Chapter 3, 4, 22
The nurse needs to add sterile dressings in peel-open packages to an established sterile field. Which method will the nurse use to prevent contamination of the field or the added items?
The nurse approaches from the side to drop the items on the sterile field.
The nurse is preparing a sterile field using a drape provided inside a sterile pack. Which area of the sterile drape can the nurse touch in order to maintain sterility?
The outer 1-inch border of the drape
The newly hired surgery nurse is preparing to open a sterile pack for the first time. Which principle will the nurse apply to maintain the sterile field?
The pack is placed unopened on top of a surgery table.
A client has hyperactive bowel sounds, diarrhea, nausea, vomiting, and has lost five pounds over the last week. Which type of nursing diagnosis statement should be created for this client?
Three-part
A nurse requires supplies and equipment that have been prepared for surgery. Which preparation method does the nurse recognize as being inadequate for surgical asepsis?
Ultrasound
The nurse reviews information collected during the assessment of clients in the community clinic. Which information needs to be reported to the authorities?
An older client is afraid of a family member. Their are multiple bruises of varying colors on the back and abdomen of a 9year old. An older client refuses to answer the nurses question because an adult child will become angry
The nurse reviews outcome statements with a new colleague. Which information about outcome statements should the new nurse identify as being appropriate?
An outcome statement should be a realistic, specific action, an outcome statement is an action that is measurable and can be evaluated, and an outcome statement has a definite time frame for completion of the action
After providing morning care the nurse forgot to put the bed in the lowest position and left one of the bed rails down causing the client to fall. For which reason could the nurse be reported to the board of nursing?
Negligence
The nurse manager recognizes that a nurse requires further teaching about infection prevention when which comment is made by the nurse?
"Surgical asepsis is based on maintaining a clean client environment."
The RN teaches a group of LPN/LVNs about sterile technique in long-term care facilities. Which comment by an attending LPN/LVN indicates understanding of the teaching?
"The presence of pathogens in a long-term facility is just as concerning as in a hospital."
The LPN/LVN prepares to assist the RN in teaching a client how to perform in-home self-catheterization. The client asks, "Will you be sending a crate of sterile gloves home with me?" Which reply is correct?
"You will not need sterile gloves to do this at home."
The surgery nurse knows that a surgical hand scrub should be performed for a minimum of which time frame
3 minutes
The legal department for a health care organization is collecting information about standards of care. For which reason will these standards be used?
A court case involving care provided by a nurse to a client
During evening rounds the nurse finds a client lying in the floor next to the bed what should the nurse do when documenting this situation?
Document the incident in the medical record but not mention an incident report was completed
The nurse has been reported to the board of nursing for performing skills that are outside the legal scope of practice. What should the nurse expect to occur next?
A hearing by the board of nursing to determine whether the charges are true
The legal department of a hospital is preparing a seminar to review the different types of laws that must be followed while providing client care. Which could be used as an example of a criminal law?
A nurse temporarily providing a client with excessive intravenous fluid to hasten death
The nurse prepares to perform a sterile dressing change. Which finding will cause the most concern for the nurse when gathering supplies?
A partial bottle of sterile saline is open in the client's room
The nurse prepares to perform a sterile dressing change. Which finding will cause the most concern for the nurse when gathering supplies?
A partial bottle of sterile saline is open in the clients room
A piece of indicator tape has been applied to the outer wrapper of a set of surgical instruments. Which finding causes the nurse to reject the instruments?
A strike-through line is present on the tape
A client telephones the home care agency to find out why the nurse did not arrive as scheduled to change a foot wound dressing. For which situation should the agency manager investigate?
Abandonment
A newly hired surgical nurse is being oriented. The nurse should expect to see surgery personnel rinse their hands following the performance of a surgery scrub by holding fingertips
Above the elbows
The nurse is planning care for an assigned client. Which information indicates that the outcome statements are written correctly?
Actions can be measured, action that the client can perform, action to be performed by the client, and action can be completed with a specific time frame
The nurse is preparing to instruct a client on how to change an ostomy appliance what should be addressed prior to beginning this teaching session to ensure optimal learning occurs?
Address lower level needs
During lunch in the cafeteria the nurse overhears two colleagues discuss the care issue of a client. Which action should the nurse take?
Ask the colleagues to stop talking about the client in a public area
While caring for a newly admitted client the RN gathers information by interviewing the client to obtain a health history and reviewing the results if laboratory and diagnostic tests. Which step in the nursing process did the nurse complete?
Assessment
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?
Below the draped surface
A client has a critical pathway to be used for providing care. Which should the nurse keep in mind when following this plan of care?
Care is based upon the day of hospitalization
The hospital is focusing on cost containment related to client care. The nurse recognizes that which situation requires medical asepsis?
Changing linens for a client with infection
A surgery technician is using a liquid to sterilize some rubber-based catheters for urological procedures. Which method of sterilization does the nurse recognize?
Chemical Disinfection
The nurse reviews a care plan written for a client. Which nursing diagnosis should the nurse delete from this plan?
Chronic fatigue syndrome related to poor diet
The nurse meets with the physical and occupational therapist to plan care for a client with nerve damage cause by a back injury. Which type of intervention will be listed on the plan of care?
Collaborative
The nurse is planning to move to another state. Which action should be done to ensure that the nurse can legally practice nursing in the new state?
Contact the state board of nursing of the new state to request state licensure
While performing a shift assessment, the nurse visually examines a clients body for rashes and breaks in the skin, and looks for a normal appearance of eyes, ears, nose, mouth, limbs, and genitals. Which assessment technique is the nurse using?
Inspection
When preparing a plan of care the nurse uses skillful reasoning and logical thought to determine the merits of an action. Which action is the nurse performing?
Critical thinking
The nurse prepares a handout about the nursing process for an orientation class of new colleagues. Which should the nurse explain this process
Decision making framework used by nurses to determine the needs of clients
A client with diabetes is being treated for an infected foot wound. Which would be an appropriate short term goal for this client?
Demonstrates correct technique for self injection of insulin
The nurse reviews a care plan for a client. Which are indirect nursing interventions in this plan of care?
Documenting a clients bath and informing the physician about a clients pain
The student is preparing a concept map prior to caring for a client during the next clinical day. Which should the student do when creating this map?
Follow the nursing process
A multi-organization health care system learns that the billing department computer software was hacked and confidential information about 10,000 current and former clients was obtained. Which should be reviewed to handle this situation?
HITECH
The nurse reviews problems identified for a client. Which problem should the nurse list as a priority?
Has irregular heart rhythm
The nurse is deciding about how to determine what size of sterile gloves fit properly. Which information will help the nurse make a correct decision?
The gloves should fit closely to the skin.
The circulating nurse is assisting in the operating room and is asked to open a sterile pack and give the contents to the surgeon. Which action should the nurse perform?
Hold the contents by the opened outer wrapper for the surgeon to grasp.
During a home visit, the nurse is asked to deposit cash in the clients bank account at the end of the visit. Which should the nurse say in response?
I cannot be held responsible for depositing money in your account. Can a family member do it?
The nurse manager is concerned about sexual harassment occurring on the care area. Which statement should be investigated further?
If I take your client in room 203 pain medication what are you going to do for me. Male nurses never carry their weight, I think they use the fact that a female client won't let them catheterize them as an excuse, so they don't have to put in a urinary catheter
The nursing student is preparing a care plan for an assigned client. Which should the nurse include that is lease likely to be placed on an individualized plan of care for the same client?
Impact of laboratory data on selection of an intervention
The nurse is preparing to care for a client. Which action should be completed before implementing any identified interventions?
Maintain privacy, explain the procedure, gather equipment and supplies, and check the health care providers order
The charge nurse is concerned that client information was inappropriately shared with family. Which would the nurse observe to come to this conclusion?
Nurse left the computer screen with laboratory data in view at the bedside with family present
An adolescent client is injured during a football game. What should the nurse do before providing this client with treatment?
Obtain a custodial parents signature on the informed consent
The nurse is preparing to care for several assigned clients. Which action should be taken to ensure that care is provided in a safe manner?
Perform the actions withing the scope of practice of the nurse practice act and check the clients armband to ensure the correct client is receiving the intervention
The nurse is reviewing the NANDA-I list of nursing diagnoses while preparing a clients plan of care. Which term should the nurse search it the client has edema of the legs causing an alteration in perfusion and risk for injury?
Perfusion
The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy. Which intervention is individualized for this client?
Provide 8 ounces enriched milkshake mid-morning and mid-afternoon
The LPN/LVN is assisting an right now who is caring for a mentally competent client with a terminal illness. The client refuses to take prescribed medications. Which action should the nurse take?
Report the clients decision to the right now in charge and the primary Heath care provider and continue to provide appropriate compassionate care
The nurse witnesses a coworker taking a narcotic medication prescribed for a client. Which action should the nurse take first?
Report the incident to the nurse supervisor
In order to develop a sterile conscious, the nurse needs to be aware of the conditions that impact sterility. Which equation is helpful to the nurse?
Sterile + sterile = sterile
The nurse understands the importance of sterile technique during certain client care procedures. Which procedure will require sterile technique?
Subcutaneous injection given
The LPN/LVN is told to provide an intravenous push medication through clients central line. Which action should the nurse take?
Suggest that an RN provide the medication
The nurse is observing as a health care provider places a central line in a client. The nurse notes that the health care providers tie is touching the sterile field. Which action must be taken by the nurse?
Tell the health care provider to stop the procedure immediately and why
The nurse is observing as a health-care provider places a central line in a client. The nurse notes that the health-care provider's tie is touching the sterile field. Which action must be taken by the nurse?
Tell the health-care provider to stop the procedure immediately and why
The RN is observing an LPN/LVN perform a sterile procedure. Which observed behavior requires the RN to intervene?
The LPN/LVN turns away from the sterile field.
A client requests a copy of the medical record for a family member. Which response should the nurse make?
The chart belongs to the hospital, but if you give written permission a copy can be made for you
The nurse is caring for an adolescent client who is married in the military and has a new baby. Which should the nurse consider when providing care to this client?
The client can sign the informed consent form for a blood transfusion
The nurse is performing a shift assessment on a client. Which information should the nurse identify as objective data?
The client demonstrates facial grimacing
The LPN/LVN assists the right now in completing an admission history with a confused client. Which information should be the identified as secondary information?
The clients spouse reports experiencing marital issues
The nurse feels that a client needs to be placed in a protective restraint device to be protected from injury. Which action should the nurse take to use the restraints?
The nurse must have documentation that other methods have been used and failed to protect the client
The nursing staff educator observes a nurse who collects and prepares sterile supplies for a procedure. Which behavior indicates to the staff educator that additional teaching is needed?
The nurse rejects packs with dark hash marks on the sterilization tape.
