prep u fundamentals exam 2 - CH 27, ch 24, 31, 33
A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Request a sedative from health care provider Conceal IV tubing with gauze wrap Ask visiting family member to stay Assure bed alarms are activated
Conceal IV tubing with gauze wrap
A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings? Complete bed bath Partial care Independent showering The client should not be bathed
Independent showering
6 components of An infection cycle (picture she wanted us to memorize)
Infectious agent Reservoir Portal of exit Means of transmission Portals of entry Susceptible host
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client? Vancomycin-resistant enterococci and urinary tract infection Clostridium difficile and colitis Coronary artery bypass grafting MRSA in the wound
MRSA in the wound
contact precautions
MRSA, VRE, C diff practices used to prevent spread of disease by direct or indirect contact gloves gowns hand hygiene at your discretion/ splatter (mask)
What best describes the nurse's role in disaster preparedness? Administration of all of the medications Counseling the victims and families Multiple roles, including triage and the distribution of resources Performance of all of the skills such as IV insertion and wound care
Multiple roles, including triage and the distribution of resources
What is the primary role of the nurse in the care of clients who experience domestic violence? Calling the police Identifying health education and counseling measures for the family Providing prompt recognition of the potential or actual threat to safety Serving as a witness in court
Providing prompt recognition of the potential or actual threat to safety
A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take? Evacuate the unit. Pull the fire alarm lever Confine the fire. Extinguish the fire.
Pull the fire alarm lever.
A nurse is shaving a male client's face. Which should the nurse do? Pull the skin taut and shave in the direction of hair growth using short strokes. Let the skin hang loose and shave in long, downward strokes. Shave against the direction of hair growth, using short strokes. Pull the skin taut and use short, upward strokes.
Pull the skin taut and shave in the direction of hair growth using short strokes.
he nurse manager notices that a nurse is wearing artificial fingernails. What is the appropriate nurse manager action? Select all that apply. Remind the nurse that artificial fingernails can spread fungal infections. Refer the nurse to the agency policy on artificial fingernails. Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene. Demand that the nurse remove the artificial fingernails immediately. Ask the nurse to use only fingernail polish instead of artificial fingernails.
Remind the nurse that artificial fingernails can spread fungal infections. Refer the nurse to the agency policy on artificial fingernails. Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene.
The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? Surgical asepsis Medical asepsis Universal precautions Contact precautions
Surgical asepsis
The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table? The brain is sending impulses to the muscles to avoid the table. The client is aware of spatial relationships to avoid the table. The client's muscles are being stretched to walk around the table. The cerebellum is responding to impulses from the inner ear.
The client is aware of spatial relationships to avoid the table.
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? The nurse should place his or her feet close together with one foot in front of the other. The nurse should rock his or her pelvis out on the opposite side of the client. The nurse should grasp the gait belt and pull the client's body backward away from his or her body. The nurse should gently slide the client down his or her body to the floor.
The nurse should gently slide the client down his or her body to the floor.
portal of entry & exit
blood, GI, GU, skin, respiratory, tissues
When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that: braids should be undone every day. combs should be washed as often as necessary. hair should be washed as often as necessary. lubricants or oils should not be used on the braids.
hair should be washed as often as necessary.
Which nursing action is a component of medical asepsis? handwashing after removing gloves insertion of an indwelling urinary catheter insertion of an intravenous catheter drawing blood from a central line
handwashing after removing gloves
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? remove the garments that are most contaminated make contact between two contaminated surfaces make contact between two clean surfaces handwashing before leaving the client's room
handwashing before leaving the client's room
A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response? "Advertised remedies that promise a cure may be a scam." "The medication your health care provider prescribed will cure psoriasis." "This is great news; please let me know how this remedy works for you." "I know you will feel much better after you have been cured of psoriasis."
"Advertised remedies that promise a cure may be a scam."
A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting? "I hold the boxes away from my body so I don't drop them on my feet." "I stand with my feet apart so I have a better stance when I lift." "I bend with my knees when I pick up boxes." "I try to rest between periods of lifting."
"I hold the boxes away from my body so I don't drop them on my feet."
A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use a washcloth to clean the auricles and cerumen when needed." "I use cotton-tipped applicators daily to remove cerumen." "I never use bobby pins or other sharp objects when cleaning cerumen." "I clean my ear mold on my hearing aid daily before use."
"I use cotton-tipped applicators daily to remove cerumen."
A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response? "I really have limited time. Let me give you your bath right now." "I will set up your bath for you. I will come back and help you with your bath." "You will need to sit up for your bath, and then I will change your bed." "You will be able to take your bath by yourself tomorrow when you can get up."
"I will set up your bath for you. I will come back and help you with your bath."
The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? "Did you leave the household chemical in reach of your child?" "Is your child breathing at this time?" "You should not have left your child alone while you showered." "Induce vomiting and call 911 right away."
"Is your child breathing at this time?"
A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply. "Stand centered between the back legs of the walker." "Keep your arms relaxed at the side of the walker." "Line up the top of the walker with the crease on the inside of your wrist." "Your elbows should be nearly straight when you grasp the walker." "Move the walker forward 12 to 18 in (30 to 45 cm) with each step and set it down."
"Stand centered between the back legs of the walker." "Keep your arms relaxed at the side of the walker." "Line up the top of the walker with the crease on the inside of your wrist."
Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? "Older people often have splotchy skin due to seborrheic keratoses." "I know these spots are called senile lentigines and they are likely cancer." "All of these spots are called seborrheic keratoses and they should be taken off." "These brown spots are senile lentigines and are common when you get older."
"These brown spots are senile lentigines and are common when you get older."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To preserve the client's functional ability to grasp and pick up objects." "To prevent foot drop." "To avoid contractures." "To prevent the legs from rotating outward."
"To prevent the legs from rotating outward."
The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? "You are free to move onto the stretcher without assistance, but I will supervise for your safety." "I can only allow you to transfer without assistance with a physician's order, so I will help you now." "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go."
"You are free to move onto the stretcher without assistance, but I will supervise for your safety."
Fire arm safety
- store gun and ammo separately and locked up -install trigger lock -discuss safety/ and risk
Fire & burn safety
-have a list of emergency phone numbers -have working smoke detectors -stop/drop/roll -test a Childs bath water with back of wrist -keep matches/lighers away from children -fire extinguisher -establish a fire escape plan -use sunscreen
preventing poisioning
-keep the phone number for local poison control -color code meds ( visibly impaired) -store in child proof cabinet -properly dispose of old meds -check that paint/finish on furniture not toxic -monoxide detector
Preventing asphyxiation or choking
-plastic bags out of child reach -remove pillows/blankets in infant crib -supervise child in tub/pool - know CPR/ Heimlich
Electrical safety
-unplug appliances that are not in use - keep space heaters away from curtains/flammable material -turn off appliances before going to bed/leaving house -dont overload outlet/ extension cord -keep equipment away from water -put safety covers on unused outlets
A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? "All visitors who enter the room must wear special masks." "Under no circumstances should you touch the client." "Everyone who enters the room must wear a gown and gloves." "No visitors are allowed in the room to decrease the spread of disease."
"All visitors who enter the room must wear special masks."
Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child? "We place our child in a front-facing car seat in the back seat of the car." "We place our child in a front-facing car seat in the front of the car." "We place our child in a rear-facing car seat in the back seat of the car." "We place our child in a rear-facing car seat in the front of the car."
"We place our child in a front-facing car seat in the back seat of the car."
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response? "Until you leave the hospital." "When your sputum culture is negative." "For 2 days as you get settled onto the unit." "Only until you begin to feel better."
"When your sputum culture is negative."
preventing falls in home
-keep stairways clear/uncluttered -non slip socks -non slip shower mat -raised toilet seat with arms -assisted devices -remove scatter rugs -keep area well lit
A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Investigate the possibility of discontinuing his or her catheter. Limit the resident's fluid intake in order to reduce his or her urge to void. Collaborate with the resident's health care provider to have his or her diuretics discontinued. Increase the resident's physical activity to reduce evening restlessness.
Investigate the possibility of discontinuing his or her catheter.
Safety event report
Is not part of the medical record and should not be mentioned in documentation
A client has been diagnosed with pediculosis corporis. Which medication is the most appropriate treatment? Keratolytic shampoo Permethrin Anti-seborrhea shampoo Lindane
Lindane
Airborne precautions
MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB, SARS hand hygiene <5mcm N95 mask gloves gown negative air pressure
5 moments of hand hygiene
Moment 1 - Before touching a patient Moment 2 - Before a clean or aseptic procedure Moment 3 - After a body fluid exposure risk Moment 4 - After touching a patient Moment 5 - After touching patient surroundings
An organism's potential to produce disease in a person depends on a variety of factors, including:
Number of organisms Virulence of the organism, or its ability to cause disease Competence of the person's immune system Length and intimacy (extent) of the contact between the person and the microorganism
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? Obtain a three-prong grounded plug adapter. Use an extension cord to provide freedom of movement. Tape the electrical cord of the pump to the floor. Run the electrical cord of the pump under the carpet.
Obtain a three-prong grounded plug adapter.
An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client? Wash hands with soap or detergent. Perform hand antisepsis using a designated bleach solution. Perform surgical hand scrub using detergent. Apply alcohol-based handrub up to the mid-forearm
Perform surgical hand scrub using detergent.
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client? Placing the client in a bed with a bed alarm Providing a bed that is elevated from the floor Raising all the side rails of the bed Using restraints on the client to prevent a fall
Placing the client in a bed with a bed alarm
four core actions to fight resistant strains:
Preventing infections, thereby preventing the spread of resistance Tracking Improving antibiotic prescribing/stewardship Developing new drugs and diagnostic tests
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Make sure the bed brakes are unlocked. Put the chair at the foot of the bed. Place the bed in the highest position. Raise the head of the bed to a sitting position.
Raise the head of the bed to a sitting position.
Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? Clostridium difficile and diabetic ketoacidosis Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Tuberculosis and pneumonia Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus
Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)
The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings? Risk for Contamination related to flaking or peeling of paint Risk for Injury related to substance use Risk for Poisoning related to medications in unlocked cabinets Risk for Suffocation related to child left unattended in the bathtub
Risk for Poisoning related to medications in unlocked cabinets
RACE
R—Rescue anyone in immediate danger. A—Activate the fire code and notify appropriate person. C—Confine the fire by closing doors and windows. E—Evacuate patients and other people to safe area.
What generalization can be made about safety in client care? Health care providers exclude safety as a client need. Although safety is a basic human need, it is provided by self-care. Safety is an important need, but not as important as self-actualization. Safety is a paramount concern underlying all nursing care.
Safety is a paramount concern underlying all nursing care.
A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline? Remove dentures whenever possible to rest the gums. Wrap dentures in a napkin when not using them. Keep dentures near you in the bed for easy access. Store dentures in cold water when not in use.
Store dentures in cold water when not in use.
The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed? The client uses the arms of the chair as support when standing up to use the walker. The client steps into the walker before moving the walker forward. The client pushes the walker ahead, following behind it. When arising from a chair, the client puts one hand at a time on the walker.
The client pushes the walker ahead, following behind it.
A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? The client should use an electric razor . The client prefers shaving gel over shaving cream. The client likes to shave while in the shower. The client would like the spouse to assist with shaving.
The client should use an electric razor
The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response? The client will refine both gross and fine motor skills but longitudinal growth will slow. The client will continue to grow rapidly but gross and fine motor skill acquisition will slow. The client will regress in fine and gross motor skill development. The client will continue to grow rapidly and will refine both gross and fine motor skills.
The client will continue to grow rapidly and will refine both gross and fine motor skills.
A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. The nurse's back is facing the sterile field. The nurse keeps hands above waist level while donning sterile gloves. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. The nurse disposes of an opened container of sterile saline after half is used.
The nurse is talking with the scrub nurse over the sterile field. The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene? The nurse uses gloves in place of hand hygiene. The nurse keeps fingernails less than 1/4 in (0.63 cm) long. The nurse uses hand hygiene instead of gloves when in contact with blood. The nurse refrains from using hand moisturizer following hand hygiene.
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? The nurse should notify the primary care physician about the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises. The nurse should request permission from the client to photograph the bruises.
The nurse should question the client about the source of the bruises.
Using proper body mechanics, which motions would the nurse make to move an object? The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity.
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. The report provides a detailed and objective account of the circumstances before, during, and after the event. The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed.
The report provides a detailed and objective account of the circumstances before, during, and after the event.
Factors Affecting the Risk for Infection
The susceptibility of the host depends on various factors: •Integrity of skin and mucous membranes, which protect the body against microbial invasion •pH levels of the gastrointestinal and genitourinary tracts, as well as the skin, which help to ward off microbial invasion •Integrity and number of the body's white blood cells, which provide resistance to certain pathogens •Age, sex, race, and hereditary, which influence susceptibility. Neonates and older adults appear to be more vulnerable to infection. (See the accompanying box, Focus on the Older Adult.) •Immunizations, natural or acquired, which act to resist infection •Level of fatigue, nutritional and general health status, the presence of preexisting illnesses, previous or current treatments, and certain medications, which play a part in the susceptibility of a potential host •Stress level, which if increased, may adversely affect the body's normal defense mechanisms •Use of invasive or indwelling medical devices, which provide exposure to and entry for more potential sources of disease-producing organisms, particularly in a patient whose defenses are already weakened by disease
Included in the targeted infections are four categories that are responsible for a majority of HAIs in the acute care hospital setting
These include: Catheter-associated urinary tract infection (CAUTI) Surgical site infection (SSI) Central line-associated bloodstream infection (CLABSI) Ventilator-associated pneumonia (VAP)
The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is most appropriate? Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath. Disconnect the IV tubing from the IV bag and quickly thread it through the arm of the gown. Cut the arm of the regular gown and replace it with a snap-arm gown at the end of the bath. Leave the gown in place, taking care to keep it dry.
Thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath.
Personal protective equipment (PPE) is used in health care facilities for primarily which reason? To protect both the staff and clients from becoming infected by one another To protect clients from becoming infected by staff members To protect staff members from becoming infected by clients To protect the hospital from legal liability
To protect both the staff and clients from becoming infected by one another
questions to ask older aged adult about falling
1. have you fallen in the past year? 2. do you feel unsteady standing or walking? 3. do you worry about falling? if they answer yes, you need to intervene further
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Logrolling can be performed by one experienced nurse. Logrolling will maintain straight alignment when the client is sitting in a chair. It is acceptable to twist the client's head, but not the hips, while logrolling.
Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply. Use of a tub/shower seat may be necessary if balance problems are present. Use vigorous rubbing motions when drying the skin to increase circulation. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility. Use scented bath oils for tubs to improve dryness of the skin and decrease odors, since bathing may occur less frequently.
Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.
The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group? Do not text while driving. Use protective sporting equipment. Be cautious of electrical outlets. Use caution when descending stairs.
Use protective sporting equipment.
Which modification to bathing should be implemented for a client who is incontinent? Use special perineal skin cleaners and moisture barriers. Use a topical antiseptic, such as povidone-iodine, in the perineal area. Decrease the frequency of bathing to preserve skin integrity. Perform a full bed bath each time the client has an episode of incontinence.
Use special perineal skin cleaners and moisture barriers.
A nurse who has finished cleansing and dressing the wound of a young client now needs to change the dressings of a client in the burn unit. Which action should the nurse perform, keeping in mind the importance of asepsis and client comfort? Wash hands thoroughly and then wear sterile gloves. Avoid using alcohol-based hand sanitizers to protect skin integrity. Avoid washing hands with an antiseptic cleansing agent. Wear gloves made of polyvinyl chloride.
Wash hands thoroughly and then wear sterile gloves.
A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? Use a private room with the door closed at all times. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. Place client in a private room that has monitored negative air pressure. Ensure that hard surfaces in the room are disinfected at least once per day.
Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.
The home health nurse is performing fall risk assessments. Which client is identified by the nurse as being a high risk for falls? Select all that apply. A client taking benzodiazepines A client with poor lighting in the home A client with scatter rugs throughout the home A client with a history of previous falls A client with type 2 diabetes A client with an irregular heart rate (dysrhythmia)
A client taking benzodiazepines A client with poor lighting in the home A client with scatter rugs throughout the home A client with a history of previous falls
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? A client who has leg strength and can cooperate with the movement A client who has an abdominal incision A client with a thoracic incision A client who is confined to bed rest
A client who has leg strength and can cooperate with the movement
Which practice is a correct application of infection control practices? A nurse performs hand washing each time the nurse removes a pair of gloves. A nurse dons a pair of gloves prior to any client contact. A nurse uses an alcohol-based hand rub each time that the nurse's hands are visibly soiled. A nurse rinses hands thoroughly after the application of an alcohol-based hand rub.
A nurse performs hand washing each time the nurse removes a pair of gloves.
Which nurse would be at the highest risk of causing a hazardous situation? A nurse who has worked 32 hours of overtime this week A nurse who has placed a client in the bed with three side rails up A nurse who is transferred to another unit to assist with care A nurse who is administering medications to four clients
A nurse who has worked 32 hours of overtime this week
A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. Fires are responsible for most hospital incidents. Between 15% and 25% of falls result in fractures or soft tissue injury. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.
A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.
Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? Adolescents School-age children Middle-age adults Older adults
Adolescents
A nurse caring for the skin of clients of different age groups should consider which accurately described condition? An infant's skin and mucous membranes are protected from infection by a natural immunity. Secretions from skin glands are at their maximum from age 3 on. The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.
An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.
A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? a dose of an antipsychotic side rails a geriatric chair with a tray a dose of an analgesic
a dose of an antipsychotic
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? Wear a protective gown and gloves with any direct contact. Apply a nonparticulate (N-95) respirator when entering the room. Have the client wear a mask during care. Wear a mask with face shield during invasive procedures.
Apply a nonparticulate (N-95) respirator when entering the room.
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? Adduction Abduction Circumduction Extension
adduction
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? airborne droplet contact none
airborne
A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect: anxiety. alopecia. dandruff. seborrhea.
alopecia
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? an older adult client with a history of heart failure a school-age child who is current with immunizations an adolescent who has a right radial fracture a middle-aged adult who takes prescribed medication to control blood pressure
an older adult client with a history of heart failure
A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action? Avoid touching the outer surfaces of the gown . Remove the gown before removing gloves. Remove the gown immediately after exiting the room. Perform hand hygiene before removing the gown.
Avoid touching the outer surfaces of the gown.
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? Instruct the toddler not to go near the pool. Avoid unattended baths for the toddler. Monitor the activities of the toddler. Allow the child to swim with friends.
Avoid unattended baths for the toddler.
A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply. Bathing removes organisms from the skin, reducing infection. Bathing can stimulate circulation. Bathing can improve appearance and self-image. Bathing decreases joint mobility if the client is on bed rest. Bathing decreases comfort because clients are being turned and repositioned.
Bathing removes organisms from the skin, reducing infection. Bathing can stimulate circulation. Bathing can improve appearance and self-image.
The following are clinical situations when an alcohol-based handrub can be used to decontaminate hands:
Before direct contact with patients After direct contact with patient's skin After contact with body fluids, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly soiled After removing gloves Before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement Before donning sterile gloves prior to an invasive procedure (e.g., inserting a central intravascular catheter) If moving from a contaminated body site to a clean body site during patient care After contact with objects (including equipment) located in the patient's environment
Factors to consider when examining skin
Cleanliness Color Temperature Turgor Moisture Sensation Vascularity Evidence of lesions
purposes of bathing (VERY INDIVIDUALIZED based on pt preference)
Cleanses the skin Acts as a skin conditioner Helps to relax a person Promotes circulation Serves as musculoskeletal exercise Stimulates the rate and depth of respirations Promotes comfort through muscle relaxation and skin stimulation Provides person with sensory input Helps improve self-image Strengthens nurse-patient relationship
The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? Clear clutter in the walkways of the new home. Change the older adult's routine. Take walks outside. Use the stairs in the new home.
Clear clutter in the walkways of the new home.
Preventing falls
Complete a risk assessment. • Indicate risk for falling on patient's door and chart. • Keep bed in low position. • Keep wheels on bed and wheelchair locked. • Leave call bell within patient's reach. • Instruct patient regarding use of call bell. • Answer call bells promptly. • Leave a night light on. • Eliminate all physical hazards in the room (clutter, wet areas on the floor). • Provide nonskid footwear. • Leave water, tissues, bedpan/urinal within patient's reach. • Move bedside commode out of sight to discourage attempts at independent transfer (as appropriate). • Document and report any changes in patient's cognitive status to the health care team at the change of shift. • Use alternative strategies when necessary instead of restraints. • As a last resort, use the least restrictive restraint according to facility policy.
The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action? Change the sterile field, but reuse the sterile equipment. Proceed with the procedure since it was only touched by the client. Discard the sterile field and the supplies and start over. Call for help and ask for new supplies.
Discard the sterile field and the supplies and start over.
The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? No action is needed. Don another pair of sterile gloves. Complete a sentinel event report. Notify the primary care provider.
Don another pair of sterile gloves.
The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?
Establish the nurse's role during a disaster
Safety risks for each developmental stage:
Fetus Abnormal growth and development Neonate (first 28 days of life) Infection, Falls, ASSB Infant Falls, Injuries from toys, Burns, Suffocation or drowning, Inhalation or ingestion of foreign bodies Toddler Falls, Cuts from sharp objects, Burns Suffocation or drowning, Inhalation or ingestion of foreign bodies/poisons Preschooler Falls, Cuts, Burns, Drowning, Inhalation or ingestion, Guns and weapons School-Aged Child Burns, Drowning, Broken bones, Concussions (TBI), Inhalation or ingestion, Guns and weapons, Substance abuse Adolescent Motor vehicle accidents, Drowning, Guns and weapons, Inhalation and ingestion Adult Stress, Domestic violence, Motor vehicle accidents, Industrial accidents, Drug and alcohol abuse Older Adult Falls, Motor vehicle accidents, Elder abuse, Sensorimotor changes, Fires
remove PPE
GLOVES goggles GOWN MASK p 626
A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition? Glossitis Gingivitis Periodontitis Stomatitis
Glossitis
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student? The use of gloves eliminates the need for hand hygiene. The use of hand hygiene eliminates the need for gloves. Hand hygiene is needed after contact with objects near the client. Hand lotions should not be used after hand hygiene.
Hand hygiene is needed after contact with objects near the client.
The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections? Advise taking prophylactic antibiotics for the prevention of pneumonia Immunize the client with the pneumococcal vaccination once in a lifetime Discuss starting corticosteroids at low doses to prevent pulmonary infections Instruct client to limit fluids when coughing and congestion occurs
Immunize the client with the pneumococcal vaccination once in a lifetime
An infection progresses through the following phases:
Incubation period- organisms are growing and multiplying. Prodromal stage- CONTAGIOUS/infectious Full (acute) stage of illness- signs and symptoms Convalescent period- recovery
ALTERNATIVES TO RESTRAINTS
assess pain Ask family members or significant other to stay with the patient. Reduce stimulation, noise, and light. Distract and redirect, using a calming voice. Use simple, clear explanations and directions. Use night light. Use an electronic alarm system on a temporary basis (e.g., bed or position-sensitive alarms) to warn of unassisted activity. Use low-height beds. Place floor mats on each side of the bed. Ensure the use of glasses and hearing aids, if necessary. Assist with toileting at frequent intervals or Arrange for a bedside commode. Make the environment as home-like as possible; provide familiar objects. Play music or video selections of the patient's choice. Offer diversional activities, such as games and books. Encourage daily exercise/provide exercise and activities or relaxation techniques. Consider relocation of the patient to a room closer to the nursing station. Conceal tubing necessary for care. Anchor tubing securely. Conceal tubing with gauze wrap; unwrap regularly to assess site for complications. Investigate possibility of discontinuing bothersome treatment devices (e.g., intravenous line, catheter, feeding tube).
A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: falls from beds. automobile accidents. play-related injuries. falls from staircases.
automobile accidents
A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? bed trapeze foot board bed cradle trochanter roll
bed trapeze
Which oral problem involves an ulceration of the lips usually caused by vitamin B complex deficiencies? A. Stomatitis B. Glossitis C. Cheilosis D. Dry oral mucosa
cheilosis
The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? standard precautions droplet precautions contact precautions airborne precautions
contact
factors that affect safety
developmental level/age, environment lifestyle, occupation mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state
Direct vs indirect
direct- touching/kissing/intercourse indirect-personal contact with inanimate object (contaminated instrument, blood, food, water)
Chemical burns in eye-
flush eyes with water for 10 min
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? supine prone Sims' Fowler's
fowlers
putting on PPE
gown mask goggles gloves
Gram-negative bacteria
gram-negative bacteria have chemically more complex cell walls and can be decolorized by alcohol (do not stain). antibiotics not effective
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? remove the garments that are most contaminated make contact between two contaminated surfaces make contact between two clean surfaces handwashing before leaving the client's room
handwashing before leaving the client's room
gram-positive bacteria
have a thick cell wall that resists decolorization (loss of color) and are stained violet antibiotics affective
intake/output a patient consumed 250cc fluid 4 oz of apple juice 6oz of ginger ale 8oz water 6oz water vomitted 90 cc drained 980 cc from foley Cath
input: 4 oz=120cc 6 oz =180cc 8 oz= 240cc 6oz= 180 cc + 250cc -------------- = 970 cc output: 980cc + 90cc = 1,070 cc = -100 negative means they had more output (could mean they are dehydrated, diuretic) if its positive it could indicate fluid overload
Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? keeping medications in clearly labeled containers alternatives to chemical-based cleaning supplies hidden sources of lead in the household environment avoiding the use of alternative and complementary therapies
keeping medications in clearly labeled containers
During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: mass trauma terrorism. chemical terrorism. bioterrorism. nuclear terrorism.
mass trauma terrorism.
A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? medications listed on the client's medication administration record (MAR) cultural views and attitudes toward facial hair and grooming client's allergies to soap since shaving cream is contraindicated in the hospital the last time shaving was performed because clients can only shave twice weekly in the hospital
medications listed on the client's medication administration record (MAR)
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs together near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed.
near the client's hip, with legs shoulder width apart and one foot near the head of the bed
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition? contagious disease infectious disease communicable disease noncommunicable disease
noncommunicable disease
A nurse is caring for four clients. Which client has the highest risk of infection? older male with an enlarged prostate toddler with a benign heart murmur woman in second trimester of pregnancy young woman with a history of scoliosis
older male with an enlarged prostate
Any microorganism capable of disrupting normal physiologic body processes is a: bacterium. fomite. pathogen. virus.
pathogen.
Which gum disease manifests as a marked inflammation of the gums that also involves a degeneration of the dental tissues and bone? A. Dental caries B. Gingivitis C. Periodontitis D. Plaque
periodontitis
The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include: polypharmacy and use of multiple extension cords. household cleaners stored under the sink and hanging cords on window blinds. peeling paint and easy access to the backyard pool. risky behaviors and cyberbullying.
polypharmacy and use of multiple extension cords.
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)? remove gloves, wash hands, remove gown remove gown, wash hands, remove gloves remove gloves, remove gown, wash hands remove gown, remove gloves, wash hands
remove gloves, remove gown, wash hands
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor installing hardwood floors
removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor
Maintaining safety (NURSES ROLE- for all ages)
safety assessment includes: 1. assess the person *nursing history (any falls, alcohol/drug abuse/assistive devices) *physical examination (level of awareness person, place, time; ability to communicate, sensory perception, mobility) 2. environment - hazards in the home/hospital/community, violence, act of aggression, terrorism; community(living in area of crime) 3 risk factors: falls, fires, suffocation, poisoning, fire arms
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? supine prone Sims' Fowler's
sims
Droplet precautions
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, >5mcm hand hygiene mask gloves, gown door doesn't need to be closed
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: uses the sides of the walker to rise from a chair. places the walker far in front when walking. steps into the walker when walking. leans over the walker when walking.
steps into the walker when walking.
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? supine lateral prone Sims'
supine
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? under the client's head supporting the client's back in front of the client's abdomen under the client's feet
supporting the client's back
A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that: there is a need to determine if the bottled water has fluoride. the preschool child should not drink bottled water. the preschool child should only drink milk. the parent should alternate bottle and tap water.
there is a need to determine if the bottled water has fluoride.
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? trochanter rolls foot boards foot splints roller sheets
trochanter rolls
5th leading cause of death
unintentional injury
WASHING HANDS
water is warm. Wet the hands and wrist area. Keep hands lower than elbows to allow water to flow toward fingertips Water should flow from the cleaner area toward the more contaminated area. Hands are more contaminated than forearms. 1 teaspoon liquid soap & lather thoroughly covering all areas of hand Wash at least 1 in above area of contamination. Removal of jewelry facilitates proper cleansing. Microorganisms may accumulate in settings of jewelry. If jewelry was worn during care, it should be left on during handwashing.
The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as: decreased elevated within normal limits stable
within normal limits
TYPES OF BACTERIAL FLORA Resident
• Normally found in skin creases • Usually stable in number and type • Cling tenaciously to skin by adhesion and absorption Considerable friction with a brush is required to remove them. Less susceptible to antiseptics than transient bacteria.
TYPES OF BACTERIAL FLORA Transient
• Occur on hands with activities of daily living • Relatively few in number on clean and exposed areas of the skin • Attached loosely on skin usually in grease, fats, and dirt • Found in greatest number under the fingernails • Can be pathogenic or nonpathogenic Can be removed relatively easily by frequent and thorough handwashing.
