Fundamentals CoursePoint Practice questions

When providing oral care, what does the nurse recognize as the most important component of the oral care process? -application of moisturizing ointment to the lips -a thorough, mechanical cleaning -selection of toothpaste -use of a mouthwash or breath freshener

-a thorough mechanical cleaning -No mouthwash, breath freshener, ointment, or paste replaces a thorough, mechanical cleaning of the oral cavity. Following the steps for cleaning the mouth thoroughly is more important than the agent used.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? -"I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." -"I will not visit my family member in the first 3 days of my cold." -"I will obtain a mask from the staff and wash my hands before touching my family member." -"If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

I will obtain a mask from the staff and wash my hands before touching my family member

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response? -"I will set up your bath for you. I will come back and help you with your bath." -"You will be able to take your bath by yourself tomorrow when you can get up." -"You will need to sit up for your bath, and then I will change your bed." -"I really have limited time. Let me give you your bath right now."

I will set up your bath for you. I will come back and help you with your bath.

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate (walk or move) independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings? -Partial care -The client should not be bathed -Complete bed bath -Independent showering

Independent showering - independence is encouraged

The nurse is changing a client's bedding. When removing the soiled sheets, what is the nurse's best action?

It is important to avoid any unnecessary contact with a client's soiled bedding to maintain the principles of infection control. The nurse must hold the bedding away from the front of his or her torso. Gloves must be worn during this task.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point? -Wash your face less frequently to avoid removing beneficial oils. -Keep hair off the face and wash hair daily. -Use cosmetics and emollients to cover the condition. -Gently squeeze the infected areas to release the infection.

Keep hair off the face and wash har daily

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? -Adolescents -Middle-age adults -School-age children -Older adults

adolescents

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? -vehicle -droplet -contact -airborne

contact

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? -Do not retract the foreskin in an uncircumcised male. -Always proceed from the most contaminated area to the least contaminated area. -Dry the cleaned areas and apply an emollient as indicated. -Powder the area to prevent the growth of bacteria.

dry the cleaned areas and apply emollient as indicated

The nurse is caring for an older adult client who has refused a bath for several days and has now developed a rash on the buttocks. What is the priority nursing intervention? -Explain that cleanliness helps to remove bacteria from skin, which can prevent infection. -Offer a choice of types of soap and shampoo. -Encourage the client to help with self-hygiene as able. -Schedule a bath in the morning or evening according to client's preferred bathing time.

explain that cleanliness helps to remove bacteria from skin, which can precent infection

When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that: -hair should be washed as often as necessary. -braids should be undone every day. -lubricants or oils should not be used on the braids. -combs should be washed as often as necessary.

hair should be washed as often as necessary

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? -handwashing before leaving the client's room -remove the garments that are most contaminated -make contact between two contaminated surfaces -make contact between two clean surfaces

hand washing before leaving the clients room

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide? -"After brushing dentures, leave them out of the client's mouth overnight." -"Use your ungloved hands to remove an unconscious client's dentures." -"Clean dentures with hot water to eliminate bacteria." -"Hold dentures over a plastic basin or towel when cleaning them."

hold dentures over plastic basin or towel when cleaning them

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps? -The client's history of oral surgery -How often the client sees the dentist for oral care -How often the client brushes and flosses the teeth -How many cavities the client has had

how often the client brushes and flosses the teeth

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene? -Wash hands with soap and hot water. -Do not wash hands; apply clean gloves. -Decontaminate hands using an alcohol-based hand rub. -Wash hands with soap and water, followed by an alcohol-based hand rub.

decontaminate hands using an alcohol-based hand rub

The nurse is making the bed in a room after a client has been discharged. What is the nurse's best action?

The nurse should put down an absorbent pad under the area where a client's pelvis would be. If it is too high in the bed, it will be ineffective. It should go under the topsheets, not over them. It should be laid down before the blankets, not pushed into place after them.

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

- Decontaminate hands using an alcohol-based hand rub - Alcohol-based hand rubs can be used if hands are not visibly soiled. If the hands are visibly soiled, the nurse should wash hands with soap and hot water. The nurse should wash their hands. The nurse does not need to wash their hands AND use an alcohol-based hand rub.

A nurse is caring for a client with rubella (German Measles). Which nursing action is an important precaution to be taken when caring for this client?

- wearing a mask when working within 3 feet (1m) of the client - Rubella spreads through droplet transmission; therefore, the nurse should wear a mask when working within 3 feet of the rubella client as a precaution against droplet transmission. Changing gloves after contact with the client's infective material and washing hands with an antimicrobial agent or waterless antiseptic agent are contact precautions used for clients with diseases that spread through contact transmission. Using a special high-filtration particulate respirator is an airborne precaution followed in cases of clients with active tuberculosis.

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply. -"It is important to include hair care and shampooing along with brushing in your hygiene routine." -"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"Hygiene measures have no affect on skin." -"Bathing regularly and applying lotion and cream as needed are important."

-"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"Hygiene measures have no affect on skin."

The nurse is caring for four clients. For which client is a site (warm shallow bath) bath most appropriate? -73-year old with pneumonia who can get up to bedside commode -60-year old who is 1-day postop from a knee replacement -51-year old with hemorrhoids -42-year old recovering from a C-section delivery

-51 year old with hemorrhoids -A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. Therefore, the client with hemorrhoids would benefit from this type of cleansing treatment. The other clients do not get as much benefit from this type of bath.

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

-All visitors who enter the room must wear special masks -Tuberculosis is an airborne respiratory disease, which requires a HEPA-style respirator or N95 mask when visitors or staff enter the room of a client with known or suspected disease. Gowning and gloving do not prevent airborne transmission. Visitors are permitted and there is no firm prohibition against touching the client.

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?

-Before entering the client's room -The nurse should don the gown before entering the client's room to prevent soiling/contamination of the nurse's clothing with infectious bacteria/viruses and/or the client's blood and body fluids. The donning of the gown should be performed prior to assessing the client or performing a full set of vital signs (e.g., pulse, respirations).

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention? -Clip the toenails with large clippers. -Contact a podiatrist to care for toenails. -Clean under the toenails with a wooden orange stick. -Use a handheld electric rotary file to reduce the length of the toenails.

-Contact a podiatrist to care for toenails -Clients who have diabetes, impaired circulation, or thick nails are at risk for vascular complications secondary to trauma. The services of a podiatrist should be obtained. It is not appropriate to clip the toenails with large clippers, use a handheld electric rotary file, or clean under the toenails with a wooden orange stick.

A client is hospitalized with uncontrolled diabetes. Which action(s) does the nurse take to promote circulation and prevent circulatory complications? Select all that apply. -Apply lotion to the tops and bottoms of the feet and between the toes. -Inspect the client's feet daily. -Cut the toenails straight across and file the edges with an emery board. -Clean the feet daily with warm water and a mild soap. Soak the feet every day in very warm water and a mild soap.

-Inspect the client's feet daily. -Clean the feet daily with warm water and a mild soap. -Cut the toenails straight across and file the edges with an emery board.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

-Raise the bed to elbow height -Proper bed height helps reduce back strain while performing the procedure. A protective pad keeps the sheets from getting wet. Placing a drain container under the shampoo board prevents a mess on the floor. Closing the curtains around the bed and closing the door to the room provides for client privacy.

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

-The clients immune system became further weakened -Unless the supporting host becomes weakened, normal flora remains controlled. If the host's defenses are weakened, as in cases of HIV/AIDS, even benign microorganisms can cause opportunistic infections. This phenomenon is not due to mutations, spore production or the direct effects of a nutritional deficit.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?

-The new nurse touches 1.5 in. (4 cm) from the outer edges. -The outer 1 in. (2.5 cm) of the sterile package is safe to touch. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

-To protect both the staff and clients from becoming infected by one another

Which are recommended guidelines for daily care of a client who has an indwelling urinary catheter? Select all that apply. -Perform care of the indwelling urinary catheter before perineal care. -Slightly pull on the catheter during the cleaning motion to dislodge crusts. -Put on sterile gloves before cleaning the catheter. -Clean 6 to 8 in of the catheter, moving from the meatus downward. -Inspect the meatus for drainage and note the characteristics of the urine. -Use an antiseptic cleaning agent or plain soap and water on a clean washcloth.

-Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. -Clean 6 to 8 in of the catheter, moving from the meatus downward. -Inspect the meatus for drainage and note the characteristics of the urine.

A nurse is changing the dressings of a client in the burn unit. Which action(s) should the nurse perform to maintain asepsis and client comfort? Select all that apply. -Practice good personal hygiene including showering before each shift. -Wash hands thoroughly and then don sterile gloves. -Ensure family visitors know they cannot bring flowers or fresh fruit to the client. -Utilize isolation precautions including donning gloves, gowns, and face mask. -Keep nails short with no polish.

-all of the above -To prevent the spread of infection and follow strict asepsis, the nurse should wash hands and wear sterile gloves before performing any invasive procedure on a client. When entering a high-risk area such as a burn unit, the nurse should use antiseptic cleansing agents, nail files, and antiseptic-impregnated scrub brushes and keep nails short with no polish. Nurses should also don all personal protective equipment including gloves, gown, and face mask while in the isolated room of a client. Flowers and fresh fruit can grow mold and family should be instructed the client cannot have these in the room. Showering and other personal hygiene activities prevent bringing pathogens into the hospital thus reducing the risk of exposure.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client? -Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next. -Provide a tub bath with bath oil every day. -Provide a full bed bath with soap and water every day -Use skin lotion daily and avoid giving bed baths.

-alternate between a full bed bath on one day and use of skin lotion or bath oil on the next

When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for: -relaxation of muscles. -promotion of conversation. -increasing circulation. -assessment of tissues.

-assessments of tissues

When providing care to a incontinent client with a history of methicillin-resistant Staphylococcus aureus (MRSA), what is the priority goal for the nurse's observable intervention? -Avoiding the introduction of microorganisms to the nurse's uniform -Preventing the introduction of microorganisms to the client -Providing a clean enviroment while providing client care -Maintaining the cleanliness of the nurse's uniform

-avoiding the introduction of microorganisms to the nurses uniform

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)? -wound care -assessment of sensation in lower extremities -skin assessment during bed bath -back massage

-back massage -A back massage can be delegated to a UAP. Assessments and wound care must be done by the RN.

What is the primary purpose for the demonstrated glove application?

-cover exposed wrist skin -Gloves are intended to protect hands and wrists from exposure to microorganisms. This is best accomplished by extending the gloves up the arm to cover the cuffs of the gown. While the proper application of the gloves does anchor the cuffs, the primary purpose is directed at the risk management of microorganism expose to the wrists. This application has no value to adjusting for glove size or to prevent tearing of the glove.

When the nurse cleanses the client's leg during a bed bath, it will allow for: -increased circulation. -promotion of social interaction. -decreased restless leg syndrome. -assessment of pain.

-increased circulation -Bathing increases circulation and helps maintain muscle tone and joint mobility.

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? -cultural views and attitudes toward facial hair and grooming -the last time shaving was performed because clients can only shave twice weekly in the hospital -client's allergies to soap since shaving cream is contraindicated (harmful to person) in the hospital -medications listed on the client's medication administration record (MAR)

-medications listed on the clients medication administration record (MAR) -Shaving guidelines note that pharmacologic considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave, so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client's request.

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?

-reaches down to the bed to pick up a sterile drape -The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

Which modification to bathing should be implemented for a client who is incontinent (loss of bladder control)? -Use special perineal skin cleaners and moisture barriers. -Perform a full bed bath each time the client has an episode of incontinence. -Use a topical antiseptic, such as povidone-iodine, in the perineal area. -Decrease the frequency of bathing to preserve skin integrity.

-use special perineal skin cleaners and moisture barriers -Moisture barriers and special skin cleaners will help prevent skin breakdown and excoriation. Povidone-iodine, also known as iodopovidone, is an antiseptic used for skin disinfection before and after surgery. It may be used both to disinfect the skin of the client and the hands of the health care provider, but is not used as a bathing agent. The client should be cleaned daily as this will not preserve skin integrity. A complete bath is not necessary each time a client has an episode of incontinence because this can dry out the skin and put the client as risk for an infection by decreasing the skin flora.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition? -An infant's skin and mucous membranes are protected from infection by a natural immunity. -The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness. -An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. -Secretions from skin glands are at their maximum from age 3 on.

An adolescents skin ordinarily has enlarged sebaceous glands and increased glandular secretions

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be? -Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). -Assign a care provider who shares the same culture as the client. -Assess the skin every day using the Braden scale. -Assess the client's cultural views regarding hygiene and self-care.

Assess the clients cultural views regarding hygiene and self-care

A nurse is caring for a client who has been transported for a diagnostic test. The nurse is changing the client's bed linens and moves them to the location in the image. Which anticipated outcome is most plausible based on the nurse's actions? -Contaminants can be transferred onto the furniture and spread microorganisms. -Some hospital policies allow for temporary placement of soiled lines on furniture. -An incident report will be created and sent to risk management. -The furniture will be tagged for removal from the hospital premise due to contamination.

Contaminants can be transferred onto the furniture and spread microorganisms.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection? -Place water-soluble lubricant on catheter tip prior to insertion -Ensure opening port of the catheter is closed -Create an area for sterile field and opening packages -Wash the perineal area with soap and water

Create an area for sterile field and opening packages

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate? -Discard it in the waste can. -Sterilize it by placing it in the autoclave. -Do nothing; it can be used again immediately. -Disinfect it with alcohol swabs.

Disinfect it with alcohol swabs

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate? -"I want to reposition the client to reduce the risk of skin breakdown." -"I am placing the new linens under the rolled, soiled lines to avoid contamination." -"The position of the client helps me to assess skin integrity before performing a back massage." -"This is not a trochanter roll. I am tucking the draw sheet tightly so it does not move when the client is in bed."

I am placing the new linens under the rolled, soiled linens to avoid contamination

Upon assessment, the nurse notes that a client has eroding tooth enamel. The nurse documents and teaches the client that this is a risk factor for which condition? -tartar - hard calcified deposit -gingivitis - inflammation of the gums -caries -periodontal disease - gum disease

caries

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate? -"I want to reposition the client to reduce the risk of skin breakdown." -"I am placing the new linens under the rolled, soiled lines to avoid contamination." -"The position of the client helps me to assess skin integrity before performing a back massage." -"This is not a trochanter roll. I am tucking the draw sheet tightly so it does not move when the client is in bed."

I am placing the new linens under the rolled, soiled lines to avoid contamination

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? -"I never use bobby pins or other sharp objects when cleaning cerumen (earwax)." -"I clean my ear mold on my hearing aid daily before use." -"I use cotton-tipped applicators daily to remove cerumen." -"I use a washcloth to clean the auricles and cerumen when needed."

I use cotton-tipped applicators daily to remove cerumen

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the prioritynursing response? -"Help me understand your thoughts about vaccinations." -"Vaccinations prevent disease." -"Transmission of certain diseases is halted with vaccination." -"Has your child received any previous vaccinations?"

Help me understand your thoughts about vaccinations

A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety? -Give the client a bed bath -Assist the client in taking a stand-up shower -Give the client a towel or bag bath -Obtain a shower chair so the client can take a sit-down shower

Obtain a shower chair so the client can take a sit-down shower

A nurse is shaving a male client's face. Which should the nurse do? -Shave against the direction of hair growth, using short strokes. -Pull the skin taut and use short, upward strokes. -Let the skin hang loose and shave in long, downward strokes. -Pull the skin taut and shave in the direction of hair growth using short strokes.

Pull the skin taut and shave in the direction of hair growth using short strokes.

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism? -"If you do not wear gloves you will also get the infection." -"Your loved-one has an antibiotic-resistant infection which means that there are a limited number or no antibiotics available to treat it." -"Your loved-one understands why you have to wear gloves because he or she has been educated about the infection and barrier precautions." -"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

The glove is an important barrier in preventing the transmission of your loved ones antibiotic-resistant infection to you or other people when you come in contact with

The nurse is caring for a client who is on warfarin (blood thinner) therapy. Which teaching will the nurse provide? -Reassure the client that prolonged bleeding of wounds and gums is normal. -Take aspirin for headaches that develop. -Buy a hard-bristled toothbrush to ensure proper oral hygiene. -Use an electric razor for shaving purposes.

Use an electric razor for shaving purposes

Personal protective equipment (PPE) is used in health care facilities to protect the staff from potentially infected clients. T or F?

True

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? -Apply a nonparticulate (N-95) respirator when entering the room. -Have the client wear a mask during care. -Wear a protective gown and gloves with any direct contact. -Wear a mask with face shield during invasive procedures.

apply a non particulate n-95 respirator when entering the room

The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team? -"Avoid touching the outside of your gown when removing it." -"Whenever possible, remove your PPE outside the client's room." -"You should remove your mask before you remove your gown." -"it's best to let me assist you with removal of your gown."

avoid touching the outside of your gown when removing it

Which guideline should the nurse follow when removing contact lenses from a client's eyes? -Before removing hard lenses, use gentle pressure to center the lens on the cornea. -If the contact lenses cannot be easily removed, they will have to be removed by the health care provider under sterile conditions. -Once removed, place both lenses in a cup and label the cup with the name of the client. -If an eye injury is present, remove lenses immediately to avoid causing additional injury.

before removing hard lenses, use gentle pressure to center the lens on the cornea

Standard precautions apply to which items? Select all that apply. -Sweat -Body fluid secretions -Nonintact skin -Blood -Intact skin -Mucous membranes

body fluid secretions, non intact skin, blood, mucous membranes

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes? -Cold feet -Redness and swelling in the joint of the big toe with reports of pain -Breaks in skin integrity and fungal nail infection -A bony bump on the joint at the base of the big toe

breaks in skin integrity and fungal nail infection

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? -Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. -Don a second pair of sterile gloves over the first pair. -Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. -Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability.

continue to don the glove, then use the other gloves hand to carefully insert the finger in the proper hole

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? -staying home when sick -the cell-mediated immune response -intact skin and mucous membranes -early intervention with antibiotics low levels of flora

intact skin and mucous membranes

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter? -Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. -Use an alcohol-based hand rub to decontaminate the hands. -Keep hands lower than elbows to allow water to flow toward fingertips. -Remove all jewelry, including wedding bands, before hand washing.

keep hands lower than elbows to allow water to flow toward fingertips

The nurse is caring for a client who has been diagnosed with pediculosis (lice). What intervention will the nurse provide? -Launder gowns, linens, and towels separate from other clients' items. -There would be no intervention, as this chronic skin disorder is noninfectious. -Lesions should be squeezed gently to release pus. -Apply cortisone to this reddened rash.

launder gowns, linens, and towels separate from other clients items

A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of: -pediculosis. -alopecia. -ticks. -fleas.

pediculosis

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? -Don a new pair of gloves to dispose of materials -Wrap all used materials together and discard in biohazard container -Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps -Perform hand hygiene

perform hand hygiene

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? -wear gloves when touching the client -perform hand hygiene before and after entering the client's room -wear a mask and gown in the client's room -avoid direct contact with the client

perform hand hygiene before and after entering the clients room

Which health problem is most clearly suggestive of a history of inadequate dental care? -periodontitis - inflammation of the gums -cheilosis - inflammation of the lips -alopecia - spot baldness -dry oral mucosa - dry mouth

periodontitis

What is the primary goal of the observable action associated with the removal of contaminated gloves? -Maintain cleanliness of ungloved hand -Maximize speed in removing contaminated glove -Minimize risk of causing a tear in the contaminated glove -Prevent contamination of ungloved hand

prevent contamination of ungloved hand

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? -Providing a back rub before bed -Giving the client something to drink -Engaging in a therapeutic conversation -Providing multiple stimuli to make the client tired

providing a back rub before bed

A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use? -Remove and discard the cap after one use and dry the client's hair with a towel. -Place a towel around the client's shoulders after placing the cap on his or her head. -Use the storage warmer to warm cap; do not put the cap in a microwave oven. -Leave the cap in place for 5 minutes before beginning to massage the scalp.

remove and discard the cap after one use and dry the clients hair with a towel

Which nursing action is appropriate when providing foot care for a client? -Soak the feet in a solution of mild soap and tepid water. -Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. -Cut off any corns or calluses. -For diabetic clients, trim the nails with nail clippers.

since the feet, dry thoroughly, and apply moisturizer on the tops and bottoms of the feet

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline? -Keep dentures near you in the bed for easy access. -Wrap dentures in a napkin when not using them. -Remove dentures whenever possible to rest the gums. -Store dentures in cold water when not in use.

store dentures in cold water when not in use

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that: -there is a need to determine if the bottled water has fluoride. -the preschool child should only drink milk. -the parent should alternate bottle and tap water. -the preschool child should not drink bottled water.

there is a need to determine if the bottled water has fluoride

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? -"All of these spots are called seborrheic keratoses (noncancerous benign skin growths) and they should be taken off." -"These brown spots are senile lentigines and are common when you get older." -"I know these spots are called senile lentigines (pigmented flat spots) and they are likely cancer." -"Older people often have splotchy skin due to seborrheic keratoses."

these brown spots are senile lentigines and are common when you get older

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? -shower with assist -traditional bed bath with linen change -bag bath -tub bath

traditional bed bath with linen change

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? -underneath the breasts and in between skinfolds -the inner and outer canthus of each eye -underneath the fingernails and toenails -the antecubital fossa and popliteal space

underneath the breasts and in between the skin folds

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: -ask another nurse to assist in giving the client a complete bath every other day. -give the client a bath pan and tell him she will return when he has finished. -encourage the client to bathe daily as part of protection from infection. -understand that his culture may influence his hygiene and ask him his preference.

understand that his culture may influence his hygiene and ask him his preference

Which modification to bathing should be implemented for a client who is incontinent? -Decrease the frequency of bathing to preserve skin integrity. -Use a topical antiseptic, such as povidone-iodine, in the perineal area. -Perform a full bed bath each time the client has an episode of incontinence. -Use special perineal skin cleaners and moisture barriers.

use special perineal skin cleaners and moisture barriers

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)? -placing the client in a regular, private room -wearing a particulate respirator for all client care and interaction -wearing protective eye wear for all client contact -wearing a face mask when entering and staying at a distance from the client

wearing a particulate respirator for all client care and interaction