skills final (back of the book questions and online)

A child with cerebral palsy can experience difficulty with movement, loss of balance, and lack of muscle control. Which gait does the nurse instruct the parents to use for crutch walking?

Four-point The four-point gait provides the most support and improves balance.

When performing catheter care, what step helps prevent traction on the catheter and CAUTI?

Grasp the catheter with two fingers to stabilize the catheter.

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)?

Hanging the urinary drainage bag below the level of the bladder

An older patient needs to have a fecal impaction removed digitally. The nurse should stop the procedure if which patient information is obtained?

Heart rate changes from 74 to 58

A nurse in the diabetic clinic is assessing blood glucose levels in patients ranging from infants to the elderly. Which techniques would best ensure that the nurse obtains an adequate amount of blood for testing any of these patients? (Select all that apply)

Hold the area to be punctured in a dependent position. warm the area to be punctured

A patient with suspected sepsis is to have blood cultures obtained but is currently receiving antibiotics. What is the most appropriate nursing action?

Notify the laboratory which antibiotics the patient is receiving.

A patient is to be placed on a ventilator. Which nursing action has been found to be most effective in reducing ventilator-associated pneumonia?

Performing mouth care at least four times a day

A patient needs to expectorate a sputum specimen. The nurse's teaching has been effective if the patient is seen doing which activity as part of the procedure?

Providing the specimen immediately after awakening before eating

The nurse contacts the prescriber and receives a STAT telephone order for a medication. What is the first thing the nurse should do after writing down the order?

Read back the telephone order to the prescriber

The nurse has redressed a wound and now plans to administer medications. What should the nurse remember to do next?

Remove gloves and perform hand hygiene before administering the medication.

A patient with chemotherapy-related stomatitis calls the physician's office to talk with the nurse. What suggestions should the nurse make to help this patient?

Rinse the mouth before and after meals and at bedtime with a saltwater or baking soda solution per protocol, and apply a moisturizing gel to the lips if needed.

A patient with a proprioceptive disorder is being assessed for his ability to walk from bed to chair. You notice that the patient is bent forward and is leaning toward the right. Which nursing diagnosis would be the primary one on which to base his care

Risk for injury

A 65 year old patient who weighs 998 kg ( 260 ibs) is to be transferred from his bed to a stretcher. the patient is unable to bear full weight on one leg. his upper body strength is good. which technique is the LEAST appropriate technique for transfer?

use a three-person carry

To reduce the risk of polypharmacy, how should the nurse advise the older patient regarding medications?

use one pharmacy to coordinate all medications

two NAP's ask for the nurse's assistance to transfer a 125 ibs patient from the bed to the stretcher. the patient is unable to assist. what is the best response?

use the slide board; it is more comfortable for the patient and will lessen the change of injury to us

Positioning a hemiplegic patient in Fowler's position will increase the patient's:

ventilator capacity cardiac output ability to swallow

The low-pressure alarm has sounded on a patient's ventilator. The nurse should check for which of the following situatio

ventilator circuit has a leak

Identify the situations in which a nurse should remove gloves and perform hand hygiene.

when leaving a patients room When the specific task for which the nurse applied the gloves is completed

n immobilized patient has a history of constipation and takes a stool softener at home. Which breakfast selection would be best?

Mixed fruit, oatmeal, whole wheat toast

patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the patient that he will undergo which diagnostic test shortly?

arterial blood gas

In the event that a medication error occurs, the nurse should do the following first:

assess and examine the patient

cleaning baths include which of the following?

bed bath tub bath shower

An older patient with limited mobility and strength is recovering from hip surgery and needs to use the bedpan. Which action by the nurse would best facilitate this procedure?

btaining the assistance of at least two other staff member

a patient who weights 145.5 kg ( 320 ibs) is being transferred from his bed to a chair. the patinet is on partial weight bearing. which of the following is the best technique for transfer?

ceiling lift

A patient asks the nurse why his mouth is so dry after radiation therapy to his head and neck. What is the most appropriate response from the nurse?

"Radiation reduces the flow of saliva."

The nurse is caring for a male patient who has asked to be shaved with a disposable razor. The nurse knows that she will need to take which of the following into consideration?

-The condition of the skin and any irritated or open areas -Laboratory values (e.g., anticoagulation studies such as PT, platelet count) -The ability of the patient to help with the procedure and to manipulate the razor

The nurse is assessing the axillary temperature of a confused patient w/ a fever. which actions by the nurse will best provide an accurate measurement?

-drying the axilla before placing the thermometer probe -holding the thermometer probe in place

Which of the following techniques is correct when obtaining a patient's blood pressure?

-ensure patient is not crossing his legs -Obtain an average of two or more readings separated by at least 2 minutes.

which of the following nursing interventions is/are correct when determining a pulse deficit? (select all that apply)

-using a peripheral artery and apical pulse -counting simultaneously with another health care provider

when a patient is to be placed on isolation precautions, there are many factors to consider regarding his or her care. (select all that apply)

1. the need for social interaction 2. the type of isolation required 3. the patients cultural background 4. education of family and friends regarding the isolation 5. organization of care to minimize trips in and out of the isolation room

which of the following blood pressures would classify as prehypertension? ( select all that apply)

126/82 130/80

The following patients require routine vital signs to be obtained by the nursing assistive personnel (NAP). You instruct the NAP to obtain vital signs on which patient first?

18-year-old teen who has been watching TV with some visitors

The nurse teaches a patient ROM exercises for the shoulder. For abduction, how high is the patient taught to raise the arm?

180 degrees

Which aspect of handwashing is most effective to loosen dirt and transient bacteria? 1. using hot water instead of warm water 2. using plenty of lather and friction 3. drying the hands vigorously from wrists to fingers 4. applying lotion to hands

2. using plenty of lather and friction

A healthcare worker has visible dirt on his hands. Which method of hand hygiene is most appropriate? 1. using an alcohol-based disinfectant 2. washing hands with water and then an alcohol-based hand rub 3. using an alcohol gel containing an emollient 4. washing with soap and water

4. washing with soap and water

The nursing assistive personnel (NAP) reports that a patient's blood pressure is 150/98. What is the pulse pressure?

52 Pulse pressure is the difference between systolic and diastolic values. (REF: p. 90)

A nurse is caring for a critically ill cardiac surgery patient who is on a ventilator. which of the following solutions has been show to decrease the incidence of ventilator-assisted pneumonia in intubated patients ?

chlorhexidine

Provide bathing at regular intervals to:

clean the outer layer of skin and removed dead skin cells

A postoperative patient is suspected of having a wound infection. Which method would be most appropriate for the nurse to use when obtaining an anaerobic culture?

Aspirating the drainage using the sterile tip of a 10-mL syringe

while giving a complete bed bath to an unconscious patient, care is taken to:

close the eyelids with the back of the fingertip and place an eye patch or shield in place with tape

a nurse enters the room of a patient who has been diagnosed with pnemonia. the nurse instructs the patent to cover the mouth when coughing. this reduces transmission of infection by:

contact

Use of noninvasive positive-pressure ventilation (CPAP or BiPAP) has the potential to cause carbon dioxide retention in selected patients. Patients with which of the following underlying diagnoses are at greatest risk for carbon dioxide retention?

COPd

The nurse is preparing to verify the placement of a patient's nasogastric tube. Which method of placement verification by the nurse would best indicate that the end of the tube is in the stomach?

Checking the pH of the aspirated gastric contents

When cleansing the eyes, which of the following should the nurse not do?

Cleanse each eye from the outer canthus to the inner canthus.

What is the best nursing action when there is no urine flow after an indwelling urinary catheter is inserted into a female patient?

Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter.

The nurse is ready to administer a patient's morning medication when the patient states, "Please leave the medication on my table. I will take it after I use the restroom." Which is the most appropriate response from the nurse?

I will bring the medication back to your room once you return from the bathroom."

a patient who has suffered a stroke will be taken care of by his daughter at home. which statement by the daughter regarding body mechanics indicates that learning has occurred?

I'll keep my knees bend and trunk erect so my muscles work together

Which of the following is not a principle of surgical asepsis?

If an item's sterility is in doubt, the nurse can check its expiration date.

A patient has a nasogastric tube after abdominal surgery. Which action by the nurse best maintains the patency of the air vent?

Irrigating the blue pigtail with 10 mL of air

A patient has an indwelling urinary catheter. Why does the catheter represent a risk for infection?

It continuously keeps the bladder sphincter open.

A patient has just returned from a liver biopsy and is ordered to lie on her right side for 1 hour. An IV is in the left basilic vein. What site do you instruct the nursing assistive personnel (NAP) to use to obtain a blood pressure reading?

Left leg The patient is lying on the right arm and the right leg. The left arm has an IV, but the left leg is available.

Besides meticulous hand hygiene, identify another practice that helps reduce the risk of spreading infection.

Maintaining a clean environment in the patient's room

a patient in the intensive care unit after a head injury had been unresponsive at times and can e aroused only after painful stimuli. which assessment by the nurse is most crucial in determining whether it is safe to perform oral hygiene?

determine the presence of gag reflex

a nurse goes in an out of a patients room an only needs a gown when coming into contact with the patient. what should the nurse do on leaving the room ( select all that apply)

discard the gown after using it perform hand hygiene

the use of a mask when the nurse is closer than 3 feet to a patient involves which type of precautions?

droplet

the nurse is transferring a patient from the bed to the chair for the first time after abdominal surgery. which initial step in the transfer is most appropriate for the nurse and the patient?

have the pateint sit on the side of the bed and dangle for a few minutes

When should a gown be worn?

When blood or body fluids may get on the nurse's clothing

electronic blood pressure monitoring cannot be used on certain patients. which of these pateints can have an electronic blood pressure monitor?

the patient with diabetius mellitus

The nurse is setting up an over-bed table with supplies to clean a wound and to replace a sterile dressing. The nurse would need to consider that contamination exists if which situation is present?

The sterile glove package is dry and intact with a water stain.

a patient with abdominal ascites is having his respiratory rate assessed. which is the best action to obtain the respiratory assessment for this patient?

the patients head is elevated to his desire

A patient is recovering from bilateral knee replacements and is prescribed bilateral partial weight bearing. You are asked to reinforce crutch walking and know that the following crutch gait would be most appropriate for this patient

Two-point gait Two-point gait requires at least partial weight bearing on each foot. The patient moves a crutch at the same time as the opposing leg, so that crutch movements are similar to arm motion during normal walking

A restless, confused patient needs to have the sterile packing in his hip wound replaced. Which approach by the nurse would be best for maintaining sterile technique?

Use nursing assistive personnel to help position the patient.

Which intervention is appropriate when an indwelling urinary catheter is secured in a male patient?

ape the catheter tubing to the lower abdomen, avoiding traction.

some patients require special positioning precautions when the hair is shampooed. special precautions are most appropriate for which patient?

a patient with arthritis in her cervical spine

The patient is being log-rolled onto his right side. The patient's position would be correct if what assessment was observed?

a straight line is evident from shoulder to hip

a young adult is admitted with an unstable spinal cord injury. what is the most appropriate method of moving this patient from her side to her back?

logroll the patient using three people

an adolescent has been admitted with an unstable spinal core injury sustained from a motor vehicle accident. the patient needs to be taken to the operating room. what is the most appropriate method to move this patient to a stretcher for transport →

logroll the patient; place a slide board; and slide the patient

Which nursing action has the highest priority for a patient receiving medication via a nasogastric feeding tube?

lush with 30 mL of water before and after feedings.

after checking the tympanic temperature tow consecutive times in an 82-year-old patient, the nurse finds the reading to be several degrees lower than expected. what is the most appropriate nursing action at this time?

observe for the presence of cerumen

You are checking the vital signs of a 75-year-old patient. the radial pulse is irregular, and about every fourth beat is different. the patient offers no complaints . what is your next action?

obtain an apical heart rate

a pateint has been on bed rest for several days. when he attempted to stand from a sitting position, he became dizzy and nauseated. these symptoms indicate which of the following conditions?

orthostatic hypotension

a patient has arrived on the unit after undergoind extensive abdominal surgery. He is awake and alert but refuses to be repositioned in bed. What should the nurse assess first to determine the reason for his refusal to move?

pain level

Two assistive personnel ask the nurse for assistance to transfer a patient from the bed to a stretcher using the three-person lift technique. What is the most appropriate response from the nurse?

please find the slide board we can use

the nurse is preparing to asssess a patient's blood pressure. which statement by the nurse will help promote an accurate reading?

please uncross your legs while I do this

an 88-year-old patient diagnosed with dementia frequently becomes very agitated and aggressive with caregivers. which approach for bathing this patient would be most appropriate?

provide a disposable bed bath in bed

Which situation is a contraindication for the use of elastic stockings

recent skin graft to the lower leg

The nurse is caring for a patient who has an order for an acetaminophen (Tylenol) rectal suppository. Which finding contraindicates the use of a rectal suppository?

rectal bleeding

An unconscious elderly patient with poor circulation has to have an arterial blood gas drawn. Which nursing diagnosis would be given priority during and after the procedure?

risk for injury

a Muslim woman needs to have a bed bath. which adjustment does the female nurse need to make when performing perineal care?

she needs to use her left hand when doing perineal care

to increase stability during patient transfer, you increase the base of support by performing which action?

spacing your feet farther apart

Mr. Marquis is 87 years old and is admitted to your medical unit for pneumonia 4 day's duration. his temp. is 37.2 C. the NaP questions why his temp is so low for a person with an active infection. your best response is...

the baseline temp of older adults is lower because of loss of subcut. fat.