Quiz 1

C. Assess the client

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. Call the client's provider B. Notify the nurse manager C. Assess the client D. Complete an incident report

C. No action is necessary, this is a normal reading

A nurse assesses an oral temperature for an adult patient and records the patient is afebrile. What would be the nurse's best response to this finding? A. Take the patient temperature using a different method B. Report the finding to the doctor C. No action is necessary, this is a normal reading D. Check the patient record for prescribed antipyretic medication

A. "It's my responsibility to remind you that we have to respect our client's privacy."

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her? " Which of the following responses should the nurse provide? A. "It's my responsibility to remind you that we have to respect our client's privacy." B. Oh, what lovely flowers. She will enjoy these." C. "It's a minor injury. I'm sure you'll see her back in the neighborhood soon." D. "You know it's not appropriate for you to ask me that."

B. Airborne

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Protective B. Airborne C. Droplet D. Contact

B. Asking the client to rate the pain

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. Inspecting the site for reduced swelling B. Asking the client to rate the pain C. Having the client perform range-of-motion of the affected arm D. Monitoring the client's pulse rate

A. Assess the apical pulse for a full minute

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the pedal pulses for a full minute C. Assess the pedal pulses with a Doppler device D. Assess the apical pulse with a Doppler device

C. "Tell me more about your concerns."

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make? A. "You have nothing to worry about." B. "Others who have had this procedure have had great results." C. "Tell me more about your concerns." D. "Why are you feeling so anxious?"

B. Use intermittent eye contact

A nurse is caring for a client is using active listening skills. Which of the following actions should the nurse take? A. Have a pen and paper handy B. Use intermittent eye contact C. Sit side-by-side with the client D. Lean back in the chair

A. Antimicrobial soap

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene? A. Antimicrobial soap B. Alcohol based hand rub C. Providone-iodine D. Chlorhexidine

C. Performing hand hygiene before, during, and after direct contact with the client

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? A. Encouraging the client to consume a high-protein diet B. Changing the client's bed linens each day C. Performing hand hygiene before, during, and after direct contact with the client D. Placing the client in a room with positive-pressure airflow

A. Point out inconsistencies in the client's behavior

A nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront this client. Which of the following approaches should the nurse use wen using confrontation? A. Point out inconsistencies in the client's behavior B. Change the subject when the client behaves defiantly C. Wait to discuss the behavior in the presence of others D. Use an aggressive tone of voice

B, C, D, E

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which. of the following actions should the nurse take? (Select all that apply.) A. Assist the client to ambulate B. Identify the client's pain level C. Remind the client to use incisional sprinting D. Change the client's position E. Offer the client a back rub

A. Nausea

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? A. Nausea B. Petechiae C. Cyanosis D. Blood Pressure

A. Sharing computer passwords with coworkers

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? A. Sharing computer passwords with coworkers B. Using a computer terminal in a non-public area C. Preventing an unidentified health care worker from viewing a health record on the computer screen D. Logging out of the computer before leaving a terminal

B. Self-report of pain

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A. Severity of the condition B. Self-report of pain C. Nonverbal behavior D. Vital signs

C. Apply 4 to 5 mL of liquid soap to the hands

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Rub hands and arms to dry B. Hold the hands higher than the elbows C. Apply 4 to 5 mL of liquid soap to the hands D. Adjust the water temperature to feel hot

A. "I will wear gloves and a gown when bathing a client who has open skin lesions."

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? A. "I will wear gloves and a gown when bathing a client who has open skin lesions." B. "I will wear gloves to minimize the number of times I have to wash my hands." C. "I will wear gloves when measuring a client's blood pressure." D. "I will wear gloves whenever I am in contact with clients."

C. Pain

A nurse notices a patient walking with a stopped gait, facial grimacing, and grasping sounds. Based on these nonverbal clues, which condition would the nurse assess? A. Depression B. Anxiety C. Pain D. Fluid volume deficit

C. Prodromal stage

A school nurse is performing an assessment of a student who says, "I'm too tired to keep my head up in class." The student has a low grade fever. The nurse would interpret these findings as indication which stage of infection? A. Convalescent period B. Incubation period C. Prodromal stage D. Full stage of illness

A. BP

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1 C (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? A. BP B. Temperature C. Respiratory rate D. Pulse rate

C. First

The prefix "primi" means A. Through B. Without C. First D. Against