Unit 3

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? "Washing the hands with soap and water is not necessary." "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." "We only wash our hands when they are visibly soiled."

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

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor? -"You should not visit your friend if you have an infection of any kind because your friend may also get sick." -"If you wash your hands before coming in contact with your friend you will prevent infection during your visit." -"As long as you cough and sneeze into the bend of your elbow you won't spread the infection to your friend." -"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

-"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? -Allow many family members to visit at once. -Deliver flowers and balloons to the room. -Remove fresh fruit from the room. -No special precautions are required.

-Remove fresh fruit from the room.

A nurse documents a client's hemoglobin as 8 g/dL (80 g/L). What nutritional condition does this biochemical data signify? Dehydration Malnutrition Malabsorption Anemia

Anemia

After teaching the client about a low-fat diet, which items selected by the client would indicate to the nurse that the client comprehends the nutritional teaching? Coffee with non-dairy creamer Peanut-butter sandwich Egg white omelet with vegetables Frozen hash browns with vegetables

Egg white omelet with vegetables

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid? Potassium Sodium Magnesium Iodine

Iodine

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the: AI level UL level EAR level RDA level

RDA level

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique? Surgical asepsis Medical asepsis Universal precautions Contact precautions

Surgical asepsis

The nurse is preparing to enter a client's room who is on airborne precautions. Which technique should the nurse use when wearing a nonparticulate respirator (N-95) mask? Select all that apply. The mask covers the nose and mouth. Replace the mask after 20-30 minutes. Remove the mask by grasping the front of mask. Tie the upper strings of mask snugly against back head. Discard the mask in a paper lined wastebasket.

The mask covers the nose and mouth. Replace the mask after 20-30 minutes. Tie the upper strings of mask snugly against back head.

A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason? To allow gas to accumulate and promote healing To rest the gastrointestinal tract and promote healing To increase mucus in the bowel that helps to promote healing To prevent gas from forming in the bowel and interfere with healing

To rest the gastrointestinal tract and promote healing

A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what? Dairy Protein Unsaturated fats Vegetables

Vegetables

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection? airborne droplet contact reverse isolation

contact

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? wear gloves when touching the client wear a mask and gown in the client's room avoid direct contact with the client perform hand hygiene before and after entering the client's room

perform hand hygiene before and after entering the client's room

The nurse is providing care to a client who had abdominal surgery yesterday. Identify the items in the scenario that break the cycle of infection between the infectious agent and reservoir. The nurse enters the room, performs hand hygiene and confirms the client's identity . Using a scanner system the nurse accesses the medication adiministration record and hangs prescribed intravenous antibiotics . The nurse then prepares a sterile field on which sterile items are aseptically placed . The soiled dressing is removed and both the wound and the dressing are assessed. The nurse removes the soiled gloves and then dons sterile gloves to clean the wound and applies a new sterile dressing.

performs hand hygiene hangs prescribed intravenous antibiotics prepares a sterile field on which sterile items are aseptically placed

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 invasion stationary resolution

prodromal

A client is receiving prescribed antibiotic therapy to treat an infection. On the fourth day of therapy, the client comes to the clinic and tells the nurse that she has developed a really sore mouth. After inspection, the nurse suspects that the client has developed a fungal oral infection. The nurse identifies this as: superinfection. bacteremia. endotoxin. healthcare-associated infection (HAI).

superinfection.

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk? new mother who is bottle-feeding a baby older adult who lives with grown children teenager who is in the second trimester of pregnancy middle-age male who works night shift

teenager who is in the second trimester of pregnancy

The most lethal infection in an older adult client is: skin. optic. otic. urinary.

urinary.

Which vitamin is found only in animal foods? vitamin C vitamin B12 vitamin A vitamin D

vitamin B12

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect? vitamin A vitamin B vitamin C vitamin D

vitamin D