NUR 240

While performing a bed bath, the nurse should A) raise the room temperature B) completely remove linens C) add soap to the water in the basin before beginning the bath D) Complete the bathing for one side of the body at a time

A) raise the room temperature Rationale: Raising the temperature of the room will keep the patient warm while various parts of the body are washed and exposed.

You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers? A. A 72-year-old female weighing 82 lbs with stress incontinence and dementia. B. A 90-year-old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities. C. A 6 month old with the flu. D. An ambulatory 88-year-old with dementia who is admitted with shingles.

A. A 72-year-old female weighing 82 lbs with stress incontinence and dementia. Rationale: Since incontinence can lead to the moisture of the skin, it increases the risk of pressure ulcers. It is important to check the patient's skin regularly for any sores and to make sure the skin is always dry.

A nurse enters a patient's room who is diagnosed with C. Difficile. The nurse is wearing personal protective equipment including a gown and gloves. What type of transmission-based precaution measures is the nurse following? A. Contact Precautions B. Standard Precautions C. Droplet Precautions D. Airborne Precautions

A. Contact Precautions Rationale: The nurse will be coming in contact with bodily fluids when caring for this patient. A gown and gloves are part of normal procedure when following contact precaution guidelines. C. Difficile is an illness that requires the use of contact precautions.

You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? A. Explain to the patient that, because of her symptoms, you need to observe the perineal area. B. Insist that you are supposed to complete the care. C. Honor the patient's request to complete her own perineal care to avoid any embarrassment. D. Ask the patient if a family member can complete the care instead.

A. Explain to the patient that, because of her symptoms, you need to observe the perineal area. Rationale: The nurse needs to examine the area that is burning and causing the patient discomfort to make sure that it is not an infection, or anything serious. It is not the family members job, the nurse needs to observe it.

A nurse is caring for a patient who ingested seafood and became very ill. How should the nurse document this condition? A. Noncommunicable disease B. Infectious disease C. Communicable disease D. Contagious disease

A. Noncommunicable disease Rationale: Since the patient's illness is caused by food, which is an environmental toxin in this case, the disease cannot be spread to others, making it noncommunicable.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? A. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown B. Superficial, which may be pinkish or red with no blistering C. May vary from brown or black to cherry red or pearly white; bullae may be present D. A superficial partial-thickness burn, which can appear dry and leathery

A. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Rationale: Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

You proceed with the process of foot care for this client. Which one of the following steps will you do for this diabetic client in order to get his feet cleaned? A. Wash his feet with lukewarm water and dry thoroughly between the toes. B. Allow the patient to soak his feet in basin of warm water for an hour. C. Clean his feet by rubbing a lotion all over his feet and toes.

A. Wash his feet with lukewarm water and dry thoroughly between the toes. Rationale: This is to be done for diabetic clients or clients with peripheral arterial disease. This prevents the tissues from being macerated and prevents any infection occurring.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? A. a transparent film B. a gauze dressing precut halfway to fit around the IV line C. a dressing with a nonadherent coating D. a gauze dressing premedicated with antibiotics

A. a transparent film Rationale: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: 1. infection 2. herniation 3. dehiscence 4. evisceration

ANSWER: Dehiscence Rationale: Dehiscence is one of the most serious postoperative complications. It is partial or total separation from the wound layers. Dehiscence is a result of increased stress put on a wound that has yet to heal.

When should the nurse provide oral care for an unconscious or comatose patient? A. Mouth care Q3Hr. B. Mouth care Q1Hr. C. Mouth care Q2Hr. D. Mouth care Q5Hr.

Answer C Not providing oral care to a comatose or unconscious patient every 2 hours could result in them developing sores in their mouth.

Which is an example of subjective data? 1) The patient has a blood pressure of 117/80 mmHg 2) The patient describes their pain as a 7 on a 1-10 scale 3) The patient has a body temperature of 100.3°F 4) The patient has a respiratory rate of 20

Answer: 2 Rationale: The correct answer is 2 because subjective data is from the clients point of view and cannot be observed or measured. Objective data is measurable and obtained through testing methods.

You were just assigned a 50-year-old male client that was just diagnosed with diabetes, and your task is to teach him proper foot-care. Why is it important to make sure this client preforms proper foot-care every day? 1)To keep his feet clean 2)Prevent gangrene 3)Prevent toe fungus 4)Keep his feet from smelling bad

Answer: 2; Prevent gangrene Rationale: Gangrene is an infection people with diabetes contract if they get cuts on their feet, and don't take care of them properly. Gangrene tends to happen on the feet because it's the least checked area on the body, and with diabetes, the immune system tends to weaken when blood sugar levels are high.

A nurse educator is reviewing the wound healing process with a group of nurses. In the information, the nurse educator should include which of the following alterations for wound healing by tertiary intention? (Select all that apply.) A. traumatic dog bite injury with delayed closure B. pressure injury left open to heal C. abdominal wound initially left open until infection is resolved D. surgical wound with staples

Answer: A and C Explanation: Tertiary intention, or delayed wound healing, occurs when there is a need to delay the closure due to poor circulation, risk of infection, etc... Closure is displayed when there is no remaining edema or infection, but this can lead to extensive drainage and tissue debris as well as a longer healing time.

When assessing a patient's wound, you will be sure to look for which of the following? (Select all that apply) A) Edema B) Approximation C) Cyanosis D) Ecchymosis

Answer: A, B, D When assessing a wound, use the acronym AREEDA (Area, Redness, Edema, Ecchymosis, Drainage, Approximation) to interpret the wound and document.

A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" which statement would be the nurse's best response? A.) "If you don't develop an infection, the wound should heal any time between 1 and 3 years from now." B.) "With your history and the type of location of the injury, it's hard to say." C.) "Wound healing is very individual but within 4 months the scar should fade." D.) "The contraction phase of wound healing can take 2 to 3 years."

Answer: B Rationale: Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

A nurse caring for an 80-year-old male patient that is A&Ox3 with incontinence and limited mobility. He has an order to be on bed rest, putting him at risk for developing pressure injuries. What interventions would the nurse put in place to help prevent pressure injuries. (Select all that apply.) A) Reposition patient every 4 hours B) Reposition patient every 2 hours C) Patient is A&Ox3 so let him rest and don't go into his room unless he hits the call light D) Make sure the patient dry E) Leave patient in supine position all shift

Answer: B and D Rationale- You would need to reposition the patient every 2 hours to take pressure off his back, increase blood flow and gives you a chance to assess the skin. The patient is incontinent so his bed may get soiled with urine or fecal matter which can cause breakdown of the skin so it would be important to ensure the patient is dry.

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which one of the following? a) client will recognize the need for self-care. b) Client will participate in self-care measures by the end of the week. c) Client will verbalize the need to use the bedpan by the end of shift. d) Client will consent to no hygiene measures.

Answer: B) Client will participate in self-care measures by the end of the week. Rationale: Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. An appropriate goal would have the client actively participate in hygiene and self-care.

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to to delegate to unlicensed assistive personnel (UAP)? a.) Shaving the face of a resident who has worn a beard for several years b.) Using a tool to remove a contact lens that has adhered to the resident's eye c.) Providing a tub bath to a resident who is unable to mobilize independently d.) Providing oral care to a client who has cognitive deficits and a decreased level of consciousness

Answer: B.) Using a tool to remove a contact lens that has adhered to the resident's eye

A client comes in with a pressure ulcer that has a shallow, partial skin thickness, eroded area but there is no necrotic areas present. The nurse would treat the area with what kind of dressing? A.) Alginate B.) Dry Gauze C.) Hydrocolloid D.) No dressing

Answer: C Hydrocolloid Rationale: Hydrocolloid dressings are used to protect shallow ulcers and maintain the appropriate healing environment. Alginate dressings are used for wounds that present with significant drainage, dry gauze will stick to the granulation tissue and cause discomfort therefore causing more damage and lastly, a dressing is needed to protect the wound and to enhance the healing process.

A nurse has posted on social media about a client's situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? A) "You may continue to post about the client, as long as you do not use the client's name." B) "Any information that can identify a person is considered a breach of client privacy." C) "All aspects of clinical practice are confidential and should not be discussed." D) "the information posted on social media is inappropriate and should only be discussed with family and friends of the client"

B) "Any information that can identify a person is considered a breach of client privacy." Rationale : Any information that can identify a client is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the facility and unit is disclosed in the post. No patient care should be discussed, even privately, with friends and family without asking client's permission.

A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to asses her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask? A) "Do you want to bathe regularly?" B) "What are your expectations about bathing at the time?" C) "Are you not able to bathe yourself?" D) "What kind of soap do you like to use?"

B) "What are your expectations about bathing at the time?" Rationale: In order to assess this client's normal pattern of self-care while on her medications, it is important to assess what her expectations are. Once these expectations are established, the nurse can work with the client to achieve them.

Question: The nurse is exhibiting critical thinking in which patient/client care situation below? A) Notifying the healthcare provider of a critical lab result. B) Performing a focused assessment on a client who is complaining of shortness of breath. C) Answering a call bell D) Transcribing orders

B) Performing a focused assessment on a client who is complaining of shortness of breath. Preforming a focused assessment on a client who is complaining of shortness of breath. Rationale: The nurse investigating a client problem by preforming a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.

A nurse is providing foot care for a patient who has a history of diabetes. What should the nurse look for while performing foot care for this patient? A) Redness and edema B) Skin breakdown and fungal infection C) Ecchymosis D) Ingrown toenails

B) Skin breakdown and fungal infection The nurse should look for skin breakdown or fungal infection in the feet of a patient with diabetes. If there is any this should be taken care of immediately to help prevent the patient from getting gangrene.

A nurse is assisting a patient out of bed and into a chair, what would be a priority teaching technique to educate the patient about offloading? A) Patients in chairs must be repositioned Q 2 hrs. B)Patients in chairs must be repositioned Q 1 hr. C) Patients in chairs have low risk of developing pressure injuries. D) The patient can only develop pressure injuries on the coccyx while in the chair.

B)Patients in chairs must be repositioned Q 1 hr. Rationale: When sitting in a chair at a 90∘angle the patient has a higher risk for pressure injury development, so the patient must be repositioned more frequently.

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? A. Taking the patient's temperature B. Applying clean gloves C. Assessing the wound for drainage D. Assessing the dressing for drainage

B. Applying clean gloves Gloves should be worn especially when dealing with a wound assessment to prevent any contamination of germs that can harm the patient and the nurse. Touching a wound with bare hands can lead to contamination.

As a nurse, you are entering a patient's room who has an MRSA. infection on their left buttocks. What particular precautions will you take before entering the room? A. Tier 1 with gown, mask, gloves B. Tier 1 and 2 with gown, gloves C. Tier 2 with gown, mask, gloves, face shield D. Tier 1 and 2 with a mask, gloves, gown, face shield

B. Tier 1 and 2 with gown, gloves This is a tier 1 and 2 precision patient. Most people would think only tier 2 but you need everything from tier 1 and 2 before you enter this room to assist the patient. Having proper PPE is important before assisting a patient with contact precautions like MRSA. Since this is a contact precaution patient you will not need a mask or face shield. With an airborne patient that is when a mask and face shield would be necessary. Along with the gown and gloves you will need proper hand washing before and after the procedure or assessment.

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

B.) 51-year old with hemorrhoids Rationale: 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 nurse is entering a room with a patient who has tuberculosis. What type of transmission based precaution must the nurse take before entering the room? A. Droplet precautions B. Contact precautions C. Airborne precautions D.There's no precautions needed

C) Airborne precautions Rational: Tuberculosis can be transmitted via inhalation of pathogen infected droplets that are suspended in the air and travel distances greater than 3 feet therefore, the use of airborne precautions is mandated.

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? A) Problem-focused B) Risk C) Health promotion D) Syndrome

C) Health promotion Rationale: A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community.

A nurse is assessing a patients pressure ulcer due to friction and shear force. They see that the wound has extended all of the way through the skin, but not through the muscle. Which stage would the pressure ulcer be at? A) stage 1 B)stage 2 C) stage 3 D) stage 4

C) Stage 3 Rationale: the dermal ulcer would be stage 3 because it has loss part of the skin (ruling out stage 1) has gone further than the dermis (ruling out stage 2) and it has not gone through the muscle (ruling out stage 4). This shows that the pressure ulcer has to be at stage 3.

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan? A: Request a stronger analgesic from the provider. B. Provide additional relief with non-pharmacologic measures. C. Evaluate the use of current pain relief measures. D. Create a new nursing diagnosis to reflect new goals.

C. Evaluate the use of current pain relief measures. Rationale: Prior to proceeding with any changes in the plan of care, the nurse must first perform an evaluation of the client's current pain relief measures. Once this has been performed, it might be appropriate to request a stronger analgesic or reinforce education for nonpharmacologic pain relief measures. Creating a new nursing diagnosis and goals would come after evaluating the current pain relief measures.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? A. Stage II B. Stage III C. Stage IV D. Stage I

C. Stage IV Rationale: Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? A.) Administering intravenous push medication B.) Administering blood products C.) Administering bedside blood glucose testing D.) Administering chemotherapy

C.) Administering bedside blood glucose testing Rationale: LPNs work under the direction of a health care provider or RN to give direct care to patients, focusing on meeting health care needs in hospitals, long-term care facilities, and home health facilities. They perform routine procedures. LPN's are not allowed to give blood products, or IV medications.

If a patient has a Braden Scale score of 15-18 are they at mild, moderate, or high risk for a pressure ulcer? A: Mild risk B: Moderate C: High D: No risk present

Correct Answer is A: Mild Risk Rationale: The patient is at mild risk. It is important to remember that the lower the number on the Braden Scale, the higher the risk is for the patient to get a pressure ulcer.

The nurse has just meet with a patient's family to give an update on a client, the nurse shakes her hands off before leaving. Which method of hand hygiene is most appropriate in this situation? A. Scrubbing hands with soap, water, and brush B. Alcohol based hand rub C. Scrubbing hands with soap and water D. Antiseptic hand rub

Correct Answer: B. Alcohol based hand rub Rationale: The nurse would use an alcohol based hand rub after speaking with the clients family because the nurses hands weren't visible soiled or contaminated with anything, she was just speaking with the family. The nurse would use an alcohol based rub every time she came in contact with the client, so before and after.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a. Clean the wound from the top to the bottom and from the center to the outside. b. Clean the wound in a circular pattern, beginning on the perimeter of the wound. c. Once the wound is cleaned, gently dry the wound with an absorbent cloth. d. Use clean technique to clean the wound.

Correct answer: A Rationale: When cleaning a wound, a nurse uses a sterile technique. By doing this, she/he does not spread the drainage from one area of the wound to another. She/he uses straight strokes from the top of the wound to the bottom. First, clean the center of the wound (on the suture line), then the side farthest from you, and lastly the side closest to you.

A nurse is caring for a patient with a variety of wounds. Which one will most likely heal by primary intention? a. cutting the skin by a kitchen knife b. pressure ulcer c. abrasion of the skin d. excoriated perineal area

Correct answer: a. cut in the skin by a kitchen knife Rationale: A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated).

The collection of a wound culture has been ordered for a patient whose traumatic abdominal wound is showing infection. When collecting this laboratory specimen, which action should the nurse take? A. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. B. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. C. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. D. Rotate the swab several times over the wound surface to obtain an adequate specimen.

D. Rotate the swab several times over the wound surface to obtain an adequate specimen. Rationale: The cotton tip of the swab absorbs wound drainage. The Levine technique is considered to provide more accurate results. Contact with skin could introduce extraneous organisms into the collected specimen, resulting in inaccurate results.

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound? A. Remove the dressing, inspect the wound, and reapply a new dressing. B. Inspect the wound and reapply the surgical dressing every 2 hours. C. Inspect the wound, and keep the dressing off until the health care provider arrives. D. Wait until the health care provider orders the removal of the surgical dressing.

D. Wait until the health care provider orders the removal of the surgical dressing. Rationale: The nurse would want to wait until the provider orders the dressing to be removed to ensure that the initial dressing is ready to come off. The nurse would not remove an initial surgical dressing for direct wound inspection until the health care provider has written an order for its removal.

The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: A . interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing. B. congratulate the nurse on the use of good technique. C. discuss dressing change technique with the nurse at a later date. D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.

D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves. Rationale: Non-sterile gloves are adequate for removing old dressings. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.

You discover that a patient has HIV, what type of PPE would be appropriate to use when assessing the patient? A. Droplet precaution B. Airborne precaution C. Standard precaution D. No precaution neccesary

Rationale: (correct answer: C) You should essentially treat every patient as if they have a disease that is communicable through fluid. You should always practice standard precautions when encountering any bodily fluids from a patient. Standard precaution includes the proper use of gloves.

A 48 years old male shows up to a follow-up appointment complaining of having itchy and dry skin. Which type of health factor that could be affecting his integumentary system? A. Diaphoresis B. Jaundice C. Paralysis D. Emaciated

The answer is B: Jaundice is the build-up of bilirubin in the blood, which causes the skin to turn yellow and become itchy and dry.

A patient has the nursing diagnosis of constipation, which of the following is a defining characteristic that could be used in charting? A. age 84 B. low motility C. No bowel movement for 6 days D. takes pain meds twice a day

The answer is C because that is a manifestation of constipation.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a. an obese woman with a history of type 1 diabetes b. a client whose breast reconstruction surgery required numerous incisions c. a man with a sedentary lifestyle and a long history of cigarette smoking d. A client who is NPO (nothing by mouth) following bowel surgery

a. an obese woman with a history of type 1 diabetes rationale: a patient with diabetes will always be at risk for impaired wound healing because they have a weakened immune system because of the high glucose levels in their blood that impairs the immune system.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? 1. serosanguineous 2. sanguineous 3. purulent 4. serous

answer: 1 Serosanguineous Rationale: this type of fluid has small amounts of blood in it which would give the drainage that pale pink color.

Maslow's Hierarchy of basic human needs is useful when planning and implementing nursing care as it provides a structure for a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care

b. Establishing priorities of care Maslow's hierarchy provides a structure for nursing assessment and for understanding the needs of patients so that treatment can meet priority needs and become a part of the care plan. Many nursing treatment plans are aimed at meeting patients' basic human needs

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? a. Gauze b. Transparent c. Hydrocolloid d. Bandage

b. Transparent Rationale:The nurse should use a transparent dressing to cover the IV insertion site because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage. A hydrocolloid dressing helps keep the wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.