seminar quiz #2

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?

Discard the supplies and field and prepare a new sterile field

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.

"Hygiene measures have no affect on skin." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums."

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?

"I am placing the new linens under the rolled, soiled lines to avoid contamination."

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 cotton-tipped applicators daily to remove cerumen."

The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.

"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person."

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?

"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date

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 is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?

Assess the client's cultural views regarding hygiene and self-care.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?

Breaks in skin integrity and fungal nail infection

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

A nurse is caring for a female client with diarrhea. What information does the nurse teach the client about perineal care and self-care?

Clean the perineal area from the front to back.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?

Cleanse and disinfect the sphygmomanometer.

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

Involve family members in the client's care.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients' items.

What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital?

Orienting clients to the surroundings decreases the potential for injury.

The nurse has completed a change of a client's bedding while the client is seated in a wheelchair. When removing the bedding, what action best maintains the principles of infection control?

Picture where nurse places onto a bed

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

What is the primary goal of the observable action associated with the removal of contaminated gloves?

Prevent contamination of ungloved hand

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

Remove extension cords from open spaces. Remove throw rugs from high traffic areas. Ensure appropriate lighting in hallways and entrances to the home. Check the batteries in all smoke detectors.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

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.

Some people are more at risk for accidents than others. A person with a history of falls is likely to fall again. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Store the hearing aid in a cool environment.

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important to use in order to individualize care for this client?

Suction toothbrush

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

The client will not experience a fall and remains free of injury.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

The nurse places the client in a private room with monitored negative air pressure

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

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 provides a detailed and objective account of the circumstances before, during, and after the event.

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

These barriers help prevent the transmission of infection to you or other people."

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

Turn on the faucet and adjust force and temperature of the water. Wet the hand and wrists. Apply soap. Wash the palms and backs of the hands for at least 20 seconds. Pat the hands dry with a paper towel. Turn the faucet off with a paper towel

The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning?

Use a special cleaning solution for eye glass lenses

Which action(s) is appropriate to safely bathe an older adult client? Select all that apply.

Use a tub/shower seat if balance problems are present. Provide the client a long-handled shower brush or attachment if experiencing limited mobility. Carefully monitor water temperature.

The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?

Use night-lights in bedrooms and bathrooms

In which situation is an alcohol-based rub not the appropriate option for hand hygiene?

When the nurse's hands are visibly soiled

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

an 84-year-old male with four recent driving violations

For which client would the use of standard precautions alone be appropriate?

an incontinent client in a nursing home who has diarrhea

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?

diligent handwashing practices

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown and gloves

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?

one that remains in the client's room

Which health problem is most clearly suggestive of a history of inadequate dental care?

periodontitis

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:

recapping a needle.

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?

wash the area with soap and water