Fundamentals exam 3

A nurse is caring for a college student admitted for acute alcohol intoxication. The client reports feeling overwhelmed and expresses an inability to cope with stressors at school. Which of the following statements should the nurse make?

"Let's talk about the coping methods that have worked for you in the past."

A nurse is teaching a client about advance directives. Which of the following client statements indicates an understanding of the teaching?

"My health care surrogate will make health care decisions for me if I am unable." The client chooses a health care surrogate who maintains the client's durable power of attorney for health care. This document allows the health care surrogate to make health care decisions on the client's behalf if they are unable to do so.

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer

A nurse is caring for a group of client who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk? (Select all the apply) Uncircumcised infants School-age children Middle adults Older adults Young adults

Uncircumcised infants School-age children Older adults

A nurse is teaching a group of newly licensed nurses about professional values. Which of the following statements by a newly licensed nurse demonstrates an understanding of social justice?

"Health care should be a right for everyone." Social justice is the recognition of and fighting for equality of every individual for equal access to health care, food, housing, educational opportunity, and fair and equal treatment in all aspects of life. This statement demonstrates an understanding of the professional value of social justice.

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask? a. protective isolation b. contact c. droplet d. airborne

d. airborne

A nurse is reinforcing teaching for a client who has an ileostomy. The nurse should identify that which of the following is true regarding an ileostomy?

An ileostomy can allow the colon time to heal from surgery

A nurse stops at the side of the road to provide care to a person involved in a motor-vehicle crash. Which of the following protects the nurse from liability when administering care at the scene of an accident?

Good Samaritan laws Good Samaritan laws protect people who provide aid in the event of an emergency from being held liable for their well-intentioned actions. The actions the nurse takes should be within their scope of practice as a licensed nurse and should not be considered grossly negligent.

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Mechanical lift

A nurse is conducting an educational session for clients who report experiencing stress-related disorders. A client asks the nurse which part of the body activates the stress response. Which of the following responses should the nurse provide?

Hypothalamus

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

A nurse is reviewing a client's list of medications and supplements. Which of the following medication classifications increases the risk of constipation?

Narcotic pain medications

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational Therapist

A nurse is reinforcing teaching with a client about foods that can irritate the bladder. Which of the following foods should the nurse identify as being a bladder irritant?

Oranges

A nurse is collecting data from a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings?

Pale yellow, clear urine

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take? a. wear an N95 respirator when caring for the client b. place the client in a private room c. place a mask on the client when they leave their room d. place the client in a negative airflow room

Place the client in a private room.

A nurse is providing discharge teaching about health promotion to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply).

Practice mindful breathing. Start each day with a to-do list. Develop habits to mitigate stress.

A nurse is talking about implementing self-care strategies to cope with the stress of caregiving with the partner of a client who has dementia. Which of the following strategies reported by the partner should the nurse identify as an example of effective coping?

Practicing deep breathing while sitting outside

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Remind the client to use incentive spirometer

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Slide board

A nurse is reviewing the primary function of they urinary tract with a group of newly licensed nurses. Which of the following information should the nurse include?

The urinary tract eliminates waste and excess fluid from the body

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfactions

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?

Toileting

A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urine. Which of the following urinary diversions should the nurse anticipate the client will need?

Ureteral stent

A nurse is planning care for a client who has an order for urinalysis. Which of the following tests should the nurse anticipate being ordered if the presence of white blood cells is detected on urinalysis?

Urine culture

A nurse is collecting data from a client who has stress incontinence. Which of the following findings should the nurse expect with this client?

Urine leakage following coughing

A nurse truthfully answers a client's questions about their laboratory results. The nurse is demonstrating which of the following ethical principles?

Veracity The ethical principle of veracity refers to the nurse's obligation to provide truthful information to the client, the provider, and the nursing supervisor. Truthfully answering a client's questions about their laboratory results is demonstrating the ethical principle of veracity.

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Muscles

A nurse is caring for a client who has a history of irritable bowel syndrome and report that their last bowel movement was 5 days ago. The nurse should identify this is which of the following types of altered elimination pattern?

Constipation

A nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding?

Consuming alcohol

A nurse is planning care for a client who reports blood in their stool. Which of the following tests should the nurse anticipate the provider ordering?

Fecal occult blood test

A nurse is caring for a client with suspected dehydration. For which of the following findings should the nurse monitor this client?

Dry mucous membranes

A nurse is caring for a client who has delivered a healthy newborn. The client is tense, refuses to hold the baby, and tells the nurse, "I have no idea how to handle having a baby. I wish this pregnancy had never happened." Which of the following statements should the nurse make?

"Becoming a parent is a new experience for you. Let's talk about your concerns."

A nurse is caring for a client who has migraine headaches and reports that they are "getting worse." Which of the following questions should the nurse ask the client to determine if the headaches are a stress-related disorder? (Select all that apply.)

"What is the intensity of your migraine headaches?" "How often do the migraine headaches occur?" "What type of support is available to you when you have a migraine headache?" "What coping strategies do you use when you experience a migraine headache?" MY ANSWER

A nurse is interviewing a client who is in distress and tells the nurse, "My ex-partner is suing for full custody of my children. I am so worried and don't know what to do." Which of the following questions should the nurse ask to evaluate the client's coping skills?

"What strategies have you used in the past to deal with stress?"

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

1. A stable center of gravity increases stability and balance 2. A wide base lowers the center of gravity 3. Proper body alignment involves tightening the abdomen

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and lower the back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat 5. Push up from the knees when lifting the object

A nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care?

A nurse did not read back a verbal medication prescription to a provider. Standards of care guide nursing practice to perform safe and effective care. Failing to verify a medication prescription can result in harm to a client and is therefore a breach of the standard of care.

A nurse is reinforcing teaching with a newly licensed nurse about urinary retention. Which of the following clients should the nurse include as having an increased risk for this condition?

A client who has an enlarged prostate

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that which of the following situations is an example of fidelity?

A nurse keeps a promise to a client not to tell their family about their diagnosis. The ethical principle of fidelity refers to the nurse's obligation to keep a promise. Keeping a promise to a client promotes trust between the client and the nurse.

A nurse is teaching a newly licensed nurse about professional values. The nurse should include that which of the following is an example of autonomy?

A nurse respects a client's wish to discontinue a treatment. The professional value of autonomy refers to respecting the client's right to make their own decisions regarding their health care, including the right to refuse care.

A nurse in an emergency department is caring for four clients. Which of the following clients requires mandatory reporting?

A young adult client who is positive for tuberculosis Diseases and illnesses that are considered a threat to public health, such as tuberculosis, HIV, and influenza, require mandatory reporting to the health department to track and develop prevention and protection protocols.

A nurse is caring for a client who is in crisis following the breakup of a long-term relationship. The client tells the nurse, "I might as well just die. My life is over." Which of the following actions should the nurse take first?

Conduct a suicidal risk evaluation.

A nurse in a community clinic is interviewing a client who is distressed and reports being unable to sleep following a neighborhood fire several days ago. The client has hypertension, tachycardia, and is diaphoretic. The nurse should identify that the client is experiencing which of the following types of stress?

Acute stress

A nurse is interviewing a client who recently experienced an act of workplace violence when an armed person held the workers at gunpoint before police intervened. The client now reports being anxious and fears the gunman might return. The nurse should identify that the client is experiencing which of the following types of crisis?

Adventitious

A nurse in a health clinic is interviewing a client who is upset and reports that their stress "is too much to handle." The client is unemployed, a single guardian to young children, and has periodic asthma attacks. Which of the following stress-related conditions is the client experiencing?

Allostatic load

A nurse is caring for a client who asks why they chose the nursing profession. The nurse states that it was because they wanted to help others. The nurse is referring to which of the following professional values?

Altruism The professional value of altruism is the selfless desire to help someone else without any benefit.

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that doctor said." Which of the following actions should the nurse take?

Ask the provider to discuss the procedure with the client. If the client states that they are unclear about a procedure, the nurse should contact the provider to return to answer the client's questions. The nurse should verify that the client has adequate knowledge to make the treatment decision before the client signs the informed consent form.

A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Atrophy

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that a client who has chosen to sign a blood product refusal form is an example of which of the following ethical principles?

Autonomy Autonomy refers to the nurse's obligation to respect the client's right to make their own decisions regarding their health care, including the right to refuse care. A client who has chosen to sign a blood product refusal form is demonstrating autonomy or the right to make their own health care decisions.

A nurse is caring for a client who is alone and has just received a serious diagnosis. The client asks the nurse if they can pray together, and the nurse agrees. The nurse is demonstrating which of the following ethical principles?

Beneficence The ethical principle of beneficence refers to the nurse's obligation to implement actions that minimize harm and benefit clients. Beneficence includes meeting a client's physical, social, or emotional needs. The nurse is demonstrating beneficence by providing comfort and praying with the client who is alone

A nurse is reinforcing teaching with a client about diagnostic urinary testing. Which of the following should the nurse recognize is consistent with cystometric testing?

Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins

A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

A nurse is caring for a client who has pancreatic cancer that is unresponsive to treatment. The client is experiencing significant weight loss and fatigue, but when the nurse asks how they are feeling, they respond with, "Great! I'm going to beat this cancer." Which of the following defense mechanisms is the client using?

Denial

A nurse at the end of their shift realizes they forgot to give a client their scheduled vitamins. The nurse decides to document that the vitamins were administered. Which of the following describes the nurse's action?

Falsification of records The nurse is falsely documenting that a medication was administered to the client, which is an example of falsification of health records. Falsification of health records can include not documenting care that occurred, documenting inaccurate data, or documenting care or events that did not occur. This action can lead to client injury and is considered failure to adhere to the standards of nursing practice.

A nurse is caring for an older adult client who reports being stressed about their health status due to problems with short-term memory, slower reaction times when driving, and urinary frequency. The nurse should recognize that the client is experiencing which of the following types of stressors?

Developmental stressors

A nurse is preparing to collect a urine sample for urinalysis a reagent strip. The nurse should identify that the reagent strip can detect substances that are consistent with which of the following conditions?

Diabetes

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse is preparing to administer a PRN pain medication to a client but withholds the medication because the client is sleeping. Which of the following actions should the nurse take to provide the expected standard of care?

Document that the medication was not administered. Standards of care guide nursing practice to perform safe and effective care. Accurate documentation facilitates communication to members of the client's health care team and is a component of expected standards of care. Documenting client data, interventions, and client responses promotes continuity of care and decreases the risk for error. The nurse should return to check the client to determine if the client requires the PRN pain medication.

A nurse is preparing to insert a nasogastric tube into a client for decompression. Which of the following actions should the nurse perform first?

Ensure client is in a sitting position

A nurse is caring for a client who has delivered a healthy newborn. The client tells the nurse that while they are somewhat stressed about being a new parent, they are thrilled by the birth of their child. The nurse should identify that the client is experiencing which of the following types of stress?

Eustress

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for?

Hernia

A nurse is caring for a client who has constipation. Which of the following diets should the nurse encourage the client to follow?

High fiber

A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors? (Select all that apply.)

History of frequent respiratory infections Consumes large amounts of dairy in their diet Currently taking cephalexin for pneumonia

A nurse is providing privacy for a client who has incontinence. The nurse is demonstrating which of the following professional values?

Human dignity The professional value of human dignity is recognizing that all human life has value and should be treated equally with respect, regardless of race, religion, gender, sexual orientation, culture, ethnicity, or socioeconomic status. Providing privacy to a client who has incontinence is demonstrating respect and preserving the client's human dignity.

A nurse is caring for a client whose partner was recently hospitalized with COVID-19. The client is experiencing manifestations related to the alarm stage of general adaptation syndrome (GAS). For which of the following manifestations should the nurse monitor? (Select all that apply.)

Hypertension Dilated pupils Increased state of arousal

A nurse is providing information to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statements by the client indicates an understanding of the information?

I can develop a kidney infection called pyelonephritis

A nurse is caring for a female client who has a prescription for a clean catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to provide a urine specimen?

I need to wipe from front to back with a sanitary wipe

A nurse who has been working 12-hr shifts on a busy unit is experiencing nurse fatigue. Which of the following effects can result from nurse fatigue?

Increase in medication errors Nurse fatigue can result in an increase in risk for medication errors that can result in client injury.

A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution?

Instruct the client to lie on their left side with their right leg pulled up to their chest

A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating which of the following professional values?

Integrity The professional value of integrity involves showing honesty and choosing to do what is right and fair, even when the situation is difficult. The nurse who admits that they administered the wrong medication to a client is demonstrating the professional value of integrity.

A nurse is reinforcing teaching with a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse identify will help facilitate urinary elimination for this client?

Intermittent catheter

A nurse is assessing a client who was sexually assaulted 6 months ago and has been diagnosed with post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect? (Select all that apply.)

Intrusive memories of the event Flashbacks of the event Exaggerated startle response when reminded of the event

A nurse is assessing a client who is working at home due to COVID-19 restrictions. The client reports abdominal cramping and bloating with diarrhea and states, "I am completely stressed out from working at home." The nurse should identify that the client is experiencing manifestations of which of the following stress-related conditions?

Irritable bowel syndrome

A nurse is providing equal care to a group of clients who have varying economic statuses. Which of the following ethical principles is the nurse demonstrating?

Justice The ethical principle of justice refers to an obligation of the nurse to treat all clients the same regardless of age, sex, race, sexual orientation, or economic status.

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward

A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client

A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence?

Loss of bladder tone

A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function?

Preform colostomy irrigation

A nurse is caring for a client who has been charged with partner violence against their spouse. The client is angry, pacing, and yells out, "I wouldn't lose my temper if my spouse would just leave me alone. It's their fault." The nurse should identify the client is displaying which of the following defense mechanisms?

Projection

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Prone

A nurse is caring for a client who reports experiencing stress over an upcoming surgical procedure. Which of the following statements describes the characteristics of stress?

Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one's state of equilibrium.

A nurse is planning care for a client who is recently divorced with two young children. The client reports difficulty sleeping, feeling hopeless, and being estranged from family. The nurse should plan to monitor the client for which of the following potential manifestations of chronic stress

Suicide

A nurse suspects their coworker might be under the influence of a chemical substance. Which of the following actions should the nurse take?

Tell the charge nurse that the coworker might be impaired. The nurse should report their suspicion to the charge nurse or supervisor to protect the safety of the clients. If the charge nurse suspects the coworker is impaired, they should remove the impaired employee from the work environment.

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone

A nurse in an emergency department overhears a provider say they will not accept any more clients who do not have health insurance. Which of the following is the provider violating?

The Emergency Medical Treatment and Labor Act (EMTALA) The EMTALA was enacted to allow clients to access the emergency departments of hospitals for equal care regardless of their ability to pay. Refusing to accept clients who do not have health insurance is a violation of the EMTALA.

A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea?

The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow

A nurse is caring for a client who is establishing a bladder training program. Which of the following indicates that the bladder training is successful?

The client has less than one urinary accident per week

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

The client has the crutches resting 5 cm (2 in) below their axilla

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

The contraction of a muscle results in flexion of a joint

A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body.

The large intestine

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

The top of the walker should be at the level of your wrist

A nurse is reinforcing instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements should the nurse identify is true regarding a nephrostomy tube?

The tube is temporary

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission? a. airborne b. droplet c. direct contact d. indirect contact

a. airborne

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests? a. c-reactive protein b. troponin c. creatine kinase d. lactic acid

a. c-reactive protein

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? a. droplet b. indirect contact c. airborne d. direct contact

a. droplet

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? a. open the first flap on the sterile package away from their body b. place objects on the sterile field at least 1.3cm (0.5in) from the edge c. unwrap both sides of the sterile package at the same time d. set up the sterile field next to a wall in the clients room

a. open the first flap on the sterile package away from their body.

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent? a. reservoir b. susceptible host c. portal of entry d. portal of exit

a. reservoir

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take? a. swab the back of the clients pharyngeal wall b. place the swab in a clean container after obtaining the culture c. insert the swab in the culture medium within 1 hours of obtaining the sample d. don sterile gloves to obtain the culture from the client

a. swab the back of the client's pharyngeal wall.

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include? a. the door to the AIIR should remain closed b. clients who are on contact precautions require AIIR c. an AIIR has at least 4 air exchanges each hr. d. a mask is not needed to care for clients who are in an AIIR

a. the door to the AIIR should remain closed.

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle? a. try to use alternatives before inserting indwelling urinary catheters b. use clean technique for insertion of indwelling urinary catheters c. check client every 2 days to evaluate the need for indwelling catheters d. disconnect the system to obtain urine samples from indwelling urinary catheters

a. try to use alternatives before inserting indwelling urinary catheters

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include? a. gowns can be reused on the same client b. masks should be removed after leaving a client's room c. gloves should be removed from the inside out d. eyeglasses can be used in place of goggles

c. gloves should be removed from the inside out.

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? a. protective b. contact c. droplet d. airborne

b. contact

A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following precautions should the nurse plan to implement? a. protective b. contact c. standard d. airborne

b. contact

A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection? a. incubation b. convalescence c. acute infection d. prodromal

b. convalescence

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? a. direct contact b. droplet c. airborne d. indirect contact

b. droplet

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first? a. mask b. gloves c. goggles d. face shield

b. gloves

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include? a. empty sharps containers when they become full b. report needlestick injuries to the nursing supervisor c. engage the safety device on a needle after documenting the medication administration d. recap needles after the medication administration

b. report needlestick injuries to the nursing supervisor.

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use? a. alcohol-based sanitizer b. soap and water c. iodine solution d. chlorhexidine solution

b. soap and water

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? a. reservoir b. susceptible host c. portal of entry d. portal of exit

b. susceptible host

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. washes their hands for 10 seconds b. turns off the faucet with a towel c. uses hot water to wash their hands d. holds their hands above their elbows while rinsing off the soap

b. turns off the faucet with a towel

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? a. use a brush to scrub the surface of the hands b. rinse the solution from the hands before it dries c. apply chlorhexidine and ethanol to the hands d. leave jewelry on the hands when cleansing them

c. apply chlorhexidine and ethanol to the hands.

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger? a. burn b. frostbite c. bacteria d. radiation

c. bacteria

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make? a. "you can wear artificial fingernails if they are kept short" b. "leave rings on your fingers when performing surgical hand sepsis" c. "keep your fingernails less than half an inch in length" d. "remove nail polish on your fingernails if it is chipped"

d. "remove nail polish on your fingernails if it is chipped."

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves? a. after donning a gown and before collecting vital signs on the client b. after removing food items off the clients tray and before removing soiled linens from the clients bed c. after helping the client stand up and before helping them brush their teeth d. after changing a dressing on the client and before documenting findings on a computer

d. after changing a dressing on the client and before documenting findings on a computer

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing? a. incubation b. convalescence c. acute illness d. prodromal

d. prodromal