scored quiz 1 questions

A nurse is caring for an older adult client who has expressed concern regarding their decreased level of mobility, particularly walking around the house. Which question by the nurse is most appropriate to gain more information related to the client's safety at home? a. "Have you fallen down at all in the last few months?" b. "Do you have anyone that can help you at home?" c. "Do you use a cane or a walker at home?" d. "Do you have any throw rugs in the home?"

a. "Have you fallen down at all in the last few months?"

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? a. 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. b. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing c. sending a VRE-positive client to the radiology department for a chest X-ray without a face mask d. delivering a meal tray to a VRE-positive client without first donning gloves and a gown

a. 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.

Which piece of personal protective equipment (PPE) should be removed first? a. Gloves b. Respirator c. Gown d. Goggles

a. Gloves

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? a. Investigate the possibility of discontinuing his or her catheter. b. Limit the resident's fluid intake in order to reduce his or her urge to void. c. Collaborate with the resident's health care provider to have his or her diuretics discontinued. d. Increase the resident's physical activity to reduce evening restlessness.

a. Investigate the possibility of discontinuing his or her catheter.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply. a. Obtain order from a licensed provider within minutes of restraint application. b. Withhold information from family regarding restraints due to HIPAA. c. Check circulation and skin condition every 2 hours. d. Offer regular, frequent opportunities for toileting. e. Maintain restraints until discharge.

a. Obtain order from a licensed provider within minutes of restraint application c. Check circulation and skin condition every 2 hours. d. Offer regular, frequent opportunities for toileting.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? a. Rescue anyone who is in immediate danger. b. Evacuate clients and staff. c. Activate the fire alarm on the unit. d. Attempt to extinguish the fire.

a. Rescue anyone who is in immediate danger.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? a. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. b. Logrolling can be performed by one experienced nurse. c. Logrolling will maintain straight alignment when the client is sitting in a chair. d. It is acceptable to twist the client's head, but not the hips, while logrolling.

a. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has: a. paralysis of the legs. b. weakness affecting one-half of the body. c. paralysis affecting one-half of the body. d. paralysis of the legs and arms.

a. paralysis of the legs

When developing a plan of care for a client who has developed neutropenia secondary to chemotherapy, which of the following would the nurse most likely include? Select all that apply. a. placing the client in a private room b. having the client wear a mask when outside the room c. providing vigorous oral care d. measuring temperatures rectally e. removing fresh flowers from the room

a. placing the client in a private room b. having the client wear a mask when outside the room e. removing fresh flowers from the room

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? a. "Washing the hands with soap and water is not necessary." b. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." c. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." d. "We only wash our hands when they are visibly soiled."

b. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? a. "Any staff who enters my room will be wearing personal protective equipment (PPE)." b. "I can leave my room any time I want as long as I wear a mask." c. "I will tell my visitors to keep their distance from me." d. "My personal belongings should remain in the room until I am discharged."

b. "I can leave my room any time I want as long as I wear a mask."

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary? a. "The hand rolls help keep my thumb positioned away from my hand." b. "The hand rolls help me develop strength in my grip." c. "I can use a rolled-up washcloth if I don't have a hand roll." d. "I need to remove the hand roll often to exercise my hand muscles."

b. "The hand rolls help me develop strength in my grip."

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? a. places bed at lowest setting b. provides slippers for ambulation c. clears a path from bed to bathroom d. has client sit in bed for a few moments before standing

b. provides slippers for ambulation

When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: a. droplet precautions. b. standard precautions. c. contact precautions. d. airborne precautions.

b. standard precautions

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client? a. "It is important to us that you remain free from injury." b. "You will mostly stay in bed while you are hospitalized." c. "Use the call bell for any needs and wear nonslip footwear." d. "Do not get up without assistance for any reason."

c. "Use the call bell for any needs and wear nonslip footwear."

The nurse is initiating isolation precautions for a client who has chronic Clostridioides difficile infection. What should the nurse be sure to include with these precautions? a. remind others to use a mask when caring for this client b. recognize that this type of infection requires droplet precautions c. be sure that there are gloves of various sizes and gowns for use d. include a N95 respirator mask for health care staff entering the room

c. be sure that there are gloves of various sizes and gowns for use

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? a. Perform a vision test with Snellen chart b. Arrange an audiology consult to evaluate hearing c. Assess the client for signs and symptoms of osteoporosis d. Arrange for a skilled home care assessment

d. Arrange for a skilled home care assessment

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? a. Shift their weight back and forth from the legs to the back muscles. b. Rock the client back and forth to raise the client up in bed. c. Turn the client from side to side while pushing upward. d. Shift their weight back and forth, from back leg to front leg.

d. Shift their weight back and forth, from back leg to front leg.

When moving a client up in bed with the assistance of another caregiver, the nurse should: a. ask another nurse about the plan of care. b. elevate the head of the bed. c. maintain a pillow under the client's head. d. have the client fold the arms across the chest.

d. have the client fold the arms across the chest

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: a. uses the sides of the walker to rise from a chair. b. places the walker far in front when walking. c. steps into the walker when walking. d. leans over the walker when walking.

d. leans over the walker when walking.