Final Exam

The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling?

Exercise regularly.

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client?

Fever, malaise, anorexia, nausea, and vomiting

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing?

Materials used in dressing this wound should keep the wound bed moist.

A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing?

Maturation

The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective?

Report critical results of tests and diagnostic procedures on a timely basis.

During morning care, unlicensed assistive personnel observe a clients abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel do?

Report the dressing changes to the nurse immediately

The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which role?

Teacher

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms?

Voiding quantity sufficient

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection?

Wash hands.

A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved?

Wheezing of breath sounds in all lobes

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer?

When the first pulsation is felt

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide?

Wipe the skin with an alcohol-free barrier film agent after cleaning.

An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent?

apply a cold pack to the injection site

The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response?

at this age, the child is developing his own personality

A client taking calcium carbonate chewable tablets and ranitidine is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment?

gastric pH of 3

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

gown and gloves

The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2 of Korotkoffs sounds?

muffled, whooshing, or swishing sound

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?

on the nonoperative side with legs abducted

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?

private room or cohort client

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply.

provide soft diet, administer ibuprofen for fever every 4 hours as prescribed and as needed, instruct parents about the need to administer the prescribed antibiotics for the full course of therapy

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

serous drainage

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse

should receive specific training.

A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause

suppression of the inflammatory process necessary for healing.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

inhalation of bacterial spores, through a cut or abraisan in skin, ingestion of contaminated undercooked meat

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate?

Using personal protective equipment

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a clients room. What action should the nurse take first for this puncture wound?

Encourage bleeding.

A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements?

. Healing time will be longer. 4. Potential for scarring is greater. 5. Susceptibility to infection is greater.

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client?

. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants

A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make?

. It depends on the number of organisms present to cause a disease. 2. It depends on how aggressive the organisms are to cause a disease. 3. It depends upon how the organisms get inside the body to cause a disease. 4. It depends upon where the person is at the time the disease is present.

A client is prescribed antiembolic stockings. How should the nurse assess the skin on the clients legs?

. Remove the stockings for this assessment.

A client has received a high score on the Life-Change Index. For which part of the clients assessment should the nurse use this information?

Life stress review

The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching?

1. Always pull a plug at the plug-in from the wall outlet.

While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client?

Loosen any clothing around the neck and chest.

The client complains of difficulty breathing. Which assessment findings should the nurse associate with that complaint?

1. Use of accessory muscles 2. Increased respiratory depth 3. Increased respiratory rate 4. Decreased respiratory depth

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation?

Loss of subcutaneous fat is noted.

A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which cultural groups?

African American

Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take?

Add an additional dressing to the wound without removing the original

The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection?

Cover the mouth and nose when sneezing.

A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration?

Adjusting to physiologic changes and limitations

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up?

A reddish-purple mark on the neck

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The clinic nurse has conducted a health screening clinic to identify clients who are at risk for cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at lowest risk for developing this type of cancer?

A single white client

Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis?

A young adult who is in a long-term relationship

A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change?

Action stage

The nurse has applied an aquathermia pad to a clients back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. How should the nurse evaluate this request?

Adaptation of the thermal receptors often results in the decreased sensation of warmth.

A client is hospitalized with numerous acute health problems. According to Maslows basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?

Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients

The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection?

An 86-year-old female client on steroid therapy

A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client?

An immunization for rabies

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client?

Anxiety

A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this clients wound?

Apply a damp-to-damp normal saline dressing. Irrigate the wound. 5. Apply impregnated hydrogel.

The nurse is preparing to irrigate a clients abdominal wound. In which order should the nurse perform this irrigation?

Apply clean gloves. Select a syringe with a catheter attached or with an irrigating tip. Insert the catheter into the wound until resistance is met. Irrigate until the solution flows clear. Dry the area around the wound. Remove and discard clean gloves.

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care

While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first?

Ask the customer if he is choking.

The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading?

Assess that the equipment used is working properly.

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do?

Assist the client with hand washing.

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan?

Black

The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use for this assessment?

Brachial

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study?

Breast biopsy

The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care?

Burns

The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP?

Cardiac catheterization client returning to the nursing unit

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?

Clean areas of granulation tissue

The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After assessing the wound the nurse should take which action?

Cleanse the wound and apply a dressing

The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client?

Client is picking at the access site for intravenous infusion of chemotherapy.

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision?

Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery.

A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior?

Competing preferences

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first?

Complaints of pain associated with numbness and tingling in both feet

The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making?

Considering how the loss of a clients job will affect the regulation of the clients diabetes

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound should the receiving nurse plan care for this client?

Contaminated

Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying?

Contemplation stage

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that something popped in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first?

Cover the area with a large saline-soaked dressing

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation?

Dispose of blood-contaminated materials in a biohazard container.

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?

Dysuria and penile discharge

The nurse is preparing to apply a moist aquathermia pack to a clients left upper leg. In which order should the nurse prepare and apply this treatment?

Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer. Set the desired temperature according to the manufacturers instructions. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use. Apply the pad to the body part. The treatment is usually continued for 30 minutes. Use tape or gauze ties to hold the pad in place.

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?

Filtration and humidification of inspired air

While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose and eyes. What should the nurse do?

Flush the nose and eyes for 5 to 10 minutes with water or normal saline.

The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging?

Forearm Lower leg

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed?

Glipizide

The nurse is preparing to remove soiled gloves. What action should the nurse take first?

Grasp the outside of the nondominant glove.

A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection?

Hand-washing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing

The nurse is using Kalishs adaptation of Maslows hierarchy of needs when planning client care. Which client should the nurse identify as exhibiting a level of Kalishs adaptation?

Has a homosexual encounter for the first time

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease?

Have the client wear a mask when coming from admission.

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity?

Having chickenpox

A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This client is modeling which behavior?

Health protection

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply.

I should not use someone else's crutches, i need to remove any scatter rugs at home, i need to have spare crutches and tips available

The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client?

Impaired Tissue Integrity

While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client?

Increase fluid intake.

A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate?

Increased intracranial pressure

A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In describing Healthy People 2010, which goal should the nurse emphasize for this group?

Increasing quality and years of life

A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase?

Inflammatory

The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing?

Information dissemination

The nurse is assessing a clients pressure ulcer. To determine the depth of the ulcer, the nurse should take which action?

Insert a sterile swab into the deepest part of the wound

A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program?

Interpersonal influences

As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls?

Keep the environment tidy.

The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound?

Notify the physician of any edema, heat, or tenderness at the wound site.

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use?

Obtain a Doppler ultrasound stethoscope.

A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this clients care?

Obtain ice packs to apply to the wounds.

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use?

Oral

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

PTSD

The nurse is applying restraints to a client. After securing a health care providers order, what should the nurse do?

Pad bony prominences

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this clients room?

Paper towels, sink, and blood pressure cuff

The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurses advocacy?

Participating in a community-focused 5-mile run., Providing an educational program to senior citizens on blood pressurecontrol strategies. 4. Attending a community meeting that is promoting the creating of a walking path in the city park. 5. Encouraging an anxious client to practice relaxation techniques.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

Particulate respirator, gown, and gloves

A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions?

Perceived benefits of action

The nurse needs to apply personal protective equipment before entering a clients room. In which order should the nurse perform the following actions?

Perform hand hygiene., Apply the gown. Apply the face mask. Apply eyewear. Apply gloves.

Which determinant of blood pressure would explain a clients blood pressure reading of 120/100?

Peripheral vascular resistance

An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client?

Place a bed safety monitoring device on the bed.

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do?

Place a crib net over the top of the crib.

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client?

Place a rocking chair in the clients room.

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client?

Poor skin turgor. Diminished pain sensation. 4. Thin epidermis. 5. Dry skin.

A clients laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing?

Primary intention

The nurse is providing care within the total care context. What should the nurse consider when using this care approach?

Principles general to all clients of the same age and condition

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client?

Provide adequate lighting.

While changing a clients dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wounds drainage?

Purulent

The nurse documents that a clients postoperative wound is purosanguinous. What did the nurse assess in this clients wound?

Pus and red blood cells

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?

Reactive hyperemia

The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which is the most appropriate diagnosis for this client?

Readiness for Enhanced Coping

The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client?

Remain free from injury.

When assessing a clients peripheral pulse, the health care provider is also assessing which of the following?

Rhythm

A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate?

Risk for Impaired Skin Integrity

The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client?

Risk for Injury

A client has had a severe brain injury and has been in a rehabilitation hospital for several months. Recently, the client developed pneumonia and is currently on intravenous antibiotic therapy. Which level of prevention should the nurse use to address the health problem of pneumonia?

Secondary

The nurse educator provides developmental testing for kindergarten through thirdgrade students. Which level of prevention is the nurse performing?

Secondary

A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslows human needs theory, at which level should the nurse recognize that the client is struggling?

Self-esteem

The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment

Semi-Fowlers

A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound?

Semipermeable film dressing

During health history taking, the client complains of weight loss and diarrhea and says that he can "feel my heart beating in my chest." The nurse anticipates that which diagnostic test will most likely be prescribed by the primary health care provider (PHCP) in order to determine the underlying condition leading to the client's signs and symptoms?

Serum thyroid-stimulating hormone

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply.

Sleep problems, bipolar disorder, aggressive behavior, adhd

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client?

Use approximately a teaspoon of soap.

The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security?

Smallpox

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client?

Social Isolation

The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the clients life. What action is the nurse assisting the client to complete?

Spiritual health assessment

The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant?

Suffocation in the crib

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client?

Susceptibility of the client

A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client?

The application of cold constricts blood vessels. 3. The application of cold decreases inflammation. 4. The application of cold reduces localized pain.

The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client?

The client will establish a buddy system.

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex?

The client with impairment of vagus nerve conduction

The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism?

The clients heart rate increases when walking up a flight of stairs. 2. The client shivers when core body temperature drops. Decreased secretion of insulin occurs when food is not ingested.

The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client. Which characteristics should the nurse keep in mind during this assessment?

They are self-regulating. They are compensatory. They are regulated by negative feedback systems. They can require several feedback mechanisms to correct only one physiologic imbalance.

The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?

The joint capsule of the hip is visible.

The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision?

The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the clients skin?

Use a turn sheet lifted by two staff members to move the client in bed.

A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor?

Time management, Healthy eating habits, bicylcle safety for children

Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status?

Toes cool to touch

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings?

Too much pressure was applied over the pulse site.

The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask?

Touch the mask by the strings only.

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis?

Touching only the inside surface of the first glove while pulling it onto the hand

The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break?

Transferring a sterile object to a sterile field with a clean gloved hand

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores?

Trending would be more accurate if the same scale was used.

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using?

Triclosan, Isopropyl alcohol, Chlorhexidine gluconate

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome?

Unlicensed assistive personnel (UAP) followed a right sidebackleft sideback turning schedule.

The nurse is preparing to leave a clients isolation room. Which action should the nurse take first when removing a grossly soiled gown?

Untie the strings at the waist first

The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus?

X-rays

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?

allow client to interact with others in his or her same age group