Nursing Practicum Test #1

5 levels for patient self care ability

0-complety independent 1-requires use of equipment/device 2-semi dependent needs some help 3-moderately dependent, nurse assists with all equipment 4-totally dependent

3 purposes of TED hose

1) facilitate venous return 2) prevent DVT 3) reduce peripheral edema

10,000 mcgs=____mgs

10

1 tablespoon = ____mL and ____ teaspoons

15, 3

60 mLs= ___ oz

2

1 kg = ___ lb

2.2

0.3 g = ___ mg

3,000

3 mgs= ____mcgs

3,000

5L= ____ mL

5,000

When caring for a patient in contact precaution, it is appropriate for the nurse to reuse which personal protective equipment ? A. clean gloves B. gown C. surgical mask D. goggles

D. goggles

A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this client's hygienic practice? A. personal preference B. culture C. health & energy D. religion

C. health & energy

In the formula H : V :: D : V What does the H stand for? A. household units B. needed to be ordered C. on hand D. per hour

C. on hand

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and A. at least 2 inches lower B. at the same height C. slightly higher D. slightly lower

C. slightly higher

During the morning bath of a client, the nurse identifies areas of erythema below the client's breasts. What should the nurse do to enhance comfort and healing for the client? A. remove hair in the area B. wash the area without soap C. wash the skin carefully D. apply alcohol free lotion

C. wash the skin carefully

Dietary service comes to the unit to deliver dinner to your patient. You see in your patient's chart that he/she is on a NPO diet, which means .... A. none of the above B. liquid only diet C. low sodium diet D. nothing by mouth

D. nothing by mouth

Unlicensed assistive personnel are caring for a client's ears. What information should be reported to the nurse? A. presence of a hearing aid B. loud talking C. excessive earwax D. presence of any drainage

D. presence of any drainage

The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? A. using long strokes B. assist the client to a prone position C. pull the skin a person D. rinse the razor after each stroke

D. rinse the razor after each stroke

The nurse is shampooing a client's hair. Which assessment finding should the nurse consider as expected? A. smooth, taut, shiny B. tender, warm scalp C. dry, dark, thin D. smooth texture & not oily or dry

D. smooth texture & not oily or dry

When planning care, the nurse should identify which client as needing logrolling for position changes? A. A client with documented pneumonia B. The client who has had abdominal surgery C. A client who has a severe headache from hypertensive crisis D. The client who fell from a house sustaining a fractured tibia

D. The client who fell from a house sustaining a fractured tibia

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? A. Hold the hands upward under the faucet B. Allow the water to splatter forcibly when it is turned on C. Clean the faucet after use D. Use approximately a teaspoon of soap

D. Use approximately a teaspoon of soap

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? A. Assess vital signs only once daily B. Raise the temperature in the client's room C. Wear a mask for all client care D. Wash hands

D. Wash hands

The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? A. place a bath blanket over the client B. slide the mattress to the head of the bed C. raise the side rail D. allow for a toe pleat

D. allow for a toe pleat

When a patient has PRN by a medication order you know the patient should receive the medication A. every 12 hours B. none of the above C. daily D. as needed

D. as needed

A client's hearing aid needs to be removed. What action should the nurse perform? A. leave the aid in place when bathing B. instruct the client to remove the aid in the sunroom C. send the aid home with the family D. assist the client with removal when necessary

D. assist the client with removal when necessary

There are several general guidelines for transfer techniques; select all that apply: A. Remove obstacles from the area used for the transfer. B. Always support or hold equipment rather than the patient to ensure safety and dignity. C. Obtain essential equipment before staring (e.g. transfer belt, wheelchair), and check its function. D. Explain the transfer to the nursing personnel who are helping; specify who will give directions (one person needs to be in charge).

A. Remove obstacles from the area used for the transfer. C. Obtain essential equipment before staring (e.g. transfer belt, wheelchair), and check its function. D. Explain the transfer to the nursing personnel who are helping; specify who will give directions (one person needs to be in charge).

What are the three steps a nurse should take to manage postural (orthostatic) hypotension when attempting to get a patient out of bed for ambulation? (select all that apply) A. Sit patient up in bed for 1 minute B. Have the patient use a walker for support for 10 minutes after getting out of bed. C. Have the patient sit on the side of the bed with legs dangling for 1 minute. D. Have patient stand with care, holding onto the edge of the bed or an immovable object for 1 minute.

A. Sit patient up in bed for 1 minute C. Have the patient sit on the side of the bed with legs dangling for 1 minute. D. Have patient stand with care, holding onto the edge of the bed or an immovable object for 1 minute.

Name the government agency that regulates guidelines for infection control. A. Centers for Disease Control B. National Institute of Health C. The State Health Department D. World Health Organization

A. Centers for Disease Control

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Select all that apply. A. Client has an indwelling urinary catheter B. Client is receiving intravenous fluids C. Client is ambulating twice a day with assistance D. Client is receiving pain medication E. Client is recovering from surgery

A. Client has an indwelling urinary catheter B. Client is receiving intravenous fluids E. Client is recovering from surgery

There are several principles of surgical asepsis that the nurse needs to know. Select all that apply. A. Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis. B. Sterile objects will become unsterile by prolonged exposure to airborne microorganisms. C. Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action. D. Sterile objects become unsterile when touched by unsterile objects. E. Sterile objects that are out of sight or below the waist or table level are considered unsterile. F. The skin can be sterilized. G. All objects used in a sterile field must be sterile. H. The edges of the sterile field are considered sterile

A. Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis. B. Sterile objects will become unsterile by prolonged exposure to airborne microorganisms. C. Moisture that passes through a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action. D. Sterile objects become unsterile when touched by unsterile objects. E. Sterile objects that are out of sight or below the waist or table level are considered unsterile. G. All objects used in a sterile field must be sterile.

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? A. Decreased in blood pressure when moving from supine to standing B. Decrease in heart rate when moving from supine to sitting C. complaints of dizziness when first sitting up D. Pale color in the legs when lying

A. Decreased in blood pressure when moving from supine to standing

While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do? A. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. B. Begin HIV high-risk exposure prophylaxis within 24 hours. C. Wash the areas with soap and water. D. Have blood drawn for hepatitis B antibodies

A. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? A. Hold the box as close to the body as possible B. Flex the knees to lower the center of gravity C. Face the box pick it up & rotate the upper body toward the table D. Place the feet together to provide a strong base of support

A. Hold the box as close to the body as possible

List factors that influence individual hygiene practices. (select all that apply) A. Personal preferences B. Health and Energy C. Culture D. Environment E. Developmental Level

A. Personal preferences B. Health and Energy C. Culture D. Environment E. Developmental Level

What are the three steps a nurse should take to manage postural (orthostatic) hypotension when attempting to get a patient out of bed for ambulation? (select all that apply) A. Sit patient up in bed for 1 minute B. Have patient stand with care, holding onto the edge of the bed or an immovable object for 1 minute. C. Have the patient sit on the side of the bed with legs dangling for 1 minute. D. Have the patient use a walker for support for 10 minutes after getting out of bed.

A. Sit patient up in bed for 1 minute B. Have patient stand with care, holding onto the edge of the bed or an immovable object for 1 minute. C. Have the patient sit on the side of the bed with legs dangling for 1 minute.

The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? Select all that apply. A. be flexible B. move slowly C. help the client feel in control D. be prepared E. avoid stopping once the bath is started

A. be flexible B. move slowly C. help the client feel in control D. be prepared

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem? A. keep linens dry & wrinkle free B. restricted fluid intake C. turn client every 3 hours D. encourage the client to eat at least 40% of meals

A. keep linens dry & wrinkle free

A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? Select all that apply. A. partial bath B. tub bath C. therapeutic bath D. shower E. self help bed bath

A. partial bath E. self help bed bath

The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? Select all that apply. A. physical conditions B. psychosocial needs C. learning needs D. financial status E. skin status

A. physical conditions B. psychosocial needs C. learning needs E. skin status

The nurse is preparing to provide a client with mouth care. What should the nurse do to ensure safe handling of the client's dentures? A. place a washcloth in the bowl of the sink B. clean biting surfaces C. replace the upper dentures first D. rinse dentures thoroughly with hot water

A. place a washcloth in the bowl of the sink

Select principle behind the reason for the patient wearing compression stockings (TED) hose the (select all that apply) A. provide continuous pressure to the lower extremities to keep blood from pooling B. Keep the blood pooling in lower extremities C. Provide relief from walking, moving too much after surgery D. keep from blood clots from developing in the deep veins of the lower extremities.

A. provide continuous pressure to the lower extremities to keep blood from pooling D. keep from blood clots from developing in the deep veins of the lower extremities.

The abbreviation for every 2 hours is A. q2h B. TID C. none of the above D. BID

A. q2h

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? A. the client with supervision will brush her teeth B. the client will eliminate safety hazards in her environment C. the nurse will stress the importance of adequate fluid intake D. the client will be able to name the staff that works on the day shift

A. the client with supervision will brush her teeth

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? A. Move the wash basin farther toward the foot of the bed so the client must reach for it B. Have the client brush the hair & teeth C. Give the client a washcloth to wash the face D. Move each of the client's hand & arm joints through passive range of motion

B. Have the client brush the hair & teeth

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? A. Add strength assessment data B. Include what mobility is impaired C. Use Level1, 2, 3, or 4 to describe immobility D. Describe what happens when the client attempts mobility

B. Include what mobility is impaired

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? A. Place a transfer belt on the client B. Lock the brakes on the bed C. Place the wheelchair parallel to the bed D. Place the bed in its lowest position

B. Lock the brakes on the bed

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? A. Deeply palpate the area for rebound tenderness B. Measure the calf & compare to the opposite calf C. Medicate the client for pain & reassess in 30 minutes D. Percuss over the area for change in tone

B. Measure the calf & compare to the opposite calf

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Select all that apply. A. Hold the cane on the weaker side of the body B. Move the cane forward while the body weight is between both legs C. Move the stronger leg forward while the weight is between the cane & the weaker leg D. The length of the cane should permit the elbow to fully extend E. Move the weaker leg forward while the weight is between the cane & the stronger leg

B. Move the cane forward while the body weight is between both legs C. Move the stronger leg forward while the weight is between the cane & the weaker leg

The nurse is providing range-of-motion exercising to the client's elbow when the client complains of pain. What action should the nurse take? A. Discontinue the treatment & document the results in the medical record B. Reduce the movement of the joint just until the point of slight resistance C. Continue to exercise the joint as before to loosen the stiffness D. Stop immediately & report the pain to the client's physician

B. Reduce the movement of the joint just until the point of slight resistance

The nurse is preparing to provide morning care to a client. What should the nurse explain to the patient as the reason for a daily bath? A. Assess skin integrity B. Stimulate circulation C. Moisturize the skin D. Develop a nurse-client relationship

B. Stimulate circulation

A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linen? Select all that apply. A. urine output B. blood pressure C. mobility status D. pulse E. respirations

B. blood pressure C. mobility status D. pulse E. respirations

In the formula H/V = D/X The D stands for? A. drip factor B. desired dose C. drops per minute D. daily intake

B. desired dose

The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure? A. the client's comments about foot care B. nothing unless a problem is noted C. the condition of skin & nails D. the amount of time taken on foot care

B. nothing unless a problem is noted

An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the client's bathing needs? A. tell the client that shower shoes can be worn to prevent falls B. obtain a shower chair & assist the client in the shower C. hold the client during the shower D. document that the client 'refused" a morning bath in the medical record

B. obtain a shower chair & assist the client in the shower

The nurse is making a client's bed. What safety measure should the nurse implement at this time?A. prepare the client B. place the soiled sheet in a laundry bag C. miter corners at the head of the bed D. begin at the head & move toward the foot, loosening bottom linens

B. place the soiled sheet in a laundry bag

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? A. A licensed practical (vocational) nurse B. It makes no difference C. A registered nurse D. The UAP

C. A registered nurse

The CDC standard precaution recommendations apply to which of the following? A. All body fluids including sweat B. Only blood and body fluids with visible blood C. All patients receiving care in hospitals D. Only patients with diagnosed infections

C. All patients receiving care in hospitals

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Select all that apply. A. Slide the client toward the head of the bed B. Stand at the head of the bed to pull the client up C. Encourage the client to assist as possible D. Always use 2 personnel to move the client E. Place a turn sheet on the bed

C. Encourage the client to assist as possible D. Always use 2 personnel to move the client E. Place a turn sheet on the bed

The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural (orthostatic) hypotension? Select all that apply A. Use of a rocking chair B. Moving in bed C. Heavy meals D. Bending down to the floor E. Hot baths

C. Heavy meals D. Bending down to the floor E. Hot baths

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? A. Provide the client with assisted range-of-motion exercising twice daily B. Increase the amount of calcium in the client's diet C. Institute an exercise plan that includes weight-bearing activities D. Protect the client's bones with strict bed rest

C. Institute an exercise plan that includes weight-bearing activities

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? A. All nursing personnel must attend annual body mechanics education B. Nurses must wear back belts when lifting clients C. No solo lifting of clients is permitted in the facility D. In order to prevent injury nurses must strive to become physically fit

C. No solo lifting of clients is permitted in the facility

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? A. Raise the opposite side rail B. Move the client to the side of the bed C. Perform hand hygiene D. Place the client's arms over the chest

C. Perform hand hygiene

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? A. Exercises to strengthen flexor muscles B. Weight-bearing activities to stimulate joint relaxation C. Range-of-Motion exercises to prevent worsening of contractures D. Frequent position changes to reverse the contractures

C. Range-of-Motion exercises to prevent worsening of contractures

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? A. Intact mucous membranes B. Dry intact skin C. Susceptibility of the client D. Active bowel sounds

C. Susceptibility of the client

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? A. Directly toward the client B. Toward the nearest corner of the head of the bed C. Toward the far corner of the foot of the bed D. Toward the side of the bed

C. Toward the far corner of the foot of the bed

The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? A. Keeping objects on the field 1 inch from the edge B. Grasping the edge of the outermost flap and opening it away from oneself C. Transferring a sterile object to a sterile field with a clean gloved hand D. Keeping the sterile field in eyesight

C. Transferring a sterile object to a sterile field with a clean gloved hand

When making an occupied bed, which of the following is most important for the nurse to do? A. Move back and forth from one side to the other when adjusting the linens B. Constantly keep the side rails raised on both sides C. Use a bath blanket or top sheet for warmth and privacy D. Keep the bed in the lowest position

C. Use a bath blanket or top sheet for warmth and privacy

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? A. Administering parenteral medications B. Changing a dressing C. Using personal protective equipment D. Performing a urinary catheterization

C. Using personal protective equipment

The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding client safety once the beds are completed? A. presence of metered corners B. direction of the pillow C. call light being readily available D. folding of the top sheet

C. call light being readily available

The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? A. inspect feet thoroughly once a week B. cut toenails in a rounded shape & file C. wash feet with water at a temperature of 90 F to 98.6F D. dry toes thoroughly

D. dry toes thoroughly

The nurse is preparing to remove soiled gloves. What action should the nurse take first? A. Hook the bare thumb inside the other glove B. Drop the gloves into the appropriate waste receptacle C. Ease the fingers into the gloves D. Grasp the outside of the non-dominant glove

D. Grasp the outside of the non-dominant glove

Fowler's position is a bed position : A. In which the patient's head and shoulders are slightly elevated on a small pillow. B. In which the patient lies on the abdomen with the head turned to one side. C. In which the person lies on one side of the body. Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability. D. In which the head and trunk are raised 46 to 60 degrees.

D. In which the head and trunk are raised 46 to 60 degrees.

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? A. High Fowler's position with 2 pillows behind the head B. Prone position with knees flexed & arms extended C. Sims position with both legs flexed D. Orthopneic position across the overbed table

D. Orthopneic position across the overbed table

The client who is unconscious is developing foot drop. What nursing action is indicated? A. Use a devise to elevate the linens off the feet B. Keep the linens on the end of the bed turned back to expose the feet C. Use only prone and Sims positions for client positioning D. Place high-topped shoes on client while in bed

D. Place high-topped shoes on client while in bed

The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention would take priority? A. Change the water when it becomes cold B. Remove the soiled dressing during the bath C. Apply lotion to extremities D. Raise the side rails when gathering supplies

D. Raise the side rails when gathering supplies

self-help bed bath

clients helps bath themselves and nurse washes place they are unable to reach

scabies

contagious skin infestation by the itch mite producing short threadlike lesions on fingers, wrists, elbows, breast, and groin (most intense itching at night, body warmer for parasites

why bore crutch weight by arms and not axillae?

continuous pressure on the axillae can injure the radial nerve and eventually cause crutch palsy

T/F Restraints prevent injury.

false

T/F When bathing a patient, it is very important to gently remove all tubings prior to starting.

false

Trendelenburg's position

head of bed is lowered and foot is raised to promote venous circulation and provide postural drainage of lung tubes

Semi-Fowler's position

head of bed raised 15-45 degrees to provide relief from lying and promote lung expansion

reverse Trendelenburg's positon

head of bed raised and food lowered to promote stomach emptying and prevent esophageal reflux

aspiration

inhaling foreign material, keep patients head to the side and can remove by suction

flat position

mattress completely horizontal allowing for patient to sleep in many different positions, maintain spinal alignment, and allow for easy moving

what must the nurse do with the foreskin of the penis after retracting for cleaning and why?

move back to its original position to prevent constriction and edema

pediculosis

nits (lice) in hair, common in school age children

flaccidity

no muscle tone, appears hanging/limp

partial bath

only areas of body that are dirty or provide discomfort/odor are washed (face, hands, axillae, perineal area, back

foot drop

plantar flexion, joint deformities causing stronger muscle to dominate opposite muscle

dangling

positioning client to sit on the side edge of the bed with feet hanging down

Fowler's position

semi-sitting where head is raised 45-60 degrees, provides relief from lying, promotes lung expansion, easy to help patient sit up on edge

what is the position an unconscious patient is placed in for oral care and why?

side-lying with head of bed lower to prevent liquid from draining down throat and allows fluid to follow easily out of mouth (prevent aspiration)

T/F A Quick Release Knot should be used to tie restraints.

true

T/F In the formula D H X V the V stands for the vehicle.

true

T/F When providing perineal care on a female always clean from pubis to rectum (front to back).

true

what 2 movements should be avoided because they could cause back injury?

twisting/rotation of the spine and stooping

towel bath

uses large heated towels (helpful for dementia patients)

bag bath

using warm wash cloths one for each area of the body

contractures

very tense muscles

complete bed bath

wash entire body of dependent client