NUR 114 PrepU Week 6-7 Ch. 20, 27, 3, 10

A nurse in an oncology care unit is reviewing the laboratory test results of several clients scheduled to receive chemotherapy. The nurse determines that the client with which leukocyte count will most likely have the chemotherapy withheld?

2,500 cells/mm3

A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision?

Autonomy

A nurse is providing care to a client with end-stage cancer. After weighing the alternatives, the client decides not to participate in a clinical trial offered and is requesting no further treatment. The nurse advocates for the client's decision based on the understanding that the client has the right to self-determination, interpreting the client's decision as reflecting which ethical principle?

Autonomy

A client has a concentration of Staphylococcus aureus located on his skin. He is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which stage?

Colonization

The nurse is providing care to a client whose condition has progressively declined. The nurse assesses and makes appropriate interventions as well as notifies the health care provider. Despite the nurse's efforts, the client expires. What element of liability has the nurse demonstrated?

Duty

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the health care provider should be notified immediately?

The client's heart rate is greater than 90 bpm.

What would be an example of the nurse practicing fidelity? The nurse:

stays with a client during death as promised.

A client who is cognitively impaired is scheduled to undergo surgery. The nurse demonstrates understanding of the principle of autonomy and checks the client's health record to ensure that consent has been obtained from which person?

surrogate decision-maker

A nurse is reviewing the white blood cell (WBC) count and differential of a client and notes that there is a significant shift to the left. The nurse interprets this as indicating:

the client has developed a bacterial infection.

The nurse is teaching a health class in the local public health center about precautions to prevent the spread of influenza. What instructions should the nurse provide as the most important measure to prevent the spread of influenza?

thorough handwashing

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all care and interaction with this client

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field?

with sterile forceps or hands wearing sterile gloves

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

The nurse is caring for a client admitted with tuberculosis. The client asks why the nurse wears a respirator, gown, and gloves whenever they are in the room. How should the nurse respond?

"Because of the tuberculosis, I need to follow airborne precautions for protection."

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

"Client is reporting abdominal pain is rated at 8/10."

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

After educating a group of nursing students about the health care record and its purposes, the instructor determines that the group needs additional instruction when the students state:

"Health care records are primarily used for communication among nurses and health care providers."

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

"I have set up this sterile field for your procedure, so please do not touch anything around the tray."

A family member calls and tells the nurse about wanting to bring in the family to visit an older adult parent on the unit. The family member has a cold and is concerned about spreading upper respiratory infection to the parent. Which instructions should the nurse provide?

"If you are sick, you should avoid visiting until symptoms are relieved."

A nurse is educating adolescents on how to prevent infections. The nurse determines which statement(s) by participants indicates more education is needed?

"It is okay to share glasses and eating utensils with my family and friends because they are all pretty healthy."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

A client the nurse is caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for 2 weeks. The client's family asks the nurse how the client got this infection. What would be the nurse's best response?

"People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse?

"Take it with you. It is recognized universally in the United States."

Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?

"The rules made by the board of nursing don't reflect my practice."

The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports this part of the SBAR?

"Will you prescribe a complete blood count to check the white blood cell count and a culture?"

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

The local high school has been exposed to methicillin-resistant Staphylococcus aureus (MRSA) infection and the school nurse is preparing an education plan on prevention of MRSA. Which steps should the nurse include? Select all that apply. 20-second handwashing online research on MRSA go to see your healthcare provider for cold-like symptoms use of hand sanitizer when necessary keep draining wounds covered

20-second handwashing use of hand sanitizer when necessary keep draining wounds covered

A client is being screened for a parasitic infection and the health care provider orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days.

Which client presents the most significant risk factors for the development of Clostridioides difficile infection?

81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

The nurse is caring for the following clients. Which client requires a negative air flow room?

81-year-old client with active tuberculosis and a productive cough

Which nursing student would most likely be held liable for negligence?

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

The nurse is caring for a client with an impaired immune system. The nurse is concerned about the client acquiring a healthcare-associated infection (HAI). What intervention would the nurse focus on to help control HAIs?

Apply principles of medical and surgical asepsis.

Which is true of collaborative pathways?

Are also called critical pathways or care maps

Which statement about glove use and hand hygiene is true?

Artificial fingernails should not be worn by staff involved in direct client care.

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval.

An oncology nurse is caring for a client suffering from metabolic encephalopathy and end-stage kidney disease. The client has no known family and no advance directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration. What is the priority action the nurse should take?

Begin CPR.

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?

Breach of duty

A nurse is preparing to document client care in the electronic medical record using the SOAP format. The client had abdominal surgery 2 days ago. How would the nurse document the "S" information?

Client states, "I have more pain in my belly today than I did yesterday. My pain is about a 7 out of 10."

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process?

Certification

Alice Jones, a registered nurse, is documenting pain assessment after the administration of pain medication in the client's medical record. How should the nurse document this assessment?

Client rates pain at 2 on a scale of 0-10. A. Jones, RN

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which precautions are implemented by the nurse to prevent the spread of infection?

Contact precautions

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.

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.

A nurse working in a high-risk area of the health care facility is receiving an annual vaccination. Employees working in which areas need to prove their immunization status? Select all that apply. Dialysis X-ray Pediatrics Pharmacy Transplantation

Dialysis Pediatrics Transplantation

A school nurse is conducting a program for the parents about common childhood illness. Which information do parents need to know about preventing childhood illness?

Early infection treatment is needed to prevent the spread of infection.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

Fidelity

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?

Hand hygiene

An experienced nurse is mentoring a new nurse on the proper use of hand hygiene. What is an accurate guideline that should be discussed?

Hand hygiene must be performed after contact with inanimate objects near the client.

Which statement is not true regarding a medication administration record (MAR)?

If the client declines the dose, the nurse does not have to document this on the MAR.

Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged?

Invasion of privacy

When pouring a sterile solution, what care should the nurse take to avoid contamination of the solution?

Pour and discard a small amount of the solution before each use.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field?

Separate the sealed flaps and drop contents onto field.

The nurse is assessing a client with an elevated temperature. Which of the following would lead the nurse to determine that the client is in the fever phase?

Skin warm and flushed

A nurse is changing the bed linen of a client admitted to the health care facility. Which precaution to prevent infection should the nurse follow?

Standard precautions

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique

A nurse witnesses a 50-year-old woman go into cardiac arrest while traveling in a train and resuscitates her. The family is very happy and insists the nurse accept a monetary compensation. Not wanting to hurt the family's feelings, the nurse reluctantly accepts the compensation. Later, in the hospital, the woman dies, and the family members file a suit against the nurse. Which of the following statements about Good Samaritan laws is applicable here?

The Good Samaritan law will not protect the nurse because she has accepted monetary compensation.

A nurse witnesses a traffic accident in which a child is badly hurt. The nurse dresses the open wounds sustained by the child. The family tries to give monetary compensation, which the nurse refuses. Later, in the hospital, the child develops complications due to infection in the wound. The family holds the nurse responsible for the complications and wants to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law?

The Good Samaritan law will provide legal immunity to the nurse.

The nurse works on a long-term care unit. In the last 2 weeks more than half the clients on the unit have been diagnosed with gastroenteritis. What is the most likely reason?

The infection is being transmitted by health care personnel.

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.

A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the health care provider. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?

The nurse should call and inform the nursing supervisor of the situation.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply.

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.

After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances?

The nurse is legally held to the same standards of care as when staffing levels are normal.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

A home care nurse is caring for a client with quadriplegia who needs regular position changes and back massages. A visitor identifying as a family friend inquires about helping the family. What should be the nurse's response be?

The nurse should ask the visitor to talk to the family directly.

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?

Virus

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern?

WBC of 25,000 mcL

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

decreased cellular immunity.

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

airborne precautions droplet precautions contact precautions

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. what time the nurse will return for the next shift identifying demographics, including diagnosis current orders any abnormal occurrences with the client during the shift what the client watched on television during the shift

any abnormal occurrences with the client during the shift identifying demographics, including diagnosis current orders

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?

applying a new dressing with the gloves that were used to remove the old dressing

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?

clear mucus

The nurse has admitted a new client to the unit. This client has an open draining sore on the leg. Which diagnostic test would the nurse anticipate being ordered?

culture and sensitivity

Which are appropriate actions for protecting clients' identities? Select all that apply. orient computer screens toward the public view ensure the clients' names on charts are visible to the public have conversations about clients in private places where they cannot be overheard document all personnel who have accessed a client's record place light boxes for examining x-rays with the client's name in private areas

document all personnel who have accessed a client's record place light boxes for examining x-rays with the client's name in private areas have conversations about clients in private places where they cannot be overheard

The nurse is caring for an older adult with influenza. Which precautions will the nurse begin?

droplet

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response?

encourage the colleague to remove the glove by grasping the cuff

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period.

exposure to the pathogen nonspecific symptoms positive laboratory tests return of appetite

A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction?

facing away from the body

The nurse will assess a client who has a draining abscess. The nurse should perform what action upon entering the room?

gown and gloves

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control?

handwashing

A client is on isolation because the client acquired a methicillin-resistant Staphylococcus aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection?

healthcare-associated (HAI)

A health care provider performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

helps to determine prescribed antibiotic therapy

A client trips while ambulating and breaks open the skin on his knee. The next day the knee is red, warm to the touch, and painful at the site of the injury. The client's complete blood count (CBC) shows a high white blood cell count. What would the nurse suspect is wrong with the client?

infection of the knee

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?

inserting an arm within each sleeve while touching the outer surface of the gown

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data.

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

into a private room

Ethical distress is:

knowing the correct action but being unable to perform it due to constraints.

A nurse is caring for a client with contact dermatitis and respiratory distress. The client has an x-ray ordered. What care should the nurse take when transporting the client with infectious disease to the x-ray unit? Select all that apply. cover the client with a bath blanket or sheet use personal protective equipment as used in client care line the surface of the wheelchair with a clean sheet inform all the departments about the infectious client wear a mask or a particulate air filter respirator

line the surface of the wheelchair with a clean sheet use personal protective equipment as used in client care

A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?

older adult

A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing?

prodromal

A client who is scheduled for abdominal surgery gives informed consent. While reviewing the client's medical record, the nurse identifies the consent form, interpreting it as most reflective of:

protection of the client's right to self-determination in decision-making.

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

A group of students is reviewing information about cellular and humoral immunity. The group demonstrates understanding of these concepts when they identify what as a function of cellular immunity?

reactivate if the same antigen reappears

Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. This action supports, among other things, infection prevention. Which assessment indicates that there is a positive outcome from this nursing care?

skin is dry and intact