Week One- Asepsis, Safety, Hygiene, and Activity.

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury? A. "Always test the temperature of bathwater before stepping in." B. "Take your insulin twice a day as we have discussed." C. "Remember to follow your diet so you lose weight this month." D. "Rub lotion on the skin of your legs and feet twice a day."

A. "Always test the temperature of bathwater before stepping in."

What will the nurse instruct nursing assistant personnel (NAP) to do regarding the management of a patient's pain? A. "Let me know at least 30 minutes before you transport her so I can administer her pain medication." B. "Be sure to keep the room temperature high and the TV on at all times." C. "Be sure to tell me if you notice grimacing, guarding, or any unusual behavior." D. "I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so."

A. "Let me know at least 30 minutes before you transport her so I can administer her pain medication."

A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply. A. "Stand centered between the back legs of the walker." B. "Keep your arms relaxed at the side of the walker." C. "Line up the top of the walker with the crease on the inside of your wrist." D. "Your elbows should be nearly straight when you grasp the walker." E. "Move the walker forward 12 to 18 in (30 to 45 cm) with each step and set it down."

A. "Stand centered between the back legs of the walker." B. "Keep your arms relaxed at the side of the walker." C. "Line up the top of the walker with the crease on the inside of your wrist."

For which patient would the nurse most likely ask for a podiatrist consult for nail care? A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot. B. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladder. C. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floor. D. A 12-year-old girl with a broken foot.

A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot.

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? A. A reservoir B. An infectious agent C. A portal of entry D. A portal of exit

A. A reservoir

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what? A. Assessing the patient's gag reflex B. Inspecting the patient's oral cavity C. Placing the bed in a flat position D. Connecting the suction equipment

A. Assessing the patient's gag reflex

Which of the following is the most significant and commonly found infection-causing agent in health care institutions? A. Bacteria B. Viruses C. Fungi D. Mold

A. Bacteria

The nurse is caring for a client that requires a dressing change. When applying the principles of asepsis, what aspect of care should the nurse include? A. Blood and body fluids are major reservoirs for microorganisms. B. It is impossible to completely eliminate microorganisms from an object. C. Visibly clean objects are considered to be sterile. D. All nonsterilized surfaces are considered to be equally contaminated.

A. Blood and body fluids are major reservoirs for microorganisms.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. A. Check the batteries in all smoke detectors. B. Remove throw rugs from high traffic areas. C. Remove extension cords from open spaces. D. Store prescription medications on the counter. E. Ensure appropriate lighting in hallways and entrances to the home.

A. Check the batteries in all smoke detectors. B. Remove throw rugs from high traffic areas. C. Remove extension cords from open spaces. E. Ensure appropriate lighting in hallways and entrances to the home.

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? A. Client with a urinary catheter B. Client with an intravenous catheter C. Client with a surgical wound D. Client with a diabetic foot ulcer

A. Client with a urinary catheter

The nurse is assessing older adult clients at a community health center. Which client is identified as being at the highest risk for developing an infection? A. Client with immobility, incontinence, and dysphagia following a stroke B. Client with uncontrolled diabetes and heart failure C. Client with a history of tuberculosis D. Client with alcohol and substance use disorders

A. Client with immobility, incontinence, and dysphagia following a stroke

A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern? Select all that apply. A. Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function B. Perform a 24-hour input and output assessment C. Assess cardiovascular function and blood pressure D. Ask the client to provide details of the exercise regimen including frequency and type E. Evaluate for diabetes mellitus

A. Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function C. Assess cardiovascular function and blood pressure D. Ask the client to provide details of the exercise regimen including frequency and type E. Evaluate for diabetes mellitus

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? A. Extremity restraint B. Waist restraint C. Elbow restraint D. Mummy restraint

A. Extremity restraint

A nurse is making the bed of a client whose limited mobility prevents her from leaving the bed. What should the nurse do when performing this procedure? A. Fan-fold soiled linens as close to the client as possible. B. Fold linen that is to be reused over the overbed table. C. Remove all covers and/or bath blankets from the client. D. Assist client to turn toward nurse's side of the bed.

A. Fan-fold soiled linens as close to the client as possible.

Which mask should the nurse don when caring for a client with tuberculosis? A. Filtered Respirator B. Low-efficiency particulate air (LEPA) C. Surgical mask D. No mask is necessary

A. Filtered respirator

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? A. Fowler's B. Low Fowler's C. Protective supine D. Semi-Fowler's

A. Fowler's

A female client is on isolation because she acquired a methicillin-resistant Staphylococcus aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? A. Healthcare-associated (HAI) B. Vital C. Iatrogenic D. Antimicrobial

A. Healthcare-associated (HAI)

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next? A. Inform the physician about this finding. B. Encourage the client to brush his teeth 3 times a day. C. Assess for the expiration dates of the antibiotics being administered. D. Inform the client that the antibiotics will resolve this problem.

A. Inform the physician about this finding.

The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change? A. Keep the HOB no lower than a 30-degree angle. B. Fold a pillow in half and place it under the patient's head. C. Lower the bed to a flat position and place two pillows beneath the patient's head. D. Ask another caregiver to hold the patient's head during the bed change.

A. Keep the HOB no lower than a 30-degree angle.

The nurse notices multiple caries upon inspecting a client's mouth. When asked if the client has dental pain, the client responds, "No, my teeth and gums never hurt." Which structural damage does the nurse anticipate? A. Nerve B. Root C. Gingiva D. Enamel

A. Nerve

The nurse provides care to clients of all age groups and is developing an education pamphlet warning about falls. Which age groups would the nurse identify as at risk for falls? Select all that apply. A. Newborns B. Toddlers C. Adolescents D. Adults E. Older adults

A. Newborns B. Toddlers E. Older adults

The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a body mass index (BMI) of 52. Which of the following strategies to transport the client is most appropriate? A. Obtaining a mechanical lateral transfer device to move the client onto a stretcher B. Enlisting the aid of two other staff members and pulling the client across the bed and onto a stretcher C. Positioning a friction-reducing sheet under the client before attempting the transfer D. Transporting the client to the radiology department in the hospital bed

A. Obtaining a mechanical lateral transfer device to move the client onto a stretcher

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall? A. Orient the client to the room and environment upon admission. B. Provide the client with a bedpan to reduce ambulating to the restroom. C. Administer pain medications sparingly in order to minimize any cognitive side effects. D. Place the client in a shared room with a client who is stable and oriented.

A. Orient the client to the room and environment upon admission.

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? A. Partial care B. As-needed care C. Self-care D. Complete care

A. Partial care

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. What is an appropriate consideration when assisting the client with morning hygiene? A. Provide the client with an electric shaver. B. Provide the client with a firm-bristled toothbrush. C. Do not allow the client to shower. D. Avoid massaging the client's back with lotion.

A. Provide the client with an electric shaver.

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should: A. Provide the client with an overhead trapeze. B. Manually roll the client to the side of the bed. C. Teach the client to pull up with the headboard. D. Use a pull sheet whenever moving the client.

A. Provide the client with an overhead trapeze.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity? A. Pull the shoulder blade forward and out from under the client B. Assess for pain C. Place the call bell within reach D. Cover the client with the bed linens

A. Pull the shoulder blade forward and out from under the client

The nurse is meeting with a group of concerned parents of school-aged children about recent events in the community involving guns. What information will the nurse include in the education of the parents about gun safety? Select all that apply. A. Reinforce to children to never touch a gun. B. Instruct children to leave a friend's home in which a gun is accessible. C. Keep guns and ammunition together in a locked container. D. Install a trigger lock on every gun in the home. E. Place the key to the locked gun storage area in a place inaccessible to children.

A. Reinforce to children to never touch a gun. B. Instruct children to leave a friend's home in which a gun is accessible. D. Install a trigger lock on every gun in the home. E. Place the key to the locked gun storage area in a place inaccessible to children.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? A. Short bones contribute to movement. B. The wrist is classified as an irregular bone. C. Flat bones are found in the spinal column. D. Long bones are relatively thin and contribute to shape.

A. Short bones contribute to movement.

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response? A. Slowly lower the patient to the floor. B. Attempt to sit the patient down on a chair just a few steps away. C. Try to hold the patient up until the dizziness passes. D. Call for assistance in a loud but calm voice.

A. Slowly lower the patient to the floor.

A nurse is changing the bed linen of a client admitted to the health care facility. Which isolation precaution should the nurse follow? A. Standard precautions B. Droplet precautions C. Contact precautions D. Airborne precautions

A. Standard precautions

A client with a stroke has left-sided paralysis. Which action(s) does the nurse take to ensure proper positioning and support for this client? Select all that apply. A. Straighten the left elbow and support it on a pillow B. Bend the left arm at a 90-degree angle and place it flat on the bed C. Bend the left knee and support the left leg on a pillow D. Place a small pillow under client's waist E. Place the left leg far enough in front of the body to prevent the client rolling onto the back

A. Straighten the left elbow and support it on a pillow D. Place a small pillow under client's waist E. Place the left leg far enough in front of the body to prevent the client rolling onto the back C. Bend the left knee and support the left leg on a pillow

Inadequate oxygenation to the body will cause the radial pulse to become: A. Tachycardic B. Bradycardic C. Irregular D. Bounding

A. Tachycardic

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?" A. The client will demonstrate safety measures to prevent falls. B. The client will identify resources for safety information. C. The client will establish safety priorities with family members. D. The client will identify unsafe situations in his or her environment.

A. The client will demonstrate safety measures to prevent falls.

The home health nurse is providing care to a number of clients. Which client assessed by the nurse will require hospitalization related to complications associated with the feet? A. The client with peripheral vascular disease B. The client who has osteoporosis C. The client who has asthma D. The client experiencing diabetes insipidus

A. The client with peripheral vascular disease

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? A. The client's ability to assist B. The client's body weight C. The client's cognitive status D. The client's age

A. The client's ability to assist

A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? A. The patient rates his pain a 7 on a scale of 0 to 10. B. The patient who winces and guards the area as the nurse gently palpates the abdomen. C. The patient is having trouble sleeping and has become irritable. D. The patient is moaning softly and frowning, with a pinched expression on his face.

A. The patient rates his pain a 7 on a scale of 0 to 10.

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? A. Transfer chair B. Repositioning lift C. Gait belt D. Powered-stand assist

A. Transfer chair

Soaps and detergents (nonantimicrobial agents) are considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganisms. A. True B. False

A. True

The oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter region. A. True B. False

A. True

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention? A. Use a tepid bath to relieve inflammation and itching. B. Use a moisturizing lotion on a wet rash to prevent itching. C. Do not use over-the-counter products on unknown rashes. D. Avoid washing the area because cleansing agents will only make the rash worse.

A. Use a tepid bath to relieve inflammation and itching.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply. A. Use filtering software to block objectionable information. B. Investigate any public chat rooms used by the children. C. Keep identifying information posted on the web sites. D. Emphasize that everything read online is usually true. E. Be alert for downloaded files with suffixes that indicate images or pictures.

A. Use filtering software to block objectionable information. B. Investigate any public chat rooms used by the children. E. Be alert for downloaded files with suffixes that indicate images or pictures.

A nurse has finished giving care to a client who has a communicable respiratory infection. In which order should the personal protective equipment (PPE) be removed? 1. Gloves 2. Respirator 3. Gown 4. Goggles A. 4, 2, 3, 1 B. 1, 4, 3, 2 C. 4, 2, 1, 3 D. 1, 2, 4, 3

B. 1, 4, 3, 2

To which patient might the nurse apply a physical restraint? A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74-year-old patient confined to bed who is at risk of pressure ulcers. D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having restraints applied for 1 hour that morning.

B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.

During the admissions process, the nurse initially assesses the patient's radial pulse primarily for what purpose? A. Assessment of peripheral blood perfusion. B. Establishment of a baseline as part of the patient's vital signs. C. Assessment of the patient's cardiovascular disease risk. D. Determination of oxygen saturation.

B. Establishment of a baseline as part of the patient's vital signs.

A nurse whose behavior is reasonable and prudent and similar to the behavior that would be expected of another nurse in similar circumstances is still likely to be found liable if a patient falls. A. True B. False

B. False

A side rail is considered a restraint even if the patient asks for it to be raised to assist in getting into and out of bed. A. True B. False

B. False

Among older adults, fires are the leading cause of injury fatality. A. True B. False

B. False. Falls.

A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply. A. Pull objects toward you rather than pushing them away. B. Flex the knees to improve balance and strength. C. Face in the direction in which you are moving the load. D. Standing with your feet close together will improve your balance. E. Work as closely to the objects you are moving as possible.

B. Flex the knees to improve balance and strength. C. Face in the direction in which you are moving the load. E. Work as closely to the objects you are moving as possible.

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. Collaborate with the resident's health care provider to have his or her diuretics discontinued. B. Investigate the possibility of discontinuing his or her catheter. C. Increase the resident's physical activity to reduce evening restlessness. D. Limit the resident's fluid intake in order to reduce his or her urge to void.

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

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply. A. Ensure that the client's bedrails are up prior to transfer. B. Lower the bed to the lowest position allowing the client's soles to contact the floor. C. Provide the client with nonskid slippers to put on prior to standing up. D. Make sure the client's weaker leg is nearest to the chair. E. Provide step-by-step instructions to the client before the transfer begins.

B. Lower the bed to the lowest position allowing the client's soles to contact the floor. C. Provide the client with nonskid slippers to put on prior to standing up. E. Provide step-by-step instructions to the client before the transfer begins.

A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client? A. Providing gentle oral care B. Obtaining rectal temperatures C. Avoiding razors with blades D. Encourage wearing a mask when out of the room

B. Obtaining rectal temperatures

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply. A. Inside edges of the ulcer appear to be drawing together B. Pain with redness and swelling C. Scabs forming over the ulcer D. Localized Heat E. Purulent or malodorous drainage

B. Pain with redness and swelling D. Localized Heat E. Purulent or malodorous drainage

During which stage of infection is the patient most contagious? A. Incubation Period B. Prodromal Stage C. Full Stage of Illness D. Convalescent Period

B. Prodromal Stage

The nurse assessing a client who had an elevated temperature 1 hour ago determines that the client is in the crisis phase of fever. What would lead the nurse to this conclusion? A. Evidence of gooseflesh B. Profuse diaphoresis C. Chills and shivering D. General malaise

B. Profuse diaphoresis

The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made? A. Lower the head of the bed B. Raise the side rails C. Apply the top sheet D. Discard the soiled linen in the linen bag

B. Raise the side rails

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field? A. While wearing sterile gloves, unwrap the package and add to the field. B. Separate the sealed flaps and drop contents onto field.

B. Separate the sealed flaps and drop contents onto field.

Which classification describes the bones located in the wrist? A. Long bones B. Short bones C. Flat bones D. Irregular bones

B. Short bones

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? A. Joint stiffness after sitting for an hour B. Shortness of breath after walking up five stairs C. A change in pulse from 80 to 84 after walking up 20 stairs D. Walking with a slow and uncoordinated movement

B. Shortness of breath after walking up five stairs

The nurse is supervising the unlicensed assistive personnel (UAP) who is performing denture care for a client in a long-term care facility. The nurse stops the UAP from performing any further denture care when which action(s) is observed? Select all that apply. A. The UAP stores the denture set in a covered container. B. The UAP uses warmed sterile water to cleanse the denture set. C. The UAP uses a regular toothbrush and natural brushing motions. D. The UAP dons clean gloves to remove dentures with dry gauze. E. The UAP holds dentures firmly in hands while carrying them to the sink to prevent breakage.

B. The UAP uses warmed sterile water to cleanse the denture set.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? A. The client should be placed in a position of comfort. B. The client should be placed in a side-lying position to prevent aspiration. C. The client should remain in an upright position to avoid the tongue blocking the airway. D. The client should be placed in the lithotomy position.

B. The client should be placed in a side-lying position to prevent aspiration.

Why is it important for the nurse to teach and role model proper body mechanics? A. To ensure knowledgeable client care B. To promote health and prevent illness C. To prevent unnecessary insurance claims D. To demonstrate knowledge and skills

B. To promote health and prevent illness

When positioning a hemiplegic patient in the semi-Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? A. To reduce the risk of fall while the side rails are down. B. To reduce the risk of contracture. C. To control pain. D. To cushion the legs.

B. To reduce the risk of contracture.

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care? A. Pull sheets B. Trapeze bar C. Trochanter rolls D. Log rolling

B. Trapeze bar

The nurse is preparing an education session on injury prevention for parents with toddlers. What will the nurse prioritize during this session to help parents to reduce the risk of injury for toddler, given their developmental stage? Select all that apply. A. Bike safety B. Water safety C. Childproof latches D. Electric outlet safety E. Safety with stairs

B. Water safety C. Childproof latches D. Electric outlet safety E. Safety with stairs

A nurse is providing oral care to children on a pediatric unit. Which guideline should the nurse follow for providing care in special situations? A. If a child has braces, mouth rinses should be used instead of a toothbrush to avoid loosening the braces. B. Water should be used to clean an infant's teeth. C. Toothpaste with fluoride should not be used until children are 16 years of age. D. Oral hygiene should begin for children when they are able to hold a toothbrush properly.

B. Water should be used to clean an infant's teeth.

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? A. Place client in a private room that has monitored negative air pressure. B. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. C. Use a private room with the door closed at all times. D. Ensure that hard surfaces in the room are disinfected at least once per day.

B. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: A. "My child needs a helmet if in a secured passenger bike seat." B. "The helmet should rest 1 in (2.5 cm) above the eyebrows." C. "I should be able to fit two fingers between my chin and the chin strap." D. "My child should wear a helmet every time he rides a bike."

C. "I should be able to fit two fingers between my chin and the chin strap."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? A. "I will close the door to the room where the fire is after clients have been removed." B. "After clients are evacuated from the room with the fire, the alarm can be sounded." C. "Only certain members of the health care team can extinguish a fire." D. "I will rescue clients from harm before doing anything else."

C. "Only certain members of the health care team can extinguish a fire."

A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement? A. "Older people often have splotchy skin due to seborrheic keratoses." B. "Those spots are benign and are known as seborrheic keratoses." C. "Those are senile lentigines and are common in older adults." D. "Those spots are senile lentigines and may be cancerous."

C. "Those are senile lentigines and are common in older adults."

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. "You will mostly stay in bed while you are hospitalized." B. "It is important to us that you remain free from injury." 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 caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? A. Wear a protective gown and gloves with any direct contact. B. Wear a mask with face shield during invasive procedures. C. Apply a nonparticulate (N-95) respirator when entering the room. D. Have the client wear a mask during care.

C. Apply a nonparticulate (N-95) respirator when entering the room.

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. Arrange for a skilled home care assessment D. Assess the client for signs and symptoms of osteoporosis

C. Arrange for a skilled home care assessment

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be? A. Assign a care provider who shares the same culture as the client. B. Assess the skin every day using the Braden scale. C. Assess the client's cultural views regarding hygiene and self-care. D. Delegate hygiene/bathing to an unlicensed assistive personnel (UAP).

C. Assess the client's cultural views regarding hygiene and self-care.

Which oral problem involves an ulceration of the lips usually caused by vitamin B complex deficiencies? A. Stomatitis B. Glossitis C. Cheilosis D. Dry oral mucosa

C. Cheilosis

A nurse stretches out a patient's leg and moves it in a circle. This is an example of what type of body movement? A. Abduction B. Flexion C. Circumduction D. Dorsiflexion

C. Circumduction

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? A. Complete a sentinel event report. B. Notify the primary care provider. C. Don another pair of sterile gloves. D. No action is needed.

C. Don another pair of sterile gloves.

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin? A. Airborne B. Contact C. Droplet D. None

C. Droplet

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death? A. Eighth B. First C. Fifth D. Tenth

C. Fifth

To which position would the nurse assist the patient who is experiencing difficulty with breathing? A. Sim's position B. 30-degree lateral position C. Fowler's position D. Prone position

C. Fowler's position

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply. A. Able to lift head from pillow B. Walks 20 feet C. Full range of motion with each joint D. No swelling, heat, tenderness, pain, nodules, or crepitation E. No masses, deformities, or muscle atrophy

C. Full range of motion with each joint D. No swelling, heat, tenderness, pain, nodules, or crepitation E. No masses, deformities, or muscle atrophy

A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection? A. Stress may adversely affect normal defense mechanisms. B. White blood cells provide resistance to certain pathogens. C. Intact skin and mucous membranes protect against microbial invasion. D. Age, race, sex, and hereditary factors influence susceptibility to infection.

C. Intact skin and mucous membranes protect against microbial invasion.

What can the nurse do to keep the patient from being chilled while receiving a bath with disposable bath-in-a-bag product? A. Dry each body part with a warmed towel after washing. B. Wash the product off of the skin with a warm, moistened washcloth. C. Lightly cover the patient with a bath towel. D. Keep the patient's gown on for the bath.

C. Lightly cover the patient with a bath towel.

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. Weakness affecting one-half of the body. B. Paralysis affecting one-half of the body. C. Paralysis of the legs. D. Paralysis of the legs and arms.

C. Paralysis of the legs.

Which gum disease manifests as a marked inflammation of the gums that also involves a degeneration of the dental tissues and bone? A. Dental caries B. Gingivitis C. Periodontitis D. Plaque

C. Periodontitis

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task? A. Apply pressure over the eye with your index finger and thumb under the eye. B. Pull up the upper lid and place your index finger under the glass edge. C. Pull down on the lower lid and exert slight pressure below the lid. D. Pull the inner canthus toward the bridge of the nose and lift under the glass.

C. Pull down on the lower lid and exert slight pressure below the lid.

Which action is the best example of a nurse donning/removing protective equipment properly? A. Donning gown after entering the patient's room B. Removing gown after leaving the patient's room C. Removing respirator after leaving the patient's room D. Donning respirator inside the patient's room

C. Removing respirator after leaving the patient's room

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as: A. Hemiparesis B. Ataxia C. Spasticity D. Disequilibrium.

C. Spasticity

Why does the nurse instruct the nursing assistant personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? A. To try a less restrictive type of restraint if a more confining restraint has proved effective. B. To double-check the size by inserting two fingers between the wrist and the restraint. C. To check the skin integrity and range of o motion of the wrist. D. To comply with Joint Commission standards.

C. To check the skin integrity and range of o motion of the wrist.

Before a long-term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? A. None; they should be placed in saline B. To increase comfort when replaced in the mouth C. To prevent drying and warping of plastic D. To ensure the dentures are not thrown away

C. To prevent drying and warping of plastic

Why would the nurse encourage a male patient to use an electric razor for shaving? A. To reduce the use of hospital supplies B. To reduce the risk of infection C. To reduce the risk of bleeding from a disposable razor D. To encourage him to shave himself

C. To reduce the risk of bleeding from a disposable razor

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? A. Use respiratory protection when entering the room B. Keep visitors 3 ft. away from the patient C. Wear gloves when entering the patient's room D. Place the patient in a negative pressure room

C. Wear gloves when entering the patient's 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. "We only wash our hands when they are visibly soiled." C. "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." D. "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

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

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her? A. "Car seats are recommended until children are at least 10 years old." B. "Your child will be safe in the car using the provided shoulder harness and lap belts." C. "Car seats are only recommended until children are 3 years old." D. "At the age of 6 your child should be using a booster seat."

D. "At the age of 6 your child should be using a booster seat."

A client with a localized inflammatory response asks the nurse why the area is reddened. Which response by the nurse would be most appropriate? A. "There is bleeding into the interstitial space in the area." B. "It's due to the fluid accumulating in the area." C. "There is pressure on, and injury to, the local nerves." D. "It is the result of blood accumulating in the dilated vessels."

D. "It is the result of blood accumulating in the dilated vessels."

On a preoperative surgical unit, as a standard of care, all clients are swabbed for methicillin-resistant Staphylococcus aureus (MRSA). Prior to his surgery, a nurse notes that a specific client's results have come back positive. the client ask the nurse what this means. What is the nurse's best response? A. "These results indicate that you are contaminated with MRSA." B. "Two positive tests are required before results can be confirmed." C. "These results indicate that you re infected with MRSA," D. "These results indicate that you are colonized with MRSA."

D. "These results indicate that you are colonized with MRSA."

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child who weighs 31 lb (14 kg)? A. "We place our child in a rear-facing car seat in the front of the car." B. "We place our child in a front-facing car seat in the back seat of the car." C. "We place our child in a front-facing car seat in the front of the car." D. "We place our child in a rear-facing car seat in the back seat of the car."

D. "We place our child in a rear-facing car seat in the back seat of the car."

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into? A. B = background B. R = recommendation C. S = situation D. A = assessment

D. A = assessment

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? A. A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. B. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg). C. A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg). D. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

D. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety? A. Transferring the client from one location in the hospital to another B. Admitting the client to the health care facility C. Electronically reporting the results of diagnostic testing to the client's primary care provider D. Administering medications to the client

D. Administering medications to the client

The family of a client being discharged home has arranged to rent a hospital bed. What should the nurse teach the family about safety when using the bed? A. How to apply the bed linens B. Proper maintenance C. How to move the client in bed D. Advisable positions and controls

D. Advisable positions and controls

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse? A. Ask the client to read and discuss a passage from a pamphlet. B. Ask the client to review his medical health history to assess for the level of organization of his thought processes. C. Discuss with the client's family any concerns about his mental stability. D. Ask the client "what if" questions to determine level of thought organization.

D. Ask the client "what if" questions to determine level of thought organization.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care? A. Flush the eyes with a cool saline solution for a 10-minute period. B. Advise the client to avoid blinking until after the eyes are irrigated. C. Wash the eyes with a hypertonic solution for at least 30 minutes. D. Flush the eyes with water for 10 minutes.

D. Flush the eyes with water for 10 minutes.

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection? A. Protozoa B. Virus C. Helminth D. Healthcare-Associated Infection (HAI)

D. Healthcare-Associated Infection (HAI)

An older adult client is reporting dry, itching skin. The nurse should assess: A. When the severe itching occurs. B. What linens they are using. C. When the client's last tub bath was. D. How often the client is bathing.

D. How often the client is bathing.

A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as: A. Endogenous. B. Exogenous. C. Antibiotic resistant. D. Iatrogenic.

D. Iatrogenic.

Which infection or disease may be spread by touching a contaminated inanimate article? A. Rabies B. Giardia C. E. Coli D. Influenza

D. Influenza

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? A. Requires crutches for mobility. B. Requires a better walking shoe. C. Should have an orthopedic consultation. D. Is demonstrating a common gait for the older adult.

D. Is demonstrating a common gait for the older adult.

The nurse has washed a patient's abdomen. What should the nurse wash next? A. Feet B. Face C. Chest D. Legs

D. Legs

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies? A. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees. B. New partnerships are established between the hospital and local schools of nursing. C. Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost. D. New systems are introduced to increase communication between nurses and the members of other health disciplines.

D. New systems are introduced to increase communication between nurses and the members of other health disciplines.

A nurse is caring for four clients. Which client has the highest risk of infection? A. Woman in second trimester of pregnancy B. Young woman with a history of scoliosis C. Toddler with a benign heart murmur D. Older male with an enlarged prostate

D. Older male with an enlarged prostate

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide? A. Allow emergency personnel to apply oxygen. B. Recommend that carbon monoxide detectors be installed in the home. C. Wait inside until emergency personnel arrive. D. Open doors and windows.

D. Open doors and windows.

What will the nurse instruct nursing assistant personnel (NAP) to do when measuring an adult patient's radial pulse? A. Place the patient in the lateral (side-lying) position before measuring pulse. B. Apply gloves with each patient before measuring the pulse. C. Document whether the patient's pulse is bounding or has diminished. D. Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers.

D. Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers.

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first? A. Leave to notify the health care provider concerning a change in client status B. Apply limb restraints to ensure client safety C. Promptly document the change in client status D. Reduce distressing environmental stimuli to maximize client safety

D. Reduce distressing environmental stimuli to maximize client safety

A client is very anxious and states, "I am so stressed." What is the reason stress affects the client's safety? A. Stress increases retention of information. B. Stress affects interpersonal relationships. C. Stress increases concern about hazards. D. Stress tends to narrow the attention span

D. Stress tends to narrow the attention span

Why does the nurse change the patient's elastic stockings at least once per shift? A. To permit the skin to breathe. B. To wash the legs with a disposable bath product. C. To air out the stockings and allows sweat to evaporate. D. To check the skin for irritation or breakdown.

D. To check the skin for irritation or breakdown.

What is the primary reason an unconscious patient is placed in a side-lying position when mouth care is provided? A. To make the oral cavity easily accessible B. To prevent possible musculoskeletal injury C. To reduce plaque buildup in the mouth D. To reduce the risk of aspiration

D. To reduce the risk of aspiration

A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient? A. To apply moisturizer after air-drying thoroughly. B. To apply moisturizer while the skin is still wet. C. To skip the moisturizer. D. To towel-dry thoroughly before applying moisturizer.

D. To towel-dry thoroughly before applying moisturizer.

The nurse is caring for a client that is comatose. What action by the nurse will prevent complications related to the provision of oral care? A. Place the client in high Fowler's position. B. Place the client in the supine position with head lowered. C. Put the client in the prone position. D. Use small amounts of water and an oral suction device.

D. Use small amounts of water and an oral suction device.

A group of children is preparing for a camping trip in the woods with camp counselors. The children are learning about health promotion activities to use on their upcoming camping trip. Which principle is most important for the nurse to teach to promote a safe camping experience? A. Avoiding poison ivy B. Running on smooth surfaces C. Wearing sturdy shoes for hiking D. Using the buddy system during the trip

D. Using the buddy system during the trip

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? A. Use a private room with the door closed at all times B. Place the patient in a private, negative pressure room C. Ensure hard surfaces in the room are disinfected at least once per day D. Wear PPE when entering the room for all interactions that may involve contact with the patient

D. Wear PPE when entering the room for all interactions that may involve contact with the patient