1423 Final

The nurse is performing a focused assessment of the clients cardiovascular system every 4 hours. Which specific assessment will the nurse include? Select all that apply

Strength and and equality of peripheral pulses Capillary refill of extremities Blood pressure Skin color, moisture, and temperature

The nurse understands the importance of sterile technique during certain client care procedures. Which procedure will require sterile technique

Subcutaneous injection given

The latest CDC guidelines designate standard precautions for all substances

Sweat

A client has been diagnosed with septicemia, a condition in which micro organisms are present in multiplying in the blood. A nurse identify as is condition as a

Systemic infection

A nurse is assessing an adult client who has a fever, and a pulse rate of 102 BPM. The nurse would expect the respiration rate to be

Tachypneic

Which of the following can a nurse asses by palpation

Temperature, turgor, edema

When assessing a client's vital signs, a nursing student has explained to the client each his/her next actions prior to assessing m the client's temperature, pulse, and blood pressure. However, the nursing student did not announce her intention to assess the client's respiratory rate prior to measuring it. What is rationale for the nursing student's decision to withhold this this information

The client may alter the rate of respirations if the client is aware that his breaths are being counted

Which situation would require the nurse to obtain a different set of sterile gloves? Select all that apply

The gloves are wrinkled in the palm, the package is wet from water on the bedside table, a tear is noted on the left ring finger

A nurse is caring for an 82 year old patient who was admitted to the healthcare facility for tachypnea and tachycardia. Which rationale below supports the clients condition

The heart and lungs work together to provide circulation of nutrients and oxygen

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without contaminating the sterile procedure?

The inner wrapping of an item on the sterile field

A nurse is wearing sterile gloves to perform a sterile procedure. Which of the following items listed below are considered sterile and can be touched by the nurse: select all that apply

The inner wrapping of an item on the sterile field, irrigation catheter on the sterile field, one sterile gloved hand touching the other sterile gloved hand

The nurse, after receiving report on assigned clients, begins assessments of the clients. What is the primary purpose of assessing clients

The nurse is able to identify actual and potential health problems of the client.

A nurse is preparing a sterile field for assisting a provider with a sterile procedure. The nurse recognizes that which of the following has contaminated the field

The nurse moistens a cotton ball with sterile normal saline in places in on the sterile field

A nurse has a sterile package and has placed it on a clean surface in preparation of an invasive procedure. What is the rationale for unfold in the first flap farthest from the body

The nurse risks reaching across the sterile package

An intervention on the part of a nursing instructor would be required in which situation? A student

Ties the lowest strings of the mask up on the head

A nurse is reviewing hand hygiene techniques with assistive personnel (AP). Which one of the following instructions should the nurse include when discussing handwashing

Use a clean paper towel to turn off hand faucets

A nurse is examining a client with cirrhosis of the liver for Adema. The nurse notes the identification of 8 mm remains on the ankle for two minutes after removing finger pressure and skin swelling is obvious on inspection. How should the nurse document the finding

4+ pitting edema

The charge nurse recognizes that a client with a______ score on the Morse fall scale is at the highest risk for falling?

50

Inappropriate intervention for a older, frail client who is at risk for falls is

A 2-hour toileting schedule while the client is awake

A piece of indicator tape has been applied to outer wrapper of a set of surgical instruments. Which findings cusses the nurse to reject the instruments?

A strike-through line is present on the tape

A nurse is conducting a neurological assessment on a client. The client was unable to remember the date and time, how would the nurse document the level of consciousness

AAOX3 to person, place, and situation

Which of the following findings should the nurse expect to hear when auscultating the thorax (chest)

Bronchovesicular

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of bread sounds are these

Bronchovesicular

The nurse is performing a focused assessment of the clients cardiovascular system every four hours. Which specific assessment will the nurse include? Select all that apply

Capillary refill of extremities, strength and equality of peripheral pulses, blood pressure, skin color moisture in temperature

The minimum data set (MDS) is used to

Collect essential information

A nurse has documented in assessment of a client and documents lordosis as part of the spinal assessment. What is lordosis

Concavity of the spine

A nurse is instructing a group of nursing students in measuring a clients respiratory rate. Which guideline should the nurse include

Count each ventilation as one breath

A nurse is cleaning the bedside table of a client who has a respiratory infection the nurse picks up the clients use tissue and then touches his/her face near the mouth and inhales the microorganism and the nurse becomes ill. How was the organism that causes disease transmitted

Direct contact

A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. The client is oriented to person, place, time and situation. Which of the following actions by the nurse are appropriate to decrease the risk of fall? Select all that apply

Ensure that the client call light is within reach, provided client with nonskid footwear, complete a fall risk assessment

An elderly female client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician orders in reads the order "NPO", based on this order, what action should the nurse take

Ensure that the client does not eat or drink anything

A nurse is caring for a client at the local healthcare facility. What ensures that the HIPPA legislation is implemented at the facility

Ensure that the nurse calls the receiving facility prior to faxing records

A nurse observe smoke coming from under the door of the nurses lounge. Which of the following is the priority action by the nurse

Evacuate the clients

A healthcare agency is applying for accreditation and the accrediting agency is conducting audits of randomly selected medical records. To support the agencies accreditation, the medical records should include

Evidence that nursing interventions have been evaluated in terms of the clients response

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. Which of the following links in the chain of infection is a dress with the nurse attempt to contain a clients diarrhea

Exit route

A nurse is caring for a client at a healthcare facility has to maintain a medical record for the client. Which of the following is the use of the medical record

Investigate the quality of care in the agency

A nurse is caring for a client that has tuberculosis. According to CDC guidelines for transmission based precautions. Which personal protective measures should be so the nurse implement

Put on a fit tested N 95 respirator and the client should be in a airborne infection isolation room

When documenting information in a clients medical record, what should the nurse do consistently for each entry

Sign each entry by name and title

A nurse is caring for a client with a fever of 103.2 F. The client's wife asks "why does his body get so hot like that?" Which is the best response by the nurse

"A fever is the body's way of creating an environment that is harmful to germs"

A nurse is planning to conduct vision screening as part of a health assessment. What equipment would be needed to test vision

Snellen chart

An older adult asks the nurse what are yellowish brown spots on his/her hands? After examining the clients hands, the nurse recognizes the skin characteristics and correctly documents it as

Solar lentigines

In order to develop a sterile conscience, The nurse needs to be aware of the conditions to impact stability. Which equation is helpful to the nurse

Sterile + sterile = sterile

The nurse is taken care of a client who is burned over 90% of the body. The nurse perform hand hygiene, before performing the daily task the nurse put on

Sterile gloves

The nurse manager recognizes that a nurse requires further teaching about infection prevention when which comment is made by the nurse

Sterile technique prevents contamination during invasive procedures

A client who is bedridden is scheduled to receive subcutaneous injections of heparin at 8:00 AM and 8:00 PM each day. The client's medication administration record be present these times as

0800 and 2000

A nursing assistant reports that a resident has been found lying on the floor of the bathroom. Prioritize the actions of the nurse from first priority to last priority

1) ask the patient if they are okay (assessing responsiveness) 2) assess the patient's vital signs 3) Notify the supervisor to determine the next action 4) Notify the MD or physician

A man is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man

Airborne

A client presents to the clinic with high fever rash and breathing difficulty. The client is a park ranger who spends most days outside in heavily wooded areas. The client remembers stepping in a tick nest recently. Which treatment does a nurse expect to treat the client with

Antibiotic

A client with a viral infection is demanding that the nurse practitioner write an order to administer an antibiotic to treat the infection. Which is the most appropriate response

Antibiotics would not be effective against a viral infection

A nurse is assessing a client during comprehensive physical examination, the nurse asses the head and neck. Which finding would the nurse expect in an older adult

Arcus Senilis

A nurse is caring for a client that has a fractured femur, the blood pressure reading is 140/94 mm Hg in the left arm. Which action should the nurse take first

Ask the client if he/she is in pain

A nurse is beginning a head to toe assessment by assessing which element of the procedure first

Assessing the clients vital signs

Adequate circulation is present if the nail beds

Blanch on pressure and color return in 5 seconds

Reminder devices that are used to help prevent falls include

Bolsters and over bed table

A nurse is reviewing with a newly hired nurse the difference in localized infection versus a systemic infection. The nurse indicates understanding when she states which of the following are manifestations of a systemic infection. Select all that apply

Fever, malaise, increased pulse in respiratory rate

A nurse is assessing the apical pulse for the rain, rhythm, and strength of the heartbeat. The nurse places the stethoscope with a die from over the point of maximal impulse which is located at the

Fifth intercostal space in the middle left midclavicular line

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold last? The

Flap closest to the body

A nurse is entering a clients room who recently had a repair of a fractured hip. The client tells the nurse "I have had a lot of pain in my abdomen". What type of assessment with a nurse conduct

Focused assessment

Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? It

Focuses on abnormal findings

The client reports experiencing abdominal pain. The nurse auscultate the clients abdomen and hears gurgling sounds. What additional information does the nurse assess about the gurgling sound

Frequency

In what order would you put on the following personal protective equipment needed to care for a client that has transmission based precautions

Gown, mask or N 95 respirator, goggles are face shields, hair cover, shoe covers, gloves

Upon entering the clients room at the beginning of a shift and throughout the shift, the nurse assesses a client. The nurse consider the clients plan of care in response to Nursing interventions during the assessments. What type of assessment the nurse is performing

Head to toe assessment

A nurse is preparing to auscultate a clients abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect

High pitched clicks

Which aseptic principal below indicates that the nurse understand surgical asepsis

Hold the bottle 4 to 6 inches above the sterile basin to pour contents

A nursing student identifies that part of the syringe needle are considered sterile. Which part of the syringe and or needle was correctly identified by the nursing student as being sterile

Hub of the needle

Which is an example of the body's defense against infection

Hydrochloric acid in the digestive tract

The nurse is Richard ministry vaccination to a client who has mini allergies, after donning gloves in wiping the clients on with an alcohol swab, the nurse notices the client has began to develop hives, swelling, watery eyes, and he's coughing. The nurse suspects

Hypersensitivity

The nurse is evaluating a clients understanding of teaching regarding home oxygen therapy. Which statement by the client indicates that teaching has been effective

I should avoid wearing wool blankets or sweater

The nurse established a sterile field for a dressing change. Which location is outside of the boundaries when considering the location of the safety zone for the sterile field

In front of the body

A nurse has received change of shift report it as briefly review in the documentation about a client in the clients medical record. A Recents entry reads, "client was upset throughout the morning". To improve the charting entry, it should

Include clearer descriptions of the clients mood and behavior

A nurse is caring for a client who is being treated by three physicians uses the source oriented format for documentation. What are the benefits of using this formal documentation

Information is documented in separate forms by each healthcare personnel

A nurse enters a room to assist a client who has used the bedside commode. The nurse washes the clients hands, put on clean gloves, assist the client in cleaning the genital area, and then assist the client into bed. The nurse then empties, rinses, and replaces the pan of the bedside commode. The nurse removes the gloves and washes his or her hands. Which is the nurse practicing

Medical Asepsis

Which of the following assessment findings requires immediate intervention

Nonblanchable erythema of both heels

The nurse is attempting to locate the pedal pulse on a client who has been admitted following injury to the upper right leg. The nurse should palpate and document the location of the pulse as

On the dorsal surface of the foot

While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds

Opening of the closed of alveoli

Which nursing intervention does not require sterile procedure

Oral suction of the mouth

A nurse is using inspection as an assessment technique. What does the nurse used during inspection

Otoscope and penlight

When measuring the blood pressure after placing a cup correctly on the arm, the nurse process which of the following

Palpate the artery

A nurse is assessing a client thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply

Palpate the thyroid in the lower half of the neck, feeling the thyroid ascend as the client swallows, and inspection of the jugular veins for distention

The nurse prepares perform a sterile dressing change. Which finding would cause the most concern for the nurse when gathering supplies. A

Partial bottle of sterile Saline is open in the client's room

To help reduce hospital-acquired infections (HAIs), the nurse's first priority is to

Perform strict hand washing before and after care of each client

When entering a client room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions with the nurse take when preparing the sterile field

Place a mask on the client to limit the spread of microorganisms into the surgical wound

A client is admitted to the hospital with tuberculosis. Which of the following will prevent microorganisms from floating from the clients room into the hallway

Placement of the client in an airborne infection isolation room

Standard precaution was developed by the CDC to

Prevent transmission of pathogens

A nurse is maintaining a problem oriented medical record for a client. Which component of the record describes the clients response as to what has been done and revisions to the initial plan

Progress note

The experienced nurse in an intensive care unit is orienting a new nurse. Which actions by the nurse requires the experienced nurse to intervene immediately? Select all that apply

Rearranges items in a sterile pack before donning gloves, turns toward the client, with the back toward on the sterile field, places sterile pack with the first flap facing toward the right

The nurses exiting the room with a client who has a clostridium difficile infection. What actions with the nurse perform select all that apply

Remove gloves by securing the first glove inside the second glove, turn gown inside out and roll gown into a bundle before discarding, wash hands with soap and water

The nurse document that the client has Kussmaul respiratory pattern. Which interpretation of the nurses documentation is correct

Respirations have a regular rhythm with abnormal deep and rapid respirations

The nurse is conducting an assessment on the integumentary system and knows that the client skin on the right arm is bluish-purple and the left arm is greenish-yellow. The nurse documents

Right arm has echoymosis in the left arm has resolved ecchymosis

As a component of a head to toe assessment, the nurse is preparing to assess consensual response of the clients eyes. How should the nurse conduct this assessment

Shine the pin light in the eyes to observe constriction of both pupils

When assessing the eyes of a client, which characteristic is commonly seen

Shining a light in the opposite eye both pupils will constrict

A nurse educator is teaching a group of new graduate nurses about how to correctly apply restraints. The nurse educator recognizes that further instruction is warranted when a new graduate nurse states, "I should

Use bolster to prevent falls

When opening a wrapper containing sterile gloves the nurse opens the outer wrapper and discards it, positions the inner wrapper of the cuffs of the gloves are towards the nurse and maintains stability by touching the 1 inch vertical flaps of the inside wrapper. What is the nurses next step

Use non-dominant hand to pick up the glove by the cuff

A nurse is caring for a client has been placed in contact based precautions due to infectious diarrhea. The nurse should follow the CDC's guidelines by performing which intervention

Wash hands, put on gloves and gown before entering the room

A nurse is informing a nursing student about the centers for disease control and prevention CDC guidelines for hand asepsis. Which guideline is in compliance with the CDC guidelines for handwashing? Washing

When hands are visibly soiled

A nurse has orders to clean the open wounds of a client who has been involved in an automobile accident. What intervention with the nurse perform and cleaning a clients open wounds to protect against infection

Where a clean pair of latex or latex free gloves

A nursing student is assisting and 88 year old client from a supine position to a sitting position to go to the bathroom. The client faints. The nursing student understand what the cause of the fainting is due to

increase vasoconstriction of the veins

A nurse charting the medical record for a client knows that which form of charting involves writing information about the client and client care in chronological order

narrative charting

When assessing the abdomen, which assessment technique is used last

palpation

Various microorganisms cause different problems. Diarrhea is often caused by

protozoa

A nurse is assessing the lung sounds of a client with respiratory disorders. What is a normal bronchial sound

shorter on inspiration than expiration, with a pause between them