. A right wrist fracture that has a splint applied B. A right ankle fracture rating her pain 5/10 C. Difficulty swallowing and nausea when eating D. A respiratory rate of 28 and a fever of 101 F

D. A respiratory rate of 28 and a fever of 101 F A. Already had an intervention. Patient is not in pain and injury is not swelling. Based on what we know they're fine B. No one ever died from the pain. Not top of the list C. Kind of worried about it. What else is wrong? Needs assessment D. Breathing issue AND fever. Fever means infection issue.

When developing a care plan for an older adult, the nurse should consider what challenges generally faced by clients in this age group? A. Selecting vocation, becoming financially independent, and managing a home B. Developing leisure activities, preparing for retirement, and resolving empty-nest crisis C. Managing a home, developing leisure activities, and preparing for retirement D. Adjusting to retirement, deaths of family members, and decreased physical strength

D. Adjusting to retirement, deaths of family members, and decreased physical strength Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming a financially independent, and managing a home. Challenges faced in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty-nest crisis.

A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last? A. Urethral meatus B. Labia minora C. Perineum D. Anus

D. Anus The nurse should identify that the basic aseptic principle applicable to perineal care is to cleanse from he area that is least contaminated to the area that is the most contaminated. The anal area is typically contaminated with coliform bacteria and should therefore be cleansed last

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care? A. Leave non bleeding wounds open to the air B. Administer a corticosteroid medication C. Initiate mechanical debridement D. Apply oxygen at 2L/min via nasal cannula

D. Apply oxygen at 2L/min via nasal cannula Following an acute injury, the body responds best by increasing oxygen to improve perfusion, which is essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in clients who have a lack of oxygen or poor perfusion.

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A. Irrigate the catheter B. Assess for peripheral edema C. Palpate for bladder distention D. Check the catheter for kinks

D. Check the catheter for kinks The nurse should identify that output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client's urine flow is not obstructed

A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection? A. Massage reddened areas of the client's skin B. Wash eyes from the outer cantos to the inner canthus C. Wash the client from the shoulder down to the fingertips with smooth, short strokes D. Clean the least-soiled areas prior to cleaning the most-soiled areas

D. Clean the least-soiled areas prior to cleaning the most-soiled areas The nurse should clean the least-soiled areas prior to cleaning the most soiled areas because this helps prevent moving more contaminants into the cleaner areas, thereby reducing the risk for infection

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A. Wrap both arms around the client's arms and shoulders. B. Move both feet together when the client begins to fall. C. Protect the client's extremities while lowering them to the floor. D. Extend one leg and allow the client to slide down the leg to the floor

D. Extend one leg and allow the client to slide down the leg to the floor This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client

A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? A. Wet-to-dry B. Abdominal pads (ABD) C. Dry gauze D. Hydrogel

D. Hydrogel The nurse should select hydrogel for this client because hydrogel does not adhere to the wound bed and maintains moisture, which results in decreased pain.

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? A. Hepatitis B B. Measles C. Meningitis D. Infectious diarrhea

D. Infectious diarrhea Contact precautions are essential for preventing the spread of certain enteric infections. These precautions mean no direct touching of the client, the environment, the equipment, or the supplies used. The client should also be placed in a private room.

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the use of critical thinking skills? A. Administer an influenza vaccine after asking a client about allergies. B. Check a client's armband before dispensing daily thyroid medication to a client who has hyperthyroidism C. Give a client who has type 1 diabetes mellitus her morning dose of insulin after checking her blood glucose level. D. Intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation.

D. Intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation. The nurse is using critical thinking when analyzing a client's critical issues and then planning to intervene with an appropriate action. The rest are clinical judgement.

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? A. Place the stockings on the client after the client ambulates to the restroom B. Ensure the client's toes are visible after placing the stockings on the client. C. After applying the stockings, place two fingers between the client's leg and stocking to check the fit D. Measure the client's calf circumference and leg length from heel to knee

D. Measure the client's calf circumference and leg length from heel to knee To ensure proper fit, the nurse should measure the widest part of the client's calf as well as the length of the client's leg from the heel to the knee. Antiembolic stockings that are too large will. not apply the pressure needed to prevent deep-vein thrombosis. Antiembolic stockings that are too small could impair circulation in the client's legs.

Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? A. Providing a back massage B. Feeding a client C. Providing air care D. Providing oral hygiene

D. Providing oral hygiene Chance you're going to come into contact with their saliva. If it's wet -- put on gloves.

A nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following? A. Unstageable B. A suspected deep tissue injury C. Stage 4 D. Stage 3

D. Stage 3 The nurse should identify that this client has a stage 3 pressure injury indicated by full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. Stage 3 pressures can have slough, but it is not necessary.

Categorize/Stage the description of the wound based off this description: Pressure injury is approximately 4.5 by 5 cm in size. Wound depth is 3.5 cm. Muscle tissue and bone are visible in the wound bed. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

D. Stage 4 pressure injury Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location.

A nurse is observing an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure? A. The AP records the task when it is completed B. The AP wears sterile gloves while making the bed C. The AP changes the client's pillowcase D. The AP reuses the client's clean blankets and spread.

D. The AP reuses the client's clean blankets and spread. The mattress pad, sheet, blanket, and bedspread can be reused for the same client if they are not wet or soiled

This evening, you are working on an orthopedic surgical unit. Each of your four clients needs assistance with ambulation and transferring, and they are all resting comfortably in bed. Which of these four clients should you see first and why? A. The client who had a fractured femur repaired and must demonstrate proper crutch walking B. The client who had a hip arthroplasty and needs one person to help him get out of bed to the chair C. The client who had a lumbar repair and is on strict bed rest D. The client who has quadriplegia and had sacral redness when last turned 2 hours ago

D. The client who has quadriplegia and had sacral redness when last turned 2 hours ago Clients who have quadriplegia are at an increased risk for skin breakdown due to impaired mobility, infrequent repositioning, impaired sensation, and skin exposure to irritants such as rough linen, urine, and stool. Any of these conditions may result in tissue damage from impaired circulation or skin breakdown. It was reported to you that the client had sacral redness when last turned 2 hours ago, so not only is the client due to be turned again now, but your immediate nursing assessment of the sacral area is your highest priority at this time.

A nurse is preparing to flush and change the dressing on a client's central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis? A. To promote the catheter's patency B. To assess the skin's integrity around the catheter site C. To provide a clean, dry environment for the catheter D. To control the introduction of micro-organisms at the catheter site

D. To control the introduction of micro-organisms at the catheter site The primary goal of surgical asepsis is to implement methods and practices directed toward keeping an area or object free of all micro-organisms

What is the primary purpose of the outcome identification and planning step of the nursing process? A. To collect and analyze data to establish a database. B. To interpret and analyze data to identify health problems. C. To write appropriate patient-centered nursing diagnoses D. To design a plan of care for and with the patient.

D. To design a plan of care for and with the patient. A is the assessment phase; B and C refer to the nursing diagnoses phase. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions.

A nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows? A. To prevent them from coming into contact with a contaminated object B. To facilitate the application of sufficient friction to their hands C. To provide good visualization of the hands as they are scrubbed D. To encourage water and soap to flow away from the clean hands

D. To encourage water and soap to flow away from the clean hands The water and soap runs by gravity from the fingertips to the elbows, thus directing the contaminated substances away from the clean hands and preventing recontamination

Categorize/Stage the description of the wound based off this description: The sacral area is covered with eschar and slough. The wound base is not visible. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

E. Unstageable Full thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Categorize/Stage the description of the wound based off this description: This pressure injury is located over the coccyx. The wound bed is covered by slough/eschar and cannot be visualized. A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury E. Unstageable F. Deep Tissue Pressure Injury (DTPI) G. Mucosal Membrane Pressure Injury

E. Unstageable Full thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

You enter a patient's room that has been diagnosed with a salmonella infection in full PPE. You adjust the client's IV fluid infusion, provide them with a bedpan, reposition them after providing perineal care, empty and clean the bedpan, document the care you provide in the notebook, and move 10 feet away to the sink. You remove and dispose of all PPE. After appropriate handwashing, you pick up both the notebook and the pen, place them onto the designated counter, and then leave the room. Within 3 days, five clients and 14 staff members have infectious diarrhea. Considering the previous information, where did you fail to maintain appropriate technique to prevent contact transmission of the salmonella bacteria in this client's stool?

You should have re-washed your hands after touching the contaminated notebook and pen. The preferred procedure would have been to document care only after removing your PPE and performing effective handwashing to avoid contaminating the notebook and the pen. Contact transmission involves contact between a contaminated object and a susceptible host.