EAQ 1 & 2
which statement made by the student nurse about precautions to take when treating a client with open burns wounds indicates the need for further teaching? a) "I should use non sterile gloves when applying ointments." b) "I should use non sterile, disposable gloves when removing old dressings." c) " I should wear personal protective equipment before caring for the client." d) " I should remove personal protective equipment before leaving one client to treat another."
a) "I should use non sterile gloves when applying ointments."
the nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? a) Don an N95 respiratory mask before entering the room. b) put on a permeable gown each time before entering the room. c) implement contact precautions and post appropriate signage. d) after finishing with client care, remove the gown first then remove the gloves.
a) Don an N95 respiratory mask before entering the room.
the nurse is developing a plan of care for a client who underwent extensive oral surgery for head and neck cancer. Which interventions would the nurse include in the plan to prevent infection? Select all that apply. One, some, or all response may be correct. a) Protect incision site. b) elevate head of the bed. c) remove thick secretions. d) offer small frequent feedings. e) provide oral care at least every 4 hours.
a) Protect incision site. c) remove thick secretions. e) provide oral care at least every 4 hours.
for which physical assessment situation would the nurse use an alcohol-based hand sanitizer for hand hygiene? a) before and after palpating a pulse b) assessing a client with norovirus c) if the hand brushes a seeping dressing d) when the hands have contacted sputum
a) before and after palpating a pulse
which technique would the nurse use to maintain surgical asepsis? a) change the sterile field after sterile water is spilled on it. b) put on sterile gloves before opening a container of sterile saline. c) place a sterile dressing no more than half an inch from the edge of the sterile field. d) clean the surgical area with a circular motion, moving from the outer edge toward the center
a) change the sterile field after sterile water is spilled on it.
which factor would the nurse consider when counseling an older adult on how often to take a tub bath? a) condition of the skin b) ability of the client to provide self-care c) degree of orientation to the environment d) type of allergic reactions experienced by the client
a) condition of the skin
which statement regarding preventive measures for genital tract infections indicates the need for further education? Select all that apply. One, some, or all responses may be correct. a) "I should take frequent bubble baths." b) " I should decrease the use of dietary sugar." c) "I should choose hosiery with a nylon crotch." d) "I should use colored and scented toilet tissues." e) "I should limit the time spent in damp exercise clothes."
a) "I should take frequent bubble baths." c) "I should choose hosiery with a nylon crotch." d) "I should use colored and scented toilet tissues."
which finding in the older adult client is associated with urinary tract infection (UTI)? Select all that apply. One, Some, or all response may be correct. a) Dysuria b) Urgency c) Confusion d) incontinence e) slight rise in temperature
c) Confusion d) incontinence e) slight rise in temperature
which client's care can be safely delegated to the unlicensed assistive personnel (UAP) to provide oral hygiene? a) dental caries b) oral cancer c) jaw fracture d) thrombocytopenia
a) dental caries
which nursing interventions enhance comfort in a dying client in the hospital? Select all that apply. one, some, or all responses may be correct. a) frequently repositioning the client b) maintaining oral hygiene in the client c) limiting frequent visits of the family members d) measuring the vital signs of client frequently e) applying body lotion to the client's skin daily
a) frequently repositioning the client b) maintaining oral hygiene in the client e) applying body lotion to the client's skin daily
the nurse is preparing to change a client's dressing. For which reason would the nurse use surgical asepsis? a) keeps the area free of microorganisms b) confines microorganisms in the wound c) protects self from microorganisms in the wound d) reduced the risk for growing opportunistic microorganisms
a) keeps the area free of microorganisms
which risk factor increases a client's risk for infection in the community? select all that apply. One, some, or all responses may be correct. a) lifestyle b) occupation c) chronic diseases d) frequent traveling e) diagnostic procedures
a) lifestyle b) occupation d) frequent traveling
which leukocyte value determines the adequacy of a client's response to inflammation? Select all that apply. One, Some, or all response may be correct. a) monocytes b) neutrophils c) plasma cells d) T-helper cells e) macrophages
a) monocytes - destroy bacteria and cellular debris b) neutrophils - ingest and phagocytize microorganisms and foreign protein e) macrophages - destroy bacteria and cellular debris
the nurse is caring for a client who underwent a hysterectomy and is admitted to a general medical-surgical unit. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. One, some, or all response may be correct. a) oral hygiene b) assistance with bathing c) oral medication administration d) intravenous fluid administration e) providing treatments with supervision
a) oral hygiene b) assistance with bathing
the nurse is caring for a two days post-surgery hip-replacement client who has had a bowel movement. which nursing intervention would the nurse perform next? a) provide perineal care. b) turn and position the client. c) give a complete bed bath. d) document the bowel movement.
a) provide perineal care.
which instruction would the nurse give to a client with reduced sensory perception? a) 'apply moisturizers.' b) 'use of a bath thermometer. ' c) 'dress warmly in cold weather.' d) 'avoid frequent bathing.'
b) 'use a bath thermometer.'
which types of immunity will clients acquire through immunizations with live or killed vaccines? a) natural active immunity b) artificial active immunity c) natural passive immunity d) artificial passive immunity
b) artificial active immunity
which nursing interventions requires the nurse to wear gloves? select all that apply. one, some, or all response may be correct. a) giving a back rub b) cleaning a newborn immediately after delivery c) interviewing a client in the emergency department d) obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)
b) cleaning a newborn immediately after delivery c) interviewing a client in the emergency department
which information would the nurse include when educating a group of daycare workers on infection control guidelines? Select all that apply. One, some, or all responses may be correct. a) child pick-up b) cleaning toys c) hand hygiene d) food preparation e) Medication administration
b) cleaning toys c) hand hygiene d) food preparation
while assessing the nails of a client with diabetes, the nurse find the skin on the client's hands and feet are dry due to infection. which rationale would the nurse associate with this dryness? a) applying moisturizing lotion between toes b) cutting nails after soaking them for 10 minutes in warm water c) cutting nails straight across and even with the tops of the fingers or toes d) using sharp object to poke or dig under the toenail or around the cuticle
b) cutting nails after soaking them for 10 minutes in warm water
which nursing intervention would the nurse implement for a client with active tuberculosis who is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions? a) ensure regular visits by staff members to meet the client needs. b) explore what the airborne precautions mean to the client. c) report the situation to the infection control nurse immediately d) reteach the concepts of airborne precautions to the client.
b) explore what the airborne precautions mean to the client.
which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? a) wound asepsis b) medical asepsis c) surgical asepsis d) concurrent asepsis
b) medical asepsis
the health care team is delegated the talk of assisting a client with bathing. Which member of the health care team is responsible and accountable for this aspect of client care? a) nursing aide b) registered nurse (RN) c) patient care associate (PCA) d) licensed vocational nurse (LVN)
b) registered nurse (RN)
which is the correct response to a parent whose child is undergoing chemotherapy and is not up to date on requires immunizations for school? a) 'By this time your child has developed sufficient antibodies to provide immunity.' b) 'Maintaining current immunizations is critical. Make sure the series is completed.' c) 'This isn't the best time to finish the immunizations, because your child's immune system is suppressed.' d) 'it's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal.'
c) 'This isn't the best time to finish the immunizations, because your child's immune system is suppressed.'
which type of isolation precautions would the postpartum nurse plan to implement for a client who has given birth by urgent cesarean section related to active herpes simplex virus (genitalia) following onset of labor and rupture of membranes 8 hours ago? a) standard b) droplet c) contact d) airborne
c) contact
which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? a) insert a urinary catheter. b) initiate droplet precautions. c) move the client to a private room. d) use a high-efficiency particulate air (HEPA) respiratory during care.
c) move the client to a private room.
which information would the nurse include when teaching about why women are more susceptible to urinary tract infections than men? a) inadequate fluid intake b) poor hygienic practices c) the length of the urethra d) the disruption of mucous membranes
c) the length of the urethra
which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? a) the nurse understand the client has pain due to a tracheostomy. b) the nurse identifies the client is anxious about the cardiac catheterization. c) the nurse realizes the client has diarrhea and needs the bedpan frequently. d) the nurse identifies the client is not aware of perineal care and has impaired skin integrity
d) the nurse identifies the client is not aware of perineal care and has impaired skin integrity
Which evaluation method is the most effective way for the nurse to evaluate the teachers' knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques? a) observe the teachers lecture the children about hand hygiene. b) administer an objectively written final examination to the teachers. c) have the teachers share their knowledge of hand washing. d) watch the teachers demonstrate infection-control techniques.
d) watch the teachers demonstrate infection-control techniques
which strategy is MOST effective for preventing the transmission of infection? a) wearing gloves and a gown b) applying face mask and a gown c) applying a face mask and gloves d) wearing gloves and hand hygiene
d) wearing gloves and hand hygiene