AH1 fundamentals- week 7

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client? A. Airborne B. Protective C. Contact D. Droplet

B. Protective Rationale: Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a stem-cell transplant, require a protective environment.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust the water temperature to feel hot. B. Apply 4 to 5 mL of liquid soap to the hands. C. Hold the hands higher than the elbows. D. Rub hands and arms to dry.

B. Apply 4 to 5 mL of liquid soap to the hands. Rationale: The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? A. Steatorrhea B. Blood C. Bacteria D. Parasites

B. Blood Rationale: A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Use a stiff toothbrush to clean the client's teeth. B. Use the thumb and index finger to keep the client's mouth open. C. Turn the client on his side before starting oral care. D. Apply petroleum jelly to the client's lips after oral care.

C. Turn the client on his side before starting oral care. Rationale: Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. "I will try to anticipate and avoid stressful situations when possible." C. "I will complete the smoking cessation program I started." D. "I will take my medications at the first sign of an attack."

D. "I will take my medications at the first sign of an attack." Rationale: Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A. Pernicious anemia B. Dehydration C. Prostate enlargement D. Bladder infection

D. Bladder infection Rationale: The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick-release tie. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints to the lowest bar of the side rail. D. Anticipate removing the restraints every 4 hr.

A. Secure the restraints using a quick-release tie. Rationale: The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Information about a client can be disclosed to family members at any time." B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." C. "A client's address would be an example of personally identifiable information." D. "HIPAA is a federal law, not a state law."

A. "Information about a client can be disclosed to family members at any time." Rationale: This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information

8. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? A. Remove the catheter and insert another into a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Administer a local anesthetic.

A. Remove the catheter and insert another into a different site. Rationale: It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction two to three times with a 60-second pause between passes. B. Perform chest physiotherapy prior to suctioning. C. Lubricate the suction catheter tip with sterile saline. D. Hyperventilate the client on 100% oxygen prior to suctioning.

A. Suction two to three times with a 60-second pause between passes. Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before the instillation. B. Assist the client to a side-lying position. C. Hold the dropper 2 cm (1 in) above the naris. D. Instruct the client to stay in the same position for 2 min.

A. Tell the client to blow her nose gently before the instillation. Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? A. Excessive thirst and urination B. Shakiness and diaphoresis C. Fever and chills D. Hypertension and crackles

B. Shakiness and diaphoresis Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying

C. Atelectasis Rationale: Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? A. He is hard of hearing. B. Pain C. Confusion D. Language barrier

C. Confusion Rationale: Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.

C. Move any clients in the immediate vicinity. Rationale: The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

D. Checking the pupillary response to light Rationale: Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse? A. Invasion of privacy B. Assault C. Battery D. False imprisonment

D. False imprisonment Rationale: False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Maintain the head of the bed in a flat position for 30 min following medication administration. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

D. Flush the NG feeding tube with 30 mL of water immediately following medication administration Rationale: The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? A. Dorsal metacarpal vein B. Radial vein in the wrist C. Antecubital vein D. Median vein in the forearm

D. Median vein in the forearm Rationale: The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? A. The client who has a tracheostomy tube attached to humidified oxygen B. The client who has an indwelling urinary catheter to gravity drainage C. The client who has a chest tube to water seal D. The client who has a nasogastric (NG) tube to suction

D. The client who has a nasogastric (NG) tube to suction Rationale: Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.