Asepsis & Infection Control Practice Questions

While changing a client's dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wound's drainage? 1. Purulent 2. Serous 3. Sanguineous 4. Serosanguinous

Answer: 1 Explanation: Purulent exudate is thick and can vary in color, including green and yellow.

A client is diagnosed with a communicable disease and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements

Answer: 1 Explanation: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.

A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client? (Select all that apply.) 1. The application of cold dilates blood vessels. 2. The application of cold constricts blood vessels. 3. The application of cold decreases inflammation. 4. The application of cold reduces localized pain. 5. The application of cold provides a calming, sedative effect.

Answer: 2, 3, 4

A client recovering from acute illness has just received a tub bath. When documenting the bath, what should the nurse include? (Select all that apply.) 1. Client's ability to maintain a conversation during the procedure 2. Client's tolerance of the procedure 3. Condition and integrity of the skin 4. Client strength 5. Percentage of bath done without assistance

Answer: 2, 3, 4, 5

The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging? (Select all that apply.) 1. Finger 2. Forearm 3. Upper leg 4. Lower leg 5. Upper arm

Answer: 2, 4

The nurse asks unlicensed assistive personnel (UAP) to help a client off of a bedpan. Which action should the UAP take first? 1. Wash hands 2. Apply gloves 3. Apply a gown 4. Apply a face mask

Answer: 1 Explanation: Before providing any type of client care, the hands should be washed. Gloves are to then be applied. There is no reason for the UAP to apply a gown or face mask.

The nurse is shampooing a client's hair. Which assessment finding should the nurse consider as expected? 1. Dry, dark, thin 2. Smooth, taut, shiny 3. Smooth texture and not oily or dry 4. Tender, warm scalp

Answer: 3 Explanation: The hair should be smooth in texture and neither oily nor dry.

A school nurse is performing an assessment of a student who states: "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 indicating which stage of infection? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period

B. Prodromal

Subcutaneous administration A. Deltoid B. 0.1 ml C. 20 seconds D. Implants

Correct AnswerD. Implants

1. Calicivirus, also referred to as ___________, is the most common cause of foodborne illness and gastroenteritis in the United States.

NORO

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the client's hand and arm joints through passive range of motion.

Answer: 3 Explanation: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face.

The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. Chest symmetrical 2. Breath sounds equal bilaterally 3. Asymmetrical chest expansion 4. Bilateral symmetric vocal fremitus

Answer: 3 Explanation: Chest expansion should be symmetrical.

The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin).

Answer: 3 Explanation: Clients who are taking diuretics must make position changes slowly in order to minimize dizziness from orthostatic hypotension. Page Ref: 1356

An older client with heart failure has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema 3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion

Answer: 3 Explanation: Edema and orthopnea are assessment findings associated with excess fluid volume.

The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care? 1. Clothes 2. Family 3. Hair 4. Nutritional

Answer: 3 Explanation: Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have life-threatening complications? A. A 4-year-old scald victim burned over 24% of the body B. A 27-year-old male burned over 36% of his body in a car accident C. A 39-year-old female client burned over 18% of her body D. A 60-year-old male burned over 16% of his body in a brush fire

ANS: A Rationale: Young children and older adults continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the client.

. The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for the client's IV site, the nurse should: A. ensure that anticoagulants are placed on hold for the duration of IV therapy. B. replace the IV dressing with a new, clean dressing if it is soiled. C. ensure that the tubing is firmly anchored to the client's skin. D. periodically remove hair from 2 cm around the IV site.

ANS: C Rationale: Anchoring the IV tubing prevents it from being accidentally dislodged. Anticoagulants are not contraindicated during IV therapy. Soiled dressings should be replaced with a new sterile dressing, not a clean dressing. Hair removal is unnecessary.

The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep-breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the client's nasogastric tube every 2 hours.

Answer: 3 Explanation: Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum.

A client reports following a vegan eating plan. For which finding should the nurse suspect the client has a protein deficiency? 1. Slow heart rate 2. Slow respiratory rate 3. Lower-extremity edema 4. Hyperactive bowel sounds

Answer: 3 Explanation: Hypoproteinemia predisposes the client to dependent edema. Edema makes skin more prone to injury by decreasing its elasticity, resilience, and vitality. A protein deficiency does not cause a slow heart rate, a slow respiratory rate, or hyperactive bowel sounds.

The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? 1. Assist the client to a prone position. 2. Pull the skin taut with the dominant hand. 3. Wear gloves during the procedure. 4. Use long strokes.

Answer: 3 Explanation: Wear gloves in case facial nicks occur and you come in contact with blood.

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia, elevated hematocrit ANS: A

ANS: A Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit.

1. Although the incubation period for chickenpox is about 21 days, it is during the _____ days before the rash develops that the newly infected host is capable of transmitting the virus to other susceptible contacts.

2

Upon assessing a pressure injury, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan? 1. Red 2. Yellow 3. Black 4. A combination of all three

Answer: 3 Explanation: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove.

Answer: 3 Explanation:In order to remove gloves after use, one must grasp the outside of the nondominant

The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing

Answer: 1 Explanation: The drop factor (number of drops per milliliter of fluid) of tubing is located on the packaging.

A client's leg wounds appear red and edematous a day after a traumatic injury. Which stage of healing should the nurse identify for this client? 1. Inflammatory 2. Proliferative 3. Maturation 4. Remodeling

Answer: 1 Explanation: The inflammatory phase is initiated immediately after injury and lasts 3— to 6 days.

The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the client's legs when turning? (Select all that apply.) 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

Answer: 3, 4, 5

Assistive personnel are caring for a client's ears. What information should be reported to the nurse? 1. Excessive earwax 2. Loud talking 3. Presence of a hearing aid 4. Presence of any drainage

Answer: 4 Explanation: The healthcare provider should report any drainage from the ears to the nurse.

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first suspect? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia

ANS: B Rationale: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

A client's laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing 4. Delayed closure

Answer: 1 Explanation: The nurse should instruct the client regarding primary intention wound healing. The edges of these wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. Which factors contribute to this phenomenon? Select all that apply. A. Decreased kidney mass B. Increased conservation of sodium C. Increased total body water D. Decreased renal blood flow E. Decreased excretion of potassium

ANS: A, D, E Rationale: Dehydration in older adults is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

The new nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. What should be done before the nurse uses the scale? 1. Receive specific training 2. Be certified 3. Ask the client's permission 4. Obtain special assessment equipment

Answer: 1 Explanation: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate.

The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? 1. Assess skin integrity 2. Develop a nurse-client relationship 3. Moisturize the skin 4. Stimulate circulation

Answer: 4 Explanation: The three major reasons for a bath are to remove waste products such as perspiration, stimulate circulation, and refresh the client.

The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? 1. Loosen the covers around the foot of the bed. 2. Place a bath blanket over the client. 3. Slide the mattress to the head of the bed. 4. Raise the side rail.

Answer: 1 Explanation: Loosen the top covers around the foot of the bed to provide space for the client's feet.

A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? A. Wearing a mask and gown when starting an IV line B. Washing hands immediately after removing gloves C. Recapping all needles promptly after use to prevent needlestick injuries D. Double-gloving when working with a client who has a bloodborne illness

ANS: B Rationale: Standard precautions are used to prevent contamination from blood and body fluids. Gloves are worn whenever exposure is possible, and hands should be washed after removing gloves. Needles are never recapped after use because this increases the risk of accidental needlesticks. Under ordinary circumstances, masks and gowns are not necessary for starting an IV line. Double-gloving is not a recognized component of standard precautions.

A client reports having a severe sunburn after being outdoors for a short period of time. For which potential cause should the nurse assess the client? 1. Takes an antibiotic 2. Eats fresh fruit everyday 3. Sleeps 7 hours each night 4. Exercises 5 days a week

Answer: 1 Explanation: Many medications increase sensitivity to sunlight and can predispose a client to severe sunburns. Some of the most common medications that cause this damage are certain antibiotics. Fresh fruit, sleep, and exercise do not increase the risk of severe sunburns.

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D. The client is likely experiencing an anaphylactic reaction to a medication

ANS: A Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury.

A nursing home resident has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? A. Contact B. Droplet C. Airborne D. Positive pressure isolation

ANS: A Rationale: Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms that can be transmitted by close, face-to-face contact, such as influenza or meningococcal meningitis. Airborne precautions are required for clients with presumed or proven pulmonary TB or chickenpox. Positive pressure isolation is unnecessary and ineffective.

12. The nurse is providing care for a client who has a diagnosis of pneumonia due to Streptococcus pneumonia infection. What aspect of nursing care would constitute part of the planning phase of the nursing process? A. Achieve SaO2 92% at all times. B. Auscultate chest q4h. C. Administer oral fluids q1h and PRN. D. Avoid overexertion at all times.

ANS: A Rationale: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a client with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.

14. The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? A. An insect bite B. Dehydration C. Sunburn D. Excessive perspiration

ANS: A Rationale: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? A. Frequent handwashing reduces transmission of pathogens from one client to another. B. Wearing gloves is known to be an adequate substitute for handwashing. C. Bar soap is preferable to liquid soap. D. Waterless products should be avoided in situations where running water is unavailable.

ANS: A Rationale: Whether gloves are worn or not, handwashing is required before and after client contact because thorough handwashing reduces the risk of cross-contamination. Bar soap should not be used because it is a potential carrier of bacteria. Soap dispensers are preferable, but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer.

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? A. Remove gown, goggles, mask, gloves, and exit the room. B. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles. C. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene. D. Remove goggles, mask, gloves, gown, and perform hand hygiene.

C. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene.

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up

Answer: 1 Explanation: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the client's central blood pressure drops when moving from supine to sitting or to standing.

The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurse's hands.

Answer: 1 Explanation: This is the technique to assess muscle grip strength.

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A. A patient diagnosed with rubella B. A patient diagnosed with diptheria C. A patient diagnosed with varicella D. A patient diagnosed with tuberculosis E. A patient diagnosed with MRSA F. An infant diagnosed with adenovirus infection

A. A patient diagnosed with rubella B. A patient diagnosed with diptheria F. An infant diagnosed with adenovirus infection

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. A. The nurse is providing a bed bath for a patient. B. The nurse has visibly soiled hands after changing the bedding of a patient. C. The nurse removes gloves when patient care is completed. D. The nurse is inserting a urinary catheter for a female patient. E. The nurse is assisting with a surgical placement of a cardiac stent. F. The nurse removes old magazines from a patient's table.

A. The nurse is providing a bed bath for a patient. F. The nurse removes old magazines from a patient's table. D. The nurse is inserting a urinary catheter for a female patient C. The nurse removes gloves when patient care is completed

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? A. Vesicle B. Macule C. Nodule D. Wheal

ANS: A Rationale: A vesicle is a primary skin lesion that is elevated and has fluid contained in the dermis. Examples of vesicles would be a blister or insect bite. Wheals, macules, and nodules are not characterized by elevation and the presence of serous fluid.

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room.

Answer: 1 Explanation: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask.

The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration, the nurse explains to a newly licensed nurse how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing which process? A. Diffusion B. Osmosis C. Active transport D. Filtration

ANS: A Rationale: Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the extracellular fluid compartment, where the sodium concentration is high, to the intracellular fluid, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

ANS: A Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care? A. Provide chlorhexidine solution for rinsing the client's mouth. B. Avoid providing regular mouth care until the client's lesions heal. C. Liaise with the primary provider to arrange for parenteral nutrition. D. Encourage the client to gargle with a hypertonic solution after each meal.

ANS: A Rationale: Frequent rinsing of the mouth with chlorhexidine solution is prescribed to rid the mouth of debris and to soothe ulcerated areas. A hypertonic solution would be likely to cause pain and further skin disruption. Meticulous mouth care should be provided and there is no reason to provide nutrition parenterally.

The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Using the incentive spirometer as prescribed B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Assessing frequently for loss of cognitive function

ANS: A Rationale: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision.

. An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many "spots" on the skin. What would be an appropriate response by the nurse? A. "As people age, they normally develop uneven pigmentation in their skin." B. "These 'spots' are called 'liver spots' or 'age spots.'" C. "Older skin is more apt to break down and tear, causing sores." D. "These are usually the result of nutritional deficits earlier in life."

ANS: A Rationale: The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults' vulnerability to skin damage do not answer the question. These lesions are not normally a result of nutritional imbalances.

A client on airborne precautions asks the nurse to leave the door open. What is the nurse's best reply? A. "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B. "I'll keep the door open for you, but please try to avoid moving around the room too much." C. "I can open your door if you wear this mask." D. "I can open your door, but I'll have to come back and close it in a few minutes."

ANS: A Rationale: The nurse is placing the client on airborne precautions, which require that doors and windows be closed at all times. Opening the curtains is acceptable. Clients should be in airborne infection isolation rooms, engineered to provide negative air pressure, rapid turnover of air, and air either highly filtered or exhausted directly to the outside. A closed door maintains the needed negative pressure and controls the spread of the disease that is spread by very small respiratory particles that are suspended as aerosol. Antibiotics, wearing a mask, and standard precautions are not sufficient to allow the client's door to be open.

A nurse on the orthopedic unit is assessing a client's peroneal nerve. The nurse should perform this assessment by doing what action? A. Pricking the skin between the great and second toe B. Stroking the skin on the sole of the client's foot C. Pinching the skin between the thumb and index finger D. Stroking the distal fat pad of the small finger

ANS: A Rationale: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect? A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

ANS: A Rationale: The pH is below 7.35, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range, so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis, but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

The nurse is preparing to transfer a client from the bed to a stretcher. At which height should the bed be placed for this transfer? 1. Slightly higher 2. Slightly lower 3. At the same height 4. At least 2 inches lower

Answer: 1 Explanation: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface.

A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A. Ischemia B. Referred pain C. Cellulitis D. Venous thromboembolism (VTE)

ANS: A Rationale: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

A nurse is caring for a client whose cancer metastasis has resulted in bone pain. What should the nurse expect the client to describe? A. A dull, deep ache that is "boring" in nature B. Soreness or aching that may include cramping C. Sharp, piercing pain that is relieved by immobilization D. Spastic or sharp pain that radiates

ANS: A Rationale: Bone pain is characteristically described as a dull, deep ache that is "boring" in nature, whereas muscular pain is described as soreness or aching and is referred to as "muscle cramps." Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve.

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A. Diminished deep tendon reflexes B. Tachycardia C. Cool, clammy skin D. Acute flank pain

ANS: A Rationale: To gauge a client's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected

Answer: 2 Explanation: A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound.

Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? A. Keloid B. Ulcer C. Fissure D. Erosion

ANS: B Rationale: A pressure ulcer that is stage 2 or greater is one that extends past the epidermal layer and can develop necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear, and erosions do not extend to the dermis.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A. Perform mechanical débridement to remove the exudate and prevent further infection. B. Inform the primary care provider promptly because the graft may need to be removed. C. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. D. Document this finding as an expected phase of graft healing.

ANS: B Rationale: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem, and the nurse would not independently perform débridement.

A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? A. Labile BP B. Weak pulse C. Fever D. Diaphoresis

ANS: B Rationale: Assessment of dehydration includes evaluation of thirst, oral mucous membrane dryness, sunken eyes, a weakened pulse, and loss of skin turgor. Diaphoresis, labile BP, and fever are not characteristic signs and symptoms of dehydration.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation ANS: B

ANS: B Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

A client has a concentration of S. aureus located on the skin. The client is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages? A. Infection B. Colonization C. Disease D. Bacteremia

ANS: B Rationale: Colonization refers to the presence of microorganisms without host interference or interaction. Infection is a condition in which the host interacts physiologically and immunologically with a microorganism. Disease is the decline in wellness of a host due to infection. Bacteremia is a condition of bacteria in the blood.

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

ANS: B Rationale: Correct, upright positioning is necessary to prevent aspiration in the client with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration.

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO2 D. Metabolic acidosis

ANS: B Rationale: Extreme anxiety can lead to hyperventilation, the most common cause of acute respiratory alkalosis. During hyperventilation, CO2 is lost through the lungs, creating an alkalotic state and a low PaCO2. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. Metabolic acidosis results from the loss of bicarbonate, not CO2.

A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. The nurse should perform interventions to prevent what complication? A. Muscle clonus B. Muscle atrophy C. Rheumatoid arthritis D. Muscle fasciculations

ANS: B Rationale: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis.

A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next? A. Obtain a swab for culture. B. Assess the characteristics of the lesion. C. Obtain a swab for pH testing. D. Apply a test dose of broad-spectrum topical antibiotic.

ANS: B Rationale: If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. Testing for culture and pH are not necessarily required, and assessment should precede these actions. Antibiotics are not applied on an empirical basis.

A client who is ambulating complains of light-headedness and begins to faint. What is the nurse's most important action? 1. Ensure for the client's modesty. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs.

Answer: 2 Explanation: The priority is ensuring the client does not strike the head on anything when falling. The nurse should ease the client down while supporting the body against the nurse, protecting the head and laying it gently on the floor.

The community health nurse is performing a home visit to an 80-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's bestresponse? A. "I will need to have your medications adjusted, so you will need to be readmitted to the hospital for a complete workup." B. "Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids." C. "It is normal to be a little confused following surgery, and it is safe not to urinate at night." D. "Confusion and bladder issues are a normal consequence of aging, so I am not too concerned."

ANS: B Rationale: In older adult clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the older adult. There is no specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in older adults.

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. Which assessment findings are most consistent with this diagnosis? A. Hot skin and a capillary refill of 1 to 2 seconds B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin C. Pain, diaphoresis, and erythema D. Jaundiced skin, weakness, and capillary refill of 3 seconds

ANS: B Rationale: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.

The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound

ANS: B Rationale: Mechanical débridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement.

. A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described with which of the following terms? A. Hydrostatic pressure B. Osmosis and osmolality C. Diffusion D. Active transport

ANS: B Rationale: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A. Psychosis B. Posttraumatic stress disorder C. Delirium D. Vascular dementia

ANS: B Rationale: Posttraumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

A client comes to the clinic for an evaluation. During the visit, the client reports a fever, malaise, hair loss, and weight loss. Further assessment reveals lymphadenopathy. The client also reports a penile ulcer that appeared about 4 weeks ago but went away. The nurse suspects the client may have syphilis and interprets the client's assessment findings as suggestive of which stage of this disease? A. primary B. secondary C. latent D. tertiary

ANS: B Rationale: Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. Secondary syphilis occurs when the hematogenous spread of organisms from the original chancre leads to generalized infection. The rash of secondary syphilis occurs about 2 to 8 weeks after the chancre and involves the trunk and the extremities, including the palms of the hands and the soles of the feet. Transmission of the organism can occur through contact with these lesions. Generalized signs of infection may include lymphadenopathy (abnormal enlargement of lymph nodes), arthritis, meningitis (inflammation of the pia mater, arachnoid mater, and the subarachnoid space), hair loss, fever, malaise, and weight loss. After the secondary stage, there is a period of latency, when the infected person has no signs or symptoms of syphilis. Latency can be interrupted by a recurrence of secondary syphilis. Tertiary syphilis is the final stage in the natural progression of the disease. It presents as a slowly progressive inflammatory disease with the potential to affect multiple organs.

12. A nurse is explaining the importance of sunlight on the skin to a client with decreased mobility who rarely leaves the house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? A. E B. D C. A D. C

ANS: B Rationale: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.

The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? 1. Cut toenails in a rounded shape and file. 2. Dry toes thoroughly. 3. Wash feet with water at a temperature of 90-98.6°F. 4. Inspect feet thoroughly once a week.

Answer: 2 Explanation: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration.

The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client: A. perform range-of-motion exercises. B. avoid placing body weight on the healing site. C. elevate body parts that are susceptible to edema. D. demonstrate the technique for massaging the wound site.

ANS: B Rationale: The major goals of pressure injury treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the client teaching.

The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client's admission, total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of TPN slowly? A. Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C. Malnourished clients who receive fluids too rapidly are at risk for hypernatremia. D. Clients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate.

ANS: B Rationale: The nurse identifies clients who are at risk for hypophosphatemia and monitors them. Because malnourished clients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Clients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.

A nurse is doing a shift assessment on a group of clients after first taking report. An older adult client is having the second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's chest. The nurse should ask what priority question regarding the presence of a reddened rash? A. "Is the rash worse at a particular time or season?" B. "Are you allergic to any foods or medication?" C. "Are you having any loss of sensation in that area?" D. "Is your rash painful?"

ANS: B Rationale: The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the client's immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this should likely be framed in the context of an allergy assessment.

18. A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones? A. Dermis B. Subcutaneous tissue C. Epidermis D. Stratum corneum

ANS: B Rationale: The subcutaneous tissue, or hypodermis, is the innermost layer of the skin that is responsible for providing a cushion between the skin layers, muscles, and bones. The dermis is the largest portion of the skin, providing strength and structure. The epidermis is the outermost layer of stratified epithelial cells and composed of keratinocytes. The stratum corneum is the outermost layer of the epidermis, which provides a barrier to prevent epidermal water loss.

A client is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute? A. Contact precautions B. Droplet precautions C. Airborne precautions D. Observation precautions

ANS: B Rationale: This client requires droplet precautions because the organism can be transmitted through large airborne droplets when the client coughs, sneezes, or fails to cover the mouth. Smaller droplets can be addressed by airborne precautions, but this is insufficient for this microorganism.

A client is alarmed about testing positive for MRSA following culture testing during admission to the hospital. What should the nurse teach the client about this diagnostic finding? A. "There are promising treatments for MRSA, so this is no cause for serious concern." B. "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces." C. "The vast majority of clients in the hospital test positive for MRSA, but the infection doesn't normally cause serious symptoms." D. "This finding is only preliminary, and your doctor will likely order further testing."

ANS: B Rationale: This client's testing results are indicative of colonization, which is not synonymous with infection. The test results are considered reliable, and would not be characterized as "preliminary." Treatment is not normally prescribed for colonization.

What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? A. To decrease nurses' susceptibility to health care-associated infections B. To decrease risk of transmission to vulnerable clients C. To eventually eradicate the influenza virus in the United States D. To prevent the emergence of drug-resistant strains of the influenza virus

ANS: B Rationale: To reduce the chance of transmission to vulnerable clients, health care workers are advised to obtain influenza vaccinations. The vaccine will not decrease nurses' risks of developing health care-associated infections, eradicate the influenza virus, or decrease the risk of developing new strains of the influenza virus.

When caring for a client with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what condition(s)? Select all that apply. A. Possible malignancy B. Epidermal necrosis C. Neurologic involvement D. Increased metabolic needs E. Possible gastrointestinal mucosal sloughing

ANS: B, D, E Rationale: Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.

A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply. A. Administer potassium by IV push. B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. C. Monitor complete blood count during potassium infusion. D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider.

ANS: B, D, E Rationale: Potassium should be administered by an infusion pump and should never be given by IV push to avoid rapid replacement. Because potassium is excreted by the kidneys, BUN, serum creatinine, and urinary output should be assessed prior to and during administration of IV potassium. Abnormal laboratory results or decreased or absent urinary output should be reported to the health care provider. Because potassium administration does not affect blood cells, the complete blood count does not need to be monitored during administration of potassium. The nurse should check facility policy on the administration of IV potassium to ensure safe care.

15. A nurse in a dermatology clinic is reading the electronic health record of a new client. The nurse notes that the client has a history of a primary skin lesion. What skin lesion may this client have? A. Crust B. Keloid C. Pustule D. Ulcer

ANS: C Rationale: A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, keloids and ulcers are secondary lesions.

A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment? A. Assessment of the client's stool for evidence of intestinal sloughing B. Assessment of the client's apical heart rate for dysrhythmias C. Assessment of the client's joints for pain and decreased range of motion D. Assessment for cognitive changes resulting from neurologic lesions

ANS: C Rationale: Asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in up to 42% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. GI, cardiovascular, and neurologic function are not affected by psoriasis.

A client's diagnostic testing revealed that the client is colonized with vancomycin-resistant enterococcus (VRE). What change in the client's health status could precipitate an infection? A. Use of a narrow-spectrum antibiotic B. Treatment of a concurrent infection using vancomycin C. Development of a skin break D. Persistent contact of the bacteria with skin surfaces

ANS: C Rationale: Colonization can progress to infection if there is a portal of entry by which bacteria can invade body tissues. The use of vancomycin, or any other antibiotic, would not necessarily precipitate a VRE infection. Prolonged skin contact is similarly unlikely to cause infection, provided the skin remains intact.

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? A. Initiating a client-controlled analgesia (PCA) of morphine sulfate B. Administering hydromorphone IV as needed C. Dimming the lights and reducing stimulation D. Distracting the client with activity

ANS: C Rationale: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the client's pain.

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? A. Avoid the application of skin emollients B. Apply antibiotic ointment, as prescribed, following baths C. Avoid using hot water during the client's baths D. Administer acetaminophen four times daily as prescribed

ANS: C Rationale: If baths have been prescribed, the client is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? A. Ensuring that the family knows that impetigo is not contagious B. Teaching about the safe and effective use of topical corticosteroids C. Teaching about the importance of maintaining high standards of hygiene D. Ensuring that the family knows how to safely burst the child's vesicles

ANS: C Rationale: Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective.

The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor? A. Overhydration is common among healthy older adults. B. Dehydration causes the skin to appear spongy. C. Inelastic skin turgor is a normal part of aging. D. Skin turgor cannot be assessed in clients over the age of 70.

ANS: C Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older clients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

While assessing a client's peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation? A. Air embolism B. Phlebitis C. Infiltration D. Fluid overload

ANS: C Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness, and a significant decrease in the flow rate. An air embolism occurs when air enters the vein; it does not have any local manifestations at the IV site but may produce palpitations, dyspnea, hypotension, and chest pain. Phlebitis, an inflammation of the vein, is characterized by redness, warmth, and tenderness at the IV site. Fluid volume overload produces systemic manifestations and is not apparent at the IV site.

The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way? A. By examining the client under a Wood light B. By inspecting the client's skin in direct sunlight C. By palpating the client's skin D. By performing percussion of major skin surfaces

ANS: C Rationale: Inspection and palpation are techniques commonly used in examining the skin. A client would only be examined under a Wood light if there were indications it could be diagnostic. The client is examined in a well-lit room, not in direct sunlight. Percussion is not a technique used in assessing the skin.

A nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the client's altered sensations? A. How does the strength in the affected extremity compare to the strength in the unaffected extremity? B. Does the color in the affected extremity match the color in the unaffected extremity? C. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? D. Does the client have a family history of paresthesia or other forms of altered sensation?

ANS: C Rationale: Questions that the nurse should ask regarding altered sensations include "How does this feeling compare to sensation in the unaffected extremity?" Asking questions about strength and color is not relevant and a family history is unlikely.

The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation? A. Endocarditis B. Multiple myeloma C. Guillain-Barré syndrome D. Overdose of amphetamines

ANS: C Rationale: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a client with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.

36. A client has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this client's care, the nurse should include what nursing diagnosis? A. Risk for deficient fluid volume related to excess sebum synthesis B. Ineffective thermoregulation related to occlusion of sebaceous glands C. Disturbed body image related to excess sebum production D. Ineffective tissue perfusion related to occlusion of sebaceous glands

ANS: C Rationale: Seborrhea causes highly visible manifestations that are likely to have a negative effect on the client's body image. Seborrhea does not normally affect fluid balance, thermoregulation, or tissue perfusion.

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A. Assess the drainage in the dressing. B. Slowly remove the soiled dressing. C. Perform hand hygiene. D. Don nonlatex gloves.

ANS: C Rationale: The nurse and health care provider must adhere to standard precautions and wear gloves when inspecting the skin or changing a dressing. Use of standard precautions and proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations. Hand hygiene must precede other aspects of wound care.

The nurse is providing care for an older adult client who has developed signs and symptoms of Calicivirus(Norovirus). What assessment should the nurse prioritize when planning this client's care? A. Respiratory status B. Pain C. Fluid intake and output D. Deep tendon reflexes and neurological status

ANS: C Rationale: The vomiting and diarrhea that accompany Norovirus create a severe risk of fluid volume deficit. For this reason, assessments relating to fluid balance should be prioritized, even though each of the listed assessments should be included in the plan of care.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? A. Maintain a low-sodium diet. B. Encourage the use of over-the-counter calcium supplements. C. Ensure the client has sufficient potassium intake. D. Encourage fluid intake.

ANS: C Rationale: Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification

ANS: C Rationale: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range-of-motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

A nurse is preparing to administer a client's scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform which action with used needles? A. For multiple injections, insert the needle into the bed. B. Recap the needle immediately before leaving the room. C. Avoid recapping the needle before disposing of it. D. Wear gloves when administering the injection.

ANS: C Rationale: Used needles should not be recapped or inserted into the bed even with multiple injections. Recapping of needles is typically done after a medication is drawn up and before injection. Specific steps are used in the process to avoid injury. Used needles are placed directly into puncture-resistant containers near the place where they are used. Gloves do not prevent needlestick injuries.

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin

Answer: 2 Explanation: When the client has the disease, the body stimulates the process of acquired active immunity.

21. A nurse is preparing to perform the physical assessment of a newly admitted client. During which of the following components of the assessment should the nurse wear gloves? Select all that apply. A. Palpation of the nailbeds B. Palpation of the client's upper extremities C. Palpation of a rash on the client's trunk D. Palpation of a lesion on the client's upper back E. Palpation of the client's finger joints

ANS: C, D Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate a client's extremities or fingers unless contact with body fluids is reasonably foreseeable.

A client's health assessment has resulted in a diagnosis of Muscle atrophy with Left/ Hemiparesis. What nursing diagnosis should the nurse most likely associate with this health problem? A. Chronic pain B. Impaired skin integrity C. Impaired tissue integrity D. Impaired Physical Mobility

ANS: D

A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A. Standard precautions only B. Droplet precautions C. Standard and contact precautions D. Standard and airborne precautions.

ANS: D Rationale: Airborne precautions are required for proven or suspected pulmonary TB. Standard precaution techniques are used in conjunction with the transmission-based precautions, regardless of the client's diagnosis. Droplet and contact precautions are insufficient.

A client's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem? A. Chronic pain B. Impaired skin integrity C. Impaired tissue integrity D. Disturbed body image

ANS: D Rationale: Alopecia areata causes hair loss in smaller defined areas. As such, it is common for the client to experience a disturbed body image. Hair loss does not cause pain and does not affect skin or tissue integrity.

31. A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections? A. Chronic obstructive pulmonary disease B. Rheumatoid arthritis C. Gout D. Diabetes

ANS: D Rationale: Clients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one client's personal hygiene? 1. A client has a newly formed ileostomy. 2. A client performs meticulous foot care. 3. A German client refuses to bathe every day. 4. The room temperature is set at 72°F.

Answer: 1 Explanation: Some of the factors that influence one's personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change, which can greatly influence whether the client will care for it or rely on others. This can pose a threat if the client chooses not to care for it.

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation has occurred. B. Keep injured areas immobilized whenever possible to promote healing. C. Administer oral or IV corticosteroids as prescribed. D. Encourage physical activity and range-of-motion exercises.

ANS: D Rationale: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A. Active transport of hydrogen ions across the capillary walls B. Pressure of the blood in the renal capillaries C. Action of the dissolved particles contained in a unit of blood D. Hydrostatic pressure resulting from the pumping action of the heart

ANS: D Rationale: Hydrostatic pressure is the pressure created by the weight of fluid against the wall that contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction. This pressure causes water and electrolytes from the arterial capillary bed to pass into the interstitial fluid, in this instance, as a result of the pumping action of the heart; this process is known as filtration. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A. Hypertension B. Kussmaul respirations C. Increased DTRs D. Shallow respirations

ANS: D Rationale: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also kidney disease. This type of client is associated with decreased DTRs, not increased DTRs.

A client has presented at the ED with copious diarrhea and accompanying signs of dehydration. During the client's health history, the nurse learns that the client recently ate oysters from the Gulf of Mexico. The nurse should recognize the need to have the client's stool cultured for microorganisms associated with what disease? A. Ebola B. West Nile virus C. Legionnaire disease D. Cholera

ANS: D Rationale: In the U.S., cholera should be suspected in clients who have watery diarrhea after eating shellfish harvested from the Gulf of Mexico.

A client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of which condition? A. Scoliosis B. Epiphyses C. Lordosis D. Kyphosis

ANS: D Rationale: Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply ice to the site of the burn for 5 to 10 minutes. B. Wrap the client's affected extremity in ice until help arrives. C. Apply an oil-based substance to the burned area until help arrives. D. Wrap cool towels around the affected extremity intermittently.

ANS: D Rationale: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Oils are contraindicated.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints and functional devices C. Administration of beta adrenergic blockers D. Prevention of venous thromboembolism

ANS: D Rationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for pressure injuries. When performing this home visit, the nurse should do which of the following? A. Assess the client for signs of electrolyte imbalances. B. Administer fluids as prescribed. C. Assess the risk for injury recurrence. D. Assess the client's psychosocial state.

ANS: D Rationale: Recovery from pressure injuries can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The plan of care includes assessment of specific gravity every four hours. The results of this test will allow the nurse to assess which aspect of the client's health? A. Nutritional status B. Potassium balance C. Calcium balance D. Fluid volume status

ANS: D Rationale: Specific gravity measures the density of urine compared with water and can assess the ability of the kidneys to excrete or conserve water. Therefore, specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury? A. I B. II C. III D. IV

ANS: D Rationale: Stage III and IV pressure injuries are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure injuries must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

Baroreceptors in the left atrium and in the carotid and aortic arches respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A. Decrease in the release of aldosterone B. Increase of filtration in the Loop of Henle C. Decrease in the reabsorption of sodium D. Decrease in glomerular filtration

ANS: D Rationale: Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior? A. The client may be experiencing an adverse drug reaction that is affecting cognition and behavior. B. The client may be experiencing neurologic or psychiatric complications of the client's injuries. C. The client may be experiencing inconsistencies in the care being provided. D. The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

ANS: D Rationale: The client may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? A. Older adults are often vague historians. B. Older adults have fewer peripheral nerves than younger adults. C. Many older adults are hesitant to admit that their body is changing. D. Many symptoms can be the result of normal aging process.

ANS: D Rationale: The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario, the client has come to the clinic seeking help for this problem; this does not indicate a desire on the part of the client to withhold information from the health care giver. The normal aging process does not include a diminishing number of peripheral nerves.

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain, and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance? A. Hypernatremia B. Hypomagnesemia C. Hypophosphatemia D. Hypercalcemia

ANS: D Rationale: The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The client's presentation is inconsistent with hypophosphatemia.

A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client's susceptibility to heat loss is related to atrophy of what skin component? A. Epidermis B. Merkel cells C. Dermis D. Subcutaneous tissue

ANS: D Rationale: The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

ANS: D Rationale: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? A. Increased thickness of the subcutaneous skin layer B. Increased vascular supply to superficial skin layers C. Changes in the character and quantity of bacterial skin flora D. Increased time required for wound healing

ANS: D Rationale: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

. The emergency-room nurse is caring for a trauma client who has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? A. Respiratory acidosis with no compensation B. Metabolic alkalosis with compensatory alkalosis C. Metabolic acidosis with no compensation D. Metabolic acidosis with compensatory respiratory alkalosis

ANS: D Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

A client comes into the emergency department (ED) by ambulance with a hip fracture after slipping and falling while at home. The client is alert and oriented but anxious and reports thirst. The client's pupils are equal and reactive to light and accommodation, and the heart rate is elevated. An indwelling urinary catheter is inserted, and 40 mL of urine is present. What is the nurse's most likely explanation for the client's urinary output? A. The client urinated prior to arrival to the ED and will probably not need to have the urinary catheter kept in place. B. The client likely has a traumatic brain injury, lacks antidiuretic hormone, and needs vasopressin. C. The client is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output. D. The client is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system, which results in diminished urine output

ANS: D Rationale: In response to the acute stress of falling at home, the sympathetic nervous system is activated. Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is most likely causing the lower urine output. The client urinating prior to arrival to the ED is unlikely; the fall and hip injury would make the ability to urinate difficult. No assessment information indicates the client has a head injury or heart failure.

5. A client who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Low Self Esteem related to use of facial prosthetic secondary to reconstructive surgery. Which nursing intervention would be appropriate for this diagnosis? A. Referring the client to a speech therapist B. Gradually adding soft foods to diet C. Administering analgesics as prescribed D. Teaching the client how to use and care for the prosthesis

ANS: D Rationale: The process of facial reconstruction is often slow and tedious. Because a person's facial appearance affects self-esteem so greatly, this type of reconstruction is often a very emotional experience for the client. Reinforcement of the client's successful coping strategies improves self-esteem. If prosthetic devices are used, the client is taught how to use and care for them to gain a sense of greater independence. This is an intervention that relates to Disturbed Body Image in these clients. None of the other listed interventions relate directly to the diagnosis of Disturbed Body Image.

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with handwashing. 2. Assist the client back to bed. 3. Change the client's bed. 4. Leave the client's room.

Answer: 1 Explanation: The client should utilize good handwashing after going to the bathroom. The unlicensed assistive personnel should assist the client with handwashing.

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the client's diet. 3. Protect the client's bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.

Answer: 1 Explanation: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities.

While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5-10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies.

Answer: 1 Explanation: After an exposure to the mucous membranes, the area should be flushed for 5-10 minutes with saline or water.

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem

Answer: 1 Explanation: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life.

The nurse is assigning assistive personnel (AP) to provide care to a group of clients. For which client reason should the AP provide mouth care more frequently? 1. Has a nasogastric tube 2. Treatments for diabetes 3. Medications for osteoarthritis 4. Receives intravenous antibiotics

Answer: 1 Explanation: Clients with nasogastric tubes are likely to develop dry oral mucous membranes, especially if they breathe through their mouths. More frequent oral hygiene will be needed. There is no reason to provide more frequent mouth care for the client being treated for diabetes, receiving medication for osteoarthritis, or receiving intravenous antibiotics.

A client has sustained multiple contusions from a motor-vehicle accident. What should the nurse do to prepare for this client's care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving.

Answer: 1 Explanation: Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours.

The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment sparingly. 4. Wear gloves at all times.

Answer: 1 Explanation: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection.

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the client's arm over the chest. 4. Raise the opposite side rail.

Answer: 1 Explanation: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the client's perception of the quality of care being provided and the nurse's concern about infection control. Page Ref: 1113

The nurse is reviewing information received during hand-off communication. Which client should the nurse assess for a potential fluid or electrolyte imbalance? 1. Older client unable to self-feed 2. School-age child with pneumonia 3. Adolescent client having an appendectomy 4. Middle-aged client scheduled for a colonoscopy

Answer: 1 Explanation: Factors that can lead to a fluid or electrolyte imbalance include a client with a decrease in food and fluid intake because of physical limitations such as the older client who is unable to self-feed. The school-age child is not at risk because will most likely be receiving fluids. The adolescent having an appendectomy will be able to ingest food and fluids after the surgery. The client having a colonoscopy would have had a restriction in intake and laxatives for a short period of time.

During the morning bath of a client, the nurse identifies areas of erythema below the client's breasts. What should the nurse do to enhance comfort and healing for the client? 1. Wash the skin carefully. 2. Apply alcohol-free lotion. 3. Wash the area without soap. 4. Remove hair in the area.

Answer: 1 Explanation: For areas of erythema, the nurse should wash the area carefully to remove microorganisms.

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.

Answer: 1 Explanation: High-topped shoes will place the client's feet in the anatomical position of dorsal flexion.

A client has a reddened area over the coccyx that disappears after an hour. In which way should the nurse document this area? 1. Reactive hyperemia 2. Stage 1 pressure injury 3. Stage 2 pressure injury 4. Stage 3 pressure injury

Answer: 1 Explanation: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred.

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Explain the effects of immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

Answer: 1 Explanation: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility.

) The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? 1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used.

Answer: 1 Explanation: Wounds that are expected to heal by secondary intention heal by "granulating in." In order to support the growth of granulation tissue, the wound bed should be kept moist and oxygen should be kept out of the wound.

A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine which of the following? (Select all that apply.) 1. Progress of the client's health problem 2. Physiological impact of the prescribed medication 3. Baseline data 4. Data to support nursing diagnoses 5. Areas for health promotion

Answer: 1, 2

A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? (Select all that apply.) 1. Handwashing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period

Answer: 1, 2, 3

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? (Select all that apply.) 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance.

Answer: 1, 2, 3 Explanation: Bacteremia can occur from an intravascular line.

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? (Select all that apply.) 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention

Answer: 1, 2, 3 Explanation: Intact skin is the body's first line of defense against microorganisms. Intact mucous membranes are the body's first line of defense against microorganisms. Peristalsis tends to move microbes out of the body.

The nurse is asked which medications originate from herbs. Which drug should the nurse say in response? (Select all that apply.) 1. Aspirin 2. Digoxin 3. Quinine 4. Atropine 5. Epinephrine

Answer: 1, 2, 3, 4 Explanation: Aspirin is from willow tree bark. Digoxin is from foxglove. Quinine is from Peruvian bark. Atropine is from deadly nightshade.

A client diagnosed with an infectious disease asks the nurse how the infection "got inside" her body. Which responses would be appropriate for the nurse to make? (Select all that apply.) 1. "It depends on the number of organisms present to cause a disease." 2. "It depends on how aggressive the organisms are to cause a disease." 3. "It depends on how the organisms get inside the body to cause a disease." 4. "It depends on where the person is at the time the disease is present." 5. "It depends on where the person works."

Answer: 1, 2, 3, 4 Explanation: This response addresses the number of microorganisms present. This response addresses the virulence and potency of the microorganisms. This response addresses the ability of the microorganisms to enter the body. This response addresses the susceptibility of the host and the ability of the microorganisms to live in the host's body.

The nurse observes a client walking down the hall. Which element of body movement should the nurse assess in this client? (Select all that apply.) 1. Posture 2. Balance 3. Joint mobility 4. Range of motion 5. Coordinated movement

Answer: 1, 2, 3, 5 Explanation: Posture, balance, joint mobility, and coordinated movement are elements of body movement. Balance is an element of body movement. Joint mobility is an element of body movement. Coordinated movement is an element of body movement.

A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linens? (Select all that apply.) 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status

Answer: 1, 2, 4, 5

A client has a history of orthostatic hypotension. Which activities should the nurse advise this client as likely to cause orthostatic hypotension? (Select all that apply.) 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor

Answer: 1, 2, 5 Explanation: Hot baths can cause venous pooling in the lower extremities. Heavy meals divert blood to the gastrointestinal organs. Bending to the floor can cause rapid changes in blood pressure upon standing up again.

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? (Select all that apply.) 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.

Answer: 1, 2, 5 Explanation: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Using two personnel will allow a "lift and move" rather than pulling or sliding the client over linens. Encouraging the client to assist as much as possible will lighten the workload.

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? (Select all that apply.) 1. Poor skin turgor 2. Elevated body temperature 3. Diminished pain sensation 4. Thin epidermis 5. Dry skin

Answer: 1, 3, 4, 5

A client recovering from surgery is turned and repositioned in bed. Which should the nurse document about this positioning? (Select all that apply.) 1. Skin status 2. Type of surgery 3. Time of position change 4. Use of supportive devices 5. Client response to the move

Answer: 1, 3, 4, 5 Explanation: The client's skin status, time of position change, use of any supportive devices, and client's response to the move should be documented. The time of position change should be documented. The use of any supportive devices should be documented. The client's response to the move should be documented.

A client living in a long-term care center is withdrawn and subdued and does not eat in the dining room because of embarrassment about physical decline. What might the nurse suggest that provides opportunities for unconditional love, achievement of trust, responsibility, and empathy toward others? 1. Chelation therapy 2. Animal-assisted therapy 3. Meditation 4. Pilates

Answer: 2 Explanation: Animal-assisted therapy is defined as the use of specifically selected animals as a treatment modality in health and human service settings. The contributions include opportunities for affection, achievement of trust, responsibility, and empathy toward others. Pets in long-term care facilities become so perceptive that they actually gravitate to the rooms of people who are most isolated or depressed. Page Ref: 404

A connection on a client's intravenous solution was dislodged and solution saturated the client's gown and bed linens. The nurse will provide which type of hygienic care to the client? 1. Hour-of-sleep care 2. As-needed care 3. Early-morning care 4. Morning care

Answer: 2 Explanation: As-needed care is provided as required by the client. Because the intravenous solution has saturated the gown and bed linens, this is the type of care the client needs at this time.

A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client's care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache

Answer: 2 Explanation: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia.

A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate? 1. Impaired Skin Integrity 2. Risk for Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection

Answer: 2 Explanation: Because the client is experiencing episodes of incontinence without any current changes in skin integrity, the client is at Risk for Impaired Skin Integrity.

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients.

Answer: 2 Explanation: Disposal of blood-contaminated materials in a biohazard container is a standard precaution.

The nurse has just been stuck with a syringe while dropping it into a sharps container that was too full in a client's room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water.

Answer: 2 Explanation: Encouraging bleeding is the first step.

An older client receiving intravenous fluids at 175 mL/hr is demonstrating crackles, shortness of breath, and distended neck veins. Which complication of intravenous fluid therapy is this client experiencing? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock

Answer: 2 Explanation: Fluid volume excess may occur if clients, especially the very young or elderly, receive IV fluid rapidly.

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. In which way should the nurse document this finding? 1. Cyanosis 2. Jaundice 3. Pallor 4. Erythema

Answer: 2 Explanation: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye.

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem? 1. Encourage the client to eat at least 40% of meals. 2. Keep linens dry and wrinkle-free. 3. Restrict fluid intake. 4. Turn client every 3 hours.

Answer: 2 Explanation: Keeping linens dry and wrinkle-free will prevent pressure areas.

The nurse documents that a client's postoperative wound is purosanguinous. What did the nurse assess in this client's wound? 1. Water and red blood cells 2. Pus and red blood cells 3. Watery drainage 4. Pus

Answer: 2 Explanation: Purosanguinous drainage consists of purulent drainage and red blood cells.

A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mother's breast milk with antibodies in it

Answer: 2 Explanation: Receiving an immunization for rabies is an example of artificially acquired passive immunity.

The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication? 1. Respiratory rate 2. Apical pulse 3. Popliteal pulse 4. Capillary blanch test

Answer: 2 Explanation: The apical pulse should be assessed before administering any cardiotonic medication.

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

Answer: 2 Explanation: The nurse should palpate for bladder fullness that could cause this discomfort.

While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. 90-degree angle 2. 30- to 45-degree angle 3. 15-degree angle 4. 60-degree angle

Answer: 2 Explanation: The nurse should place the client in the semi-Fowler position (30- to 45-degree angle) while inspecting the jugular veins for distention.

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowler position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

Answer: 2 Explanation: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion.

A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this client's wound? (Select all that apply.) 1. Cover it with transparent film. 2. Apply a damp-to-damp normal saline dressing. 3. Cover it with a dry dressing. 4. Irrigate the wound. 5. Apply impregnated hydrogel.

Answer: 2, 4, 5 Explanation: A damp-to-damp normal saline dressing will remove nonviable tissue from the wound and is appropriate for a yellow wound. Irrigating the wound is appropriate for a yellow wound. Applying impregnated hydrogel is appropriate for a yellow wound.

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? (Select all that apply.) 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

Answer: 2, 4, 5 Explanation: The cane should be moved forward while the body weight is borne by both legs. The weaker leg is moved forward while the weight is borne by the cane and stronger leg. The stronger leg is moved forward while the weight is borne by the cane and weak leg.

The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? 1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide.

Answer: 3 Explanation: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection.

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush the teeth. 4. The nurse will stress the importance of adequate fluid intake.

Answer: 3 Explanation: A client with cognitive impairment would be able to brush the teeth but only with supervision. The client would not voluntarily brush teeth without prompting from the staff.

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure injury development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development.

Answer: 3 Explanation: All of these scores indicate risk for development of a pressure injury, so some trending is possible, but it would be more accurate if the same scale was always used.

A client is removing soft contact lenses. Which should the nurse do to support the client's lenses? 1. Provide disposable tissues 2. Obtain a bottle of sterile normal saline 3. Remind to place each lens in the correct side of the container 4. Prepare to irrigate the client's eyes after removal

Answer: 3 Explanation: All users should have a special container for their lenses. Some contain a solution so that the lenses are stored wet; in others, the lenses are dry. Each lens container has a slot or cup with a label indicating whether it is for the right or left lens. It is essential the correct lens be stored in the appropriate slot so that it will be placed in the correct eye. The lenses are not stored in tissues. There is not enough information to determine if the client needs sterile normal saline. There is no reason to irrigate the client's eyes after removal of the lenses.

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.

Answer: 3 Explanation: Although all of these activities address important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall.

During a home visit, a client reports feeling sad and upset about personal appearance. For which reason should the nurse assist the client with a bath? 1. Improve circulation 2. Establish trust with the client 3. Improve morale and self-concept 4. Remove dead skin cells and bacteria

Answer: 3 Explanation: Bathing produces a sense of well-being. It is refreshing and relaxing and frequently improves morale, appearance, and self-concept. The purpose of the bath for this client is not to improve circulation, establish trust, or remove dead skin cells and bacteria.

A client has a documented stage 3 pressure injury on the right hip. What nursing diagnosis problem statement is most appropriate for use with this client? 1. Altered Tissue Perfusion 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Injury

Answer: 3 Explanation: Because a stage 3 pressure injury involves tissues, not just skin, this client has criteria for using the problem statement Impaired Tissue Integrity.

While providing a complete bed bath to a client, the nurse discovers abrasions along the client's back and upper buttock area. What should the nurse do to help this client? 1. Apply antiseptic spray to the abrasions. 2. Do not wash the client with soap. 3. Find assistance to help with the remainder of the bath. 4. Apply alcohol-free lotion to the abrasions.

Answer: 3 Explanation: Because the client has abrasions over the back and upper buttock area, the nurse should lift and not pull or slide the client. The nurse needs to find assistance to help with the remainder of the bath.

The postoperative client is preparing to ambulate for the first time since surgery. Which staff member should ambulate this client? 1. The AP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

Answer: 3 Explanation: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the client's response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse.

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

Answer: 3 Explanation: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range-of-motion exercises.

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this client's room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door

Answer: 3 Explanation: Paper towels and a sink for handwashing should be in the client's room so they can be used before the staff leaves the room. A blood pressure cuff needs to stay in the client's room to prevent cross contamination.

The nurse is making a client's bed. What safety measure should the nurse implement at this time? 1. Begin at the head and move toward the foot, loosening the bottom linen. 2. Miter corners at the head of the bed. 3. Place the soiled sheet in a laundry bag. 4. Prepare the client.

Answer: 3 Explanation: Placing the soiled sheet in the laundry bag reduces the spread of microorganisms, which is a safety measure for both the nurse and client.

The nurse is preparing to bathe a client on the first postoperative day. Which nursing intervention should take priority? 1. Apply lotion to the extremities. 2. Change the water when it becomes cold. 3. Raise side rails when gathering supplies. 4. Remove the soiled dressing during the bath.

Answer: 3 Explanation: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslow's hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall.

The nurse is providing range-of-motion exercising to the client's elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the client's physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

Answer: 3 Explanation: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued.

) A client has a wound that is approximately 10 cm in diameter, surrounded by edematous and boggy tissue, with the edges curling towards the center. Which additional finding would indicate to the nurse that this is a stage 4 pressure injury? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top.

Answer: 3 Explanation: Stage 4 injuries demonstrate damage to muscle, bone, tendons, or the joint capsule.

The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful?1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room.

Answer: 3 Explanation: The best way to keep odors controlled is to keep the wound dressing dry and clean.

An older client who is incontinent and wears incontinence briefs develops an irritated rash in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears.

Answer: 3 Explanation: The care should include wiping the skin with an alcohol-free barrier film agent after cleaning.

When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining fractured vertebrae 4. A client who has a severe headache from hypertensive crisis

Answer: 3 Explanation: The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house.

A client who is bed-bound complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.

Answer: 3 Explanation: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis.

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin? 1. Keep the head of the client's bed at 30°F. 2. Coat the client's back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement.

Answer: 3 Explanation: The nurse should plan to use a turn sheet lifted by two staff members to move the client up in bed.

A client being mechanically ventilated has an arterial blood gas analysis that indicates respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air

Answer: 3 Explanation: This client needs to "blow off" more CO2, therefore the respiratory rate would be increased.

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the client's room. 3. Wash hands. 4. Wear a mask for all client care.

Answer: 3 Explanation: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections.

A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements? (Select all that apply.) 1. Minimal tissue loss. 2. Closure of the wound will occur within 5 days. 3. Healing time will be longer. 4. Potential for scarring is greater. 5. Susceptibility to infection is greater.

Answer: 3, 4, 5 Explanation: In secondary intention healing, the repair time is longer. In secondary intention healing, the scarring is greater. In secondary intention healing, the susceptibility to infection is greater.

A client asks the nurse about chiropractic medicine. What should the nurse explain as being among the goals of this type of health intervention? (Select all that apply.) 1. Improvement of blood and lymph flow through the body 2. Stimulation of specific points to help with pain relief, cure certain illnesses, and promote wellness 3. Reduce or eliminate pain 4. Correct spinal dysfunction 5. Preventive maintenance

Answer: 3, 4, 5 Explanation: The first clinical goal of chiropractic care is to reduce or eliminate pain. By correcting spinal dysfunction, biomechanical balance is restored to the body to reestablish shock absorption, leverage, and range of motion. Muscles and ligaments are strengthened by spinal rehabilitative exercises to increase resistance to further injury. Preventive maintenance of chiropractic medicine ensures that the problem does not recur.

A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? (Select all that apply.) 1. Shower 2. Tub bath 3. Self-help bed bath 4. Therapeutic bath 5. Partial bath

Answer: 3, 5 Explanation: Because the client is prescribed bed rest with bathroom privileges, the self-help bed bath would be appropriate because the client can independently wash with some help from the nurse. Because the client is prescribed bed rest with bathroom privileges, the partial bath would be appropriate because the client can independently wash with some help from the nurse to wash the back area.

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? (Select all that apply.) 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol 4. Hydrogen peroxide 5. Chlorhexidine gluconate

Answer: 3, 5 Explanation: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant. Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant.

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper handwashing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap.

Answer: 4 Explanation: Approximately 1 teaspoon of soap should be used when performing proper hand-washing technique.

The nurse has established an expected outcome that the client will demonstrate healing of a stage 2 pressure injury over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome? 1. The rubber doughnut pressure relief device was not delivered by central supply. 2. The client's serum albumin increased over the last month. 3. Nurses did not document disinfection of the wound with alcohol with each dressing change. 4. AAP followed a right side—back—left side—back turning schedule.

Answer: 4 Explanation: Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the client's condition. Of the options listed, the only one that would result in poor healing is the right side—back—left side—back turning schedule. This schedule places the client on the back for 50% of the time. The schedule should be right side—back—left side—right side.

A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing? 1. Exudative 2. Proliferative 3. Inflammatory 4. Maturation

Answer: 4 Explanation: Dark, thick scars, or keloids, are caused by an abnormal amount of collagen during the maturation phase of healing.

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client

Answer: 4 Explanation: How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact.

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.

Answer: 4 Explanation: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible.

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have been unsuccessful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour

Answer: 4 Explanation: Normal urine output for adult clients is at least 0.5 mL/kg/hour. This client weighs 70 kg, so adequate urine output would be 35 mL/hour. A urine output of 30/mL/hr indicates that efforts at rehydration have not been successful.

A client who has a long-standing history of depression has been on a prescribed antidepressant for several months and states trying St. John's wort. Which vital sign should the nurse assess for possible adverse effects? 1. Temperature 2. Respiratory rate 3. Oxygen saturation 4. Pulse rate

Answer: 4 Explanation: St. John's wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems.

The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy

Answer: 4 Explanation: The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system.

The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first.

Answer: 4 Explanation: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. After the neck ties are untied, the gown is allowed to fall forward.

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist 3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand

Answer: 4 Explanation: Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile.

The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only.

Answer: 4 Explanation: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated.

The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand

Answer: 4 Explanation: Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile.

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment

Answer: 4 Explanation: Using personal protective equipment demonstrates medical asepsis.

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient

Answer: 4 Explanation: Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus.

The nurse is preparing to apply a moist aquathermia pack to a client's left upper leg. In which order should the nurse prepare and apply this treatment? 1. Use tape or gauze ties to hold the pad in place. 2. Set the desired temperature according to the manufacturer's instructions. 3. Apply the pad to the body part. The treatment is usually continued for 30 minutes. 4. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer. 5. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use.

Answer: 4, 2, 5, 3, 1 Explanation: 1. The last step is to apply tape or gauze to hold the pad in place. 2. Second, set the temperature according to the manufacturer's instructions. 3. The fourth step is to apply the pad to the body part being treated and expect to keep the pad in place for 30 minutes. 4. First, the reservoir of the unit should be filled two-thirds full with water. 5. The third step is to cover the pad and plug in the unit, making sure the pad is checked for leaks or malfunctions before use.

The nurse is preparing to irrigate a client's abdominal wound. In which order should the nurse perform this irrigation? 1. Dry the area around the wound. 2. Insert the catheter into the wound until resistance is met. 3. Remove and discard clean gloves. 4. Apply clean gloves. 5. Irrigate until the solution flows clear. 6. Select a syringe with a catheter attached or with an irrigating tip.

Answer: 4, 6, 2, 5, 1, 3 Explanation: 1. After irrigating, the nurse should dry the area around the wound. 2. The nurse should then insert the catheter into the wound until resistance is met. 3. The nurse should then remove and discard the clean gloves. 4. The nurse first should apply clean gloves. 5. The nurse should then irrigate the wound until the solution flows clear. 6. The nurse should then select a syringe with a catheter attached or with an irrigating tip.

The nurse needs to apply personal protective equipment before entering a client's room. In which order should the nurse perform the following actions? Place the steps in the order in which they should be performed. 1. Apply gloves. 2. Apply eyewear. 3. Apply the gown. 4. Apply the face mask. 5. Perform hand hygiene.

Answer: 5, 3, 4, 2, 1 Explanation: 1. Gloves are applied last. 2. Protective eyewear is applied after the face mask. 3. The gown is applied after hand hygiene. 4. The face mask is applied after the gown. 5. Before applying personal protective equipment, hand hygiene should be performed.

A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered: A. The nurse's preference B. Safe for the home setting C. Unethical behavior D. Grossly negligent

B. Safe for the home setting

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? A. The nurse puts on PPE after entering the patient room. B. The nurse works from "clean" areas to "dirty" areas during bath. C. The nurse personalizes the care by substituting glasses for goggles. D. The nurse removes PPE prior to leaving the patient room.

B. The nurse works from "clean" areas to "dirty" areas during bath.

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure? A. Report the incident to the appropriate person and file an incident report. B. Wash the exposed area with warm water and soap. C. Consent to postexposure prophylaxis at appropriate time. D. Set up counseling sessions regarding safe practice to protect self.

B. Wash the exposed area with warm water and soap.

The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? A. A 60-year-old patient who smokes two packs of cigarettes daily B. A 40-year-old patient who has a white blood cell count of 6,000/mm3 C. A 65-year-old patient who has an indwelling urinary catheter in place D. A 60-year-old patient who is a vegetarian and slightly underweight

C. A 65-year-old patient who has an indwelling urinary catheter in place

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? A. Ask another nurse to hold the hand of the patient and continue setting up the field. B. Remove the instrument that was touched by the patient and continue setting up the sterile field. C. Discard the supplies and prepare a new sterile field with another person holding the patient's hand. D. No action is necessary since the patient has touched his or her own sterile field.

C. Discard the supplies and prepare a new sterile field with another person holding the patient's hand.

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? A. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. B. The nurse places soiled bed linens and hospital gowns on the floor when making the bed. C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal. D. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

C. The nurse moves the patient table away from the nurse's body when wiping it off after a meal.

DTI may first appear as a A. Dry skin B. Laceration C. Bruise D. Scrap

C.Bruise DTI stands for Deep Tissue Injury, which is a type of injury that occurs deep within the tissues of the body. It may first appear as a bruise, which is a discoloration of the skin caused by bleeding underneath the surface. Unlike a dry skin, laceration, or scrape, a bruise indicates damage to the underlying tissues. This could be due to trauma or pressure, leading to the rupture of blood vessels and subsequent bleeding. Therefore, a bruise is a more likely presentation for DTI compared to the other options provided.

A raised blister-like area onthe skin caused by and intradermal injection A. Buccal B. Wheal C. Intradermal D. Suppository

Correct Answe B. Wheal ExplanationA wheal is a raised blister-like area on the skin that is caused by an intradermal injection. This means that when a substance is injected into the skin, it can cause a localized reaction resulting in the formation of a wheal. This can happen due to various reasons such as an allergic reaction or irritation caused by the injected substance.

Which safety measure is most important when using a mechanical lift to move a patient from a bed to a wheelchair? A. Hook the shorter chains on the sling closest to the patient's feet B. Cross the patient's arms across the chest throughout the transfer C. Center the sling under the patient from the shoulders to just above the knees D. Release the hydraulic valve on the lift swiftly while lowering the patient on the chair.

Correct Answe rC. Center the sling under the patient from the shoulders to just above the knees Explanation(a) This will place the lower part of the body level to or above the lower body, which is an unsafe, unstable position because the body is not balanced with the center of gravity in the "seat" of the sling. The shorter chains go in the holes closes to the head, not the feet. (b) The patient can either cross the arms on the chest or grasp the shorter chains during the transfer(c) Centering the sling ensures full support between the shoulders and the knees and with the correct placement of the chains places the center of gravity in the "seat" if the sling. Centering the sling just above the knees prevents pressure on the popliteal space and prevents extension of the lower legs, which would alter the center of gravity and be unsafe. (d) The hydraulic valve should be opened slowly, not swiftly because sling movement can be frightening and sudden movement can unbalance the lift.

Which will not be caused by particulate material in an intravenous injection? A. Air emboli B. Thrombus C. Phlebitis D. Blood clots

Correct Answer A. Air emboli ExplanationAir emboli are not caused by particulate material in an intravenous injection. Air emboli occur when air bubbles enter the bloodstream and can be caused by improper administration of IV fluids or the presence of air in the IV tubing. This can lead to blockages in blood vessels and potentially serious complications. However, particulate material such as thrombus, phlebitis, or blood clots can cause blockages and are potential risks associated with intravenous injections.

The procedures employed to reduce or eliminate disease-causing organisms or their action or to minimize the area where disease -causing organisms exist in order to protect against infection are called: A. Aseptic techniques B. Isolation procedures C. Sanitary techniques D. Zone procedures

Correct Answer A. Aseptic techniques ExplanationAseptic techniques refer to the procedures used to minimize or eliminate disease-causing organisms and their effects in order to prevent infections. This can include practices such as sterilizing equipment, using sterile gloves and gowns, maintaining a clean environment, and properly disposing of waste. These techniques are crucial in healthcare settings to protect both patients and healthcare workers from the spread of infections.

What is DTI? A. Deep tissue injury B. Discolored tissue injury C. Detected tissue injury

Correct Answer A. Deep tissue injury ExplanationDTI stands for deep tissue injury. This refers to a type of injury that occurs in the deeper layers of the skin and underlying tissues. It is characterized by damage to the underlying tissues, such as muscles, tendons, or bones, while the surface of the skin may appear intact. This type of injury is often caused by prolonged pressure or shear forces on the skin, leading to damage to the underlying tissues. It is important to recognize and treat DTIs promptly to prevent further complications.

Intramuscular administration A. Deltoid B. 0.1 ml C. 20 seconds D. Implants

Correct Answer A. Deltoid ExplanationThe correct answer is "deltoid" because it is a specific muscle in the body that is commonly used for intramuscular administration of medications. The deltoid muscle is located in the shoulder and is easily accessible for injections. The other options mentioned in the question, such as 0.1 ml, 20 seconds, and implants, are not relevant to the administration of medications in the deltoid muscle.

Raising the arm of over the head during range-of-motions exercise is called A. Flexion B. Abduction C. Supination D. Hyperextension

Correct Answer A. Flexion Explanation(a) The shoulder, a ball and socket joint, flexes by raising the arm from a position by the side of the body forward and upward to a position beside the head(b) Abduction of the should occurs by moving the arm laterally from a resting position at the side of the body to a side position above the head, with the palm of the hand held facing away from the head. (c) Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward(d) Hyperextension of the arms occurs by moving an arm from a resting position at the side of the body to a position behind the body.

Which causes the MOST concern when a person is in the supine position? A. Increased cardiac workload B. Urinary tract infection C. Venous pooling D. Sacral pressure

Correct Answer A. Increased cardiac workload Explanation(a) The supine position increases venous return because the blood does not flow against gravity to return to the heart. An increased venous return increases the workload on the heart by 30 percent, which places the patient at risk for heart failure. (b) Although prolonged immobility in the supine position can cause urinary stasis that increases the risk for urinary tract infections, it is not the greatest concern. (c) Venous pooling occurs when the legs are dependent, not when they are level with the heart as they are in the supine position. (d) Although the supine position causes sacral pressure, is is not the greatest cocnern.

Which parenteral route of administration would typically use the longest needle with the smallest gauge A. Intravenous B. Intramuscular C. Subcutaneous D. Intradermal

Correct Answer A. Intravenous ExplanationThe intravenous route of administration typically uses the longest needle with the smallest gauge. This is because the needle needs to reach the vein, which is deeper in the body compared to other routes. The longer needle ensures that it can penetrate the skin and reach the vein, while the smaller gauge helps minimize discomfort and potential damage to the vein.

A stage II ulcer is not A. Just red area B. Partial thickness loss of dermis C. Shallow open ulcer D. May be intact or open

Correct Answer A. Just red area ExplanationA stage II ulcer is not just a red area. It involves partial thickness loss of the dermis, meaning that the top layer of the skin is damaged. It can appear as a shallow open ulcer or may still be intact.

Increase in cell death A. Necrosis B. Stratum corneum C. Dermis D. Intradermal

Correct Answer A. Necrosis ExplanationNecrosis refers to the death of cells or tissues due to injury, infection, or lack of blood supply. In the context of the given options, an increase in cell death can lead to necrosis. The other terms mentioned, such as stratum corneum, dermis, and intradermal, are related to the layers of the skin and do not directly explain the concept of necrosis.

How is the right arm positioned when using the left Sims' position? A. On a pillow B. Behind the back C. With the palm up D. In internal rotation

Correct Answer A. On a pillow Explanation(a) In the left Sim's position the patient's right arm and leg are supported on pillows to prevent internal rotation of the shoulder and the hip.(b) The right arm is positioned in front of, not behind, the back(c) The right hand is positioned in pronation, not supination(d) The right arm is positioned to maintain the shoulder in external, not internal rotation.

To best evaluate an ambulating patient's balance, the nurse should assess the patient's: A. Posture B. Strength C. Energy level D. Respiratory Care

Correct Answer A. Posture Explanation(a) Assessing posture will identify whether the patient's center of gravity is in the midline from the middle of the forehead to a midpoint between the feet and therefore balanced within the patient's base of support. (b) Strength has more to do with the exertion of power, not balance. (c) energy has more to do with endurance, not balance(d) Assessing respiratory rate establishes a baseline against which to compare respiratory rate after activity to determine tolerance, not balance.

Which health problem would place a patient at the greatest risk for complications associated with immobility? A. Quadriplegia B. Incontinence C. Hemiparesis D. Confusion

Correct Answer A. Quadriplegia Explanation(a Quadriplegia, the paralysis of all four extremities, places the patient at greatest risk for pressure ulcers because the patient has no ability to shift the body weight off of bony prominences or change position without total assistance(b) Bladder and bowel retraining, incontinence devices, and meticulous skin care limit the potential for skin breakdown when patients are incontinent(c) Hemiparesis, muscle weakness on one side of the body, does not prevent a person from shifting or changing position to relieve pressure on the skin(d) Confused patients can move independently when uncomfortable or when encouraged and assisted to move by the nurse.

Logrolling when positioning a patient is most important when the patient has had: A. Spinal cord trauma B. Abdominal surgery C. A long leg cast applied D. Cerebral vascular accident

Correct Answer A. Spinal cord trauma Explanation(a) Logrolling turns a patient while keeping the vertebral column, including the head and neck, in straight alignment to prevent twisting (rotation) that can injure the spinal cord(b) Pressure of a pillow or the hands held against the abdomen supports an abdominal surgical incision, not log rolling. (c) This patient does not need to be logrolled. The entire leg from hip to ankle should be supported when turning a patient with a long leg cast. (d) This patient does not need to be logrollwed. The side of the body with hemiparesis or hemiplegia must be supported.

When a drug is introduce into the circulatory system and carried to the site of activity A. Systemic effect B. Transcorneal transport C. Necrosis D. Inhalation

Correct Answer A. Systemic effect ExplanationWhen a drug is introduced into the circulatory system and carried to the site of activity, it can have a systemic effect. This means that the drug can affect the entire body, not just the specific site where it was administered. The drug is distributed throughout the bloodstream and can interact with various tissues and organs, leading to its desired therapeutic effect. This is in contrast to other options like transcorneal transport, which refers to the transport of a drug through the cornea of the eye, necrosis, which is the death of cells or tissues, and inhalation, which involves the intake of a substance through the respiratory system.

U-Slings are best for Patients A. That can sit up by themselves B. With no upper body strength C. That cannot sit up by themselves D. That need to transfer from a bed to a chair

Correct Answer A. That can sit up by themselves ExplanationU-Slings are best for patients who can sit up by themselves because these slings provide support and stability to individuals who have the ability to sit upright without assistance. They are designed to fit around the patient's waist and under their arms, allowing them to maintain an upright position while being lifted or transferred. This type of sling is not suitable for patients who lack upper body strength or cannot sit up by themselves, as they may require different types of slings or additional support for safe and comfortable transfers.

Stage III appears as a blister with or without skin intact? A. True B. False

Correct Answer A. True ExplanationStage III pressure ulcers appear as a blister with or without skin intact. This means that at this stage, the skin is broken and there may be a blister formation. The blister can either have the skin intact, meaning it is still covering the area, or it can be open, with the skin broken and exposing the underlying tissue. This is a characteristic feature of stage III pressure ulcers and helps in their identification and classification.

All pressure ulcers are found where? A. Fatty area B. Bony area

Correct Answer B. Bony area ExplanationPressure ulcers, also known as bedsores, are typically found in bony areas of the body. This is because these areas have less padding and are more susceptible to pressure and friction, which can lead to the breakdown of skin and underlying tissues. Bony areas, such as the heels, hips, tailbone, and elbows, are particularly prone to developing pressure ulcers in individuals who are immobile or spend prolonged periods in one position. The lack of adequate blood flow and oxygen to these areas further increases the risk of pressure ulcer formation.

Which new strategy has been demonstrated to reduce the incidence of fractured hips among institutionalized older adults? A. Placing bolsters on the sides of a patient's bed B. Dressing a patient with a hip protector undergarment C. Putting an alarm under a patient's wheelchair cushion D. Positioning mats on the floor alongside a patient's bed

Correct Answer B. Dressing a patient with a hip protector undergarment Explanation(a) Bolsters prevent arms and legs from becoming entangled in bed rails(b) If a padded undergarment is worn when a fall occurs, the padding provides protection for the bony prominences of the pelvis and femurs. (c) Although this has reduced accidents, not all patients at risk for falls need wheelchairs. The majority of patients who fracture their hips are ambulatory. (d) Rugs or mats on the floor increase the risk of falls and injury.

In Stage III bone and tendons are visable A. True B. False

Correct Answer B. False ExplanationIn Stage III of bone and tendon injuries, they are not visible. This stage typically involves complete rupture or severe damage to the bone or tendon, resulting in loss of function and significant pain. It may require surgical intervention for repair. Therefore, the correct answer is False.

Universal precautions should be used on every infected person A. True B. False

Correct Answer B. False ExplanationUniversal precautions should not be used on every infected person. Universal precautions are a set of infection control practices that are used to prevent the transmission of bloodborne pathogens and other infectious diseases. These precautions are only necessary when there is a risk of exposure to blood or other body fluids. Therefore, they should be used selectively based on the specific situation and the level of risk involved.

Which route of administraton is not an enternal route? A. Rectal B. Inhalation C. Buccal D. Subligual

Correct Answer B. Inhalation ExplanationInhalation is not an enteral route of administration because it involves the direct delivery of drugs into the respiratory system through inhalation. Enteral routes of administration involve the delivery of drugs through the gastrointestinal tract, such as oral or rectal administration. Inhalation bypasses the gastrointestinal tract and delivers drugs directly to the lungs, where they are absorbed into the bloodstream. Therefore, inhalation is considered a non-enteral or non-oral route of administration.

In stage IV which is flase A. Bone/tendon are visable B. Just a flesh wound C. Osteomylitis is possible D. Slough or eschar may be present

Correct Answer B. Just a flesh wound ExplanationThe statement "just a flesh wound" is the correct answer because it contradicts the other options mentioned in the question. In stage IV, bone/tendon visibility, the possibility of osteomyelitis, and the presence of slough or eschar are all indicative of severe tissue damage and infection, which are not characteristics of a "just a flesh wound."

The most important action when assisting a patient to move from the bed to a wheelchair A. Applying pressure under the patient's axillae when standing up B. Letting the patient help as much as possible when permitted C. Keeping the patient's feet next to each other 1 foot apart D. Lowering the bed to below the height of the wheel chair

Correct Answer B. Letting the patient help as much as possible when permitted Explanation(a) This should be avoided because it can injure nerves and blood vessels(b) Encouraging the patient to be as self-sufficient as possible ensures that the transfer is conducted at their pace, promotes self-esteem and decreases the physical effort expended by the nurse. (c) This will provide a narrow base of support and is unsafe(d) The bed should be higher, not lower, than the wheelchair so that gravity can facilitate transfer

Which statement by the patient would indicate immobility-induced thrombophlebitis. "My lower left leg..." A. Is tingling B. Looks swollen C. Has very dry skin D. Feels cold when touched.

Correct Answer B. Looks swollen Explanation(a) the patient would feel discomfort por pain, not tingling, with thrombophlebitis(b) A slowed blood flow and increased viscosity of the blood allow platelets and calcium to settle out against the intimal lining of a vein, which can result in thrombus formation. The inflammatory process causes calf edema, pain, heat, and erythema(c) The skin would appear taut and shiny, not dry with thrombophlebitis(d) The area would feel warm, not cool, to the touch with thrombophlebitis

Which is the most important action related to the use of antiembolism hose? A. Put them on after the patient's legs have been dependent for several minutes B. Monitor the heels for blanchable erythema every eight hours C. Apply body lotion before putting them on D. Remove and reapply them once a day

Correct Answer B. Monitor the heels for blanchable erythema every eight hours Explanation(a) this is unsafe because pressure injures fluid-filled tissue. They should be applied before, not after, the legs are dependent. (b) Elastic stockings provide external pressure on the patient's legs to prevent pooling of blood in the veins while not interfering with arterial circulation. Inspecting the skin 3 times a day is adequate. (c) when applying elastic stockings, lotion increases friction that can injure tissue. Baby powders can be applied to facilitate application. (d) this is unsafe. Elastic stockings should be removed for 30 minutes 3 times a day.

The best known example of a drug given by sublingual administration is A. Nifedipine B. Nitroglycerin C. Digoxin D. Diltiazem

Correct Answer B. Nitroglycerin ExplanationNitroglycerin is the best known example of a drug given by sublingual administration. This is because nitroglycerin is a vasodilator that is rapidly absorbed through the blood vessels under the tongue, providing quick relief for angina symptoms. Sublingual administration allows the drug to bypass the digestive system and enter the bloodstream directly, resulting in a faster onset of action compared to oral administration. Therefore, nitroglycerin is commonly administered sublingually to treat angina attacks

A person says that medical and surgical aseptic techniques refer to the same procedures used in two separate locations. Is this correct A. Yes B. No

Correct Answer B. No ExplanationNo, this is not correct. Medical aseptic techniques and surgical aseptic techniques are not the same procedures used in two separate locations. Medical aseptic techniques refer to the practices used to prevent the spread of infection in healthcare settings, such as hand hygiene and disinfection. Surgical aseptic techniques, on the other hand, specifically pertain to the procedures used in surgical settings to maintain a sterile environment during surgeries. While there may be some overlap in the principles of aseptic techniques, they are distinct in their application and purpose.

Which position would contribute most to the formation of a hip flexion contracture? A. Semi-fowler's B. Orthopneic C. Supine D. Sim's

Correct Answer B. Orthopneic Explanation(a) In the semi-Fowler's position the hips are slightly flexed (135-165 degrees)(b) While in the high-Fowler's position the patient is then positioned leaning forward with arms resting on an over-bed table. In the orthopneic position, the hips are extensively flexed at the hips creating an angle less than 90 degrees.(c) In the supine position, the hips are extended (180 degrees) and not flexed. (d) In the Sims' position, the him and knee of the upper leg are just slightly flexed

What is the best thing a nurse can do to prevent plantar flexion when making the bed? A.Tuck in the top linens on just the sides of the bed B.Place a toe pleat in the top linens over the feet C.Let the top linens hang off the end of the bed D.Use trochanter rolls to position the feet

Correct Answer B. Place a toe pleat in the top linens over the feet Explanation(a) Top sheets tucked in along the sides of the bed would still exert pressure on the upper surface of the feet, which may promote plantar flexion. The sides of top sheets, mitered at the foot of the bed, hang freely off the side of the bed (b) Making a vertical or horizontal toe pleat at the foot of the bed over the patient's feet laves room for the feet to move freely and avoids exerting pressure on the upper surface of the feet, thus preventing plantar flexion. (c) The weight of the top sheets would still exert pressure on the upper surface of the feet, promoting plantar flexion. (d) Trochanter rolls prevent external hip rotation, not plantar flexion.

Which intervention is unnecessary when assisting the patient with active range of motion exercises? A. Supporting above and below the joint being moved B. Positioning the patient in the supine position in bed C. Providing on-going encouragement and supervision D. Moving the joint through its full range at least three times

Correct Answer B. Positioning the patient in the supine position in bed Explanation(a) Stabilization of body parts ensures that only the joint moves through its full range of motion. (b) The supine position is more appropriate for performing passive range-of-motion exercises. Active range-of-motion exercises can be performed in any comfortable position. (c) This promotes motivation and correct completion of the procedure. (d) Subsequent contraction of muscles tends to be more extensive and efficient, facilitating fuller range of motion.

What is the greatest potential problem associated with Low Fowler's position? A.Dorsiflexion contractures of the feet B.Pressure on the ischial tuberosities C.External rotation of the hips D.Adduction of the legs

Correct Answer B. Pressure on the ischial tuberosities Explanation(a) Plantar flexion contractures (foot drop), not dorsiflexion contractures, can occur in the low-Fowler's position. (b) In the low-Fowler's position, the majority of the body's weight is borne by portions of the pelvis: bony protuberances of the lower portion of the ischium (ischial tuberosities) and the triangular bone at the dorsal part of the pelvis (sacrum) (c) This is more likely to occur in the spine, rather than the low-Folwer's position. (d) Abduction, rather than adduction, of the legs is more likely to occur in the low-Fowler's position.

Before opening a sterile package: A. Remember the edge is sterile B. Remember the edge is not sterile

Correct Answer B. Remember the edge is not sterile ExplanationThe correct answer is "remember the edge is not sterile." This means that before opening a sterile package, it is important to remember that the edge of the package is not sterile. This is crucial information because it helps to prevent contamination of the sterile contents inside the package. By being aware that the edge is not sterile, healthcare professionals can take necessary precautions to avoid touching or contaminating the sterile field while opening the package.

Which position should be avoided for a patient at the greatest risk for the development of pressure ulcers? A. Low Fowler's B. Side-lying C. Supine D. Prone

Correct Answer B. Side-lying Explanation(a) although in the low-Fowler's position the sacral area is at the greatest risk for pressure, the muscles and adipose tissues in the buttocks do provide some protection compared to other vulnerable areas of the body. (b) In the side-lying position, the majority of the body weight is borne by the greater trochanter. the bone is close to the surface of the skin, with minimal overlying protective tissue. (c) Although in the supine position, the occiput, scapulae, spine, elbows, sacrum, and heels are at risk for pressure, the body weight is distributed more evenly than in some other positions. (d) Although in the prone position the ears, cheeks, acromion process, anterior superior spinous process, knees, toes, male genitalia, and female breasts are at risk for pressure, the body weight is distributed more evenly than in some other positions.

Which stage pressure ulcer would just have partial thickness skin loss involving epidermis and dermis? A.Stage I B.Stage II C.Stage III D.Stage IV

Correct Answer B. Stage II Explanation(a) In Stage I pressure ulcer, the skin is still intact and presents clinically as reactive hyperemia. (b) In Stage II pressure ulcer the partial-thickness skin loss presents clinically as an abrasion, blister; or shallow crater(c) In Stage III pressure ulcer, there is full-thickness skin loss involving the subcutaneous tissue that may extent to the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining. (d) In Stage IV pressure ulcer there is full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscles, bone or supporting structures.

What is the most common cause of skin infections? A. Streptococcus pyogenes B. Staphylococcus aureus C. Group B hemolytic Strep D. MRSA

Correct Answer B. Staphylococcus aureus ExplanationStaphylococcus aureus is the most common cause of skin infections. This bacterium is commonly found on the skin and can cause a range of infections, including boils, cellulitis, and impetigo. It is highly contagious and can easily spread through direct contact or contaminated objects. Staphylococcus aureus can also be resistant to antibiotics, leading to more severe infections that are difficult to treat. Therefore, it is important to practice good hygiene and take precautions to prevent the spread of this bacterium. Rate this question:

Drug transfer into the eye A. Viscosity B. Transcorneal transport C. Opthalmic D. Sublingual

Correct Answer B. Transcorneal transport ExplanationTranscorneal transport refers to the movement of drugs across the cornea, which is the transparent outer layer of the eye. This process is important for drug delivery into the eye because the cornea acts as a barrier and limits the penetration of drugs. Understanding transcorneal transport is crucial for developing ophthalmic drugs that can effectively reach the target tissues within the eye. The given answer suggests that transcorneal transport is the most relevant concept in the context of drug transfer into the eye.

Which would be the best example of a discharge goal for a patient with a nursing diagnosis of Impaired Physical mobility? The patient will: A. Understand range of motion exercises B. Transfer independently to a chair C. Be taught ROM exercises D. Be kept clean and dry

Correct Answer B. Transfer independently to a chair Explanation(a) This goal is not measurable as stated. Understanding is not measurable unless parameters are identified. (b) This goal is patient-centered and measurable. (c) This is a nursing intervention, not a patient goal. (d) This is a nursing goal, not a patient goal.

Reactive hyperemia over a bony prominence occurs in response to: A.Applying a warm soak B.Turning a patient off an affected site C.Using an effleurage massage technique D.Pulling a patient up in bed without a pull sheet

Correct Answer B. Turning a patient off an affected site Explanation(a) heat causes vasodilation that increases circulation to the area and results in erythema, not reactive hyperemia.(b) compressed skin appears pale because circulation to the area is impaired. When pressure is relieved, the skin takes on a bright red flush as extra blood flows to the area to compensate for the period of impeded blood flow. (c) effleurage, light stroking of the skin, simulates the peripheral nerves and should not change skin coloration. (d) The can cause a friction burn or a shearing force that can injure blood vessels and tissues.

When lifting a patient, strain to the nurse can be reduced when the nurse: A. Moves the patient up against gravity B. Uses the large muscles of the legs C. Keeps the knees locked D. Bends from the waist

Correct Answer B. Uses the large muscles of the legs Explanation(a) Muscle strain is reduced when moving patients with gravity, not with added effort needed to move patients against gravity. (b) The gluteal and leg muscles should be used rather than the sacrospinal muscles of the back to exert an upward lift. These larger muscles fatigue less quickly, and their use protects the intervertebral disks. (c) the muscles of the legs are used inefficiently when the knees are kept locked. This increases the strain on the other muscles being used. (d) Bending from the waist increases the strain on the sacrospinal muscles and intervertebral disks.

When administering a nasal spray A. Lay on the bed with the head hanging over the edge B. Keep both nostrils open C. Breathe through the nostril while spraying D. Exhale immediately

Correct Answer C. Breathe through the nostril while spraying ExplanationWhen administering a nasal spray, it is important to breathe through the nostril while spraying. This is because breathing through the nostril helps to ensure that the medication is properly distributed and reaches the desired area in the nasal passages. By inhaling while spraying, the medication is more likely to be absorbed effectively and provide the intended relief or treatment.

This is an example of an acute spreading infection of the skin that involves the subcutaneous, fat tissue. A. Folliculitis B. Erysipelas C. Cellulitis D. Gangrene

Correct Answer C. Cellulitis ExplanationCellulitis is an acute spreading infection of the skin that affects the subcutaneous fat tissue. It is characterized by redness, warmth, swelling, and pain in the affected area. Unlike folliculitis, which is an infection of the hair follicles, cellulitis involves a deeper layer of the skin. Erysipelas is a type of cellulitis that affects the upper layers of the skin, while gangrene refers to tissue death caused by a lack of blood supply. Therefore, the correct answer is cellulitis.

An agent that removes disease-causing organisms by loosening and removing the dirt and grime to which the organisms are attached is called a/an: A. Antiseptic agent B. Chemical disinfectant C. Cleansing agent D. Sterilizing agent

Correct Answer C. Cleansing agent ExplanationA cleansing agent is the correct answer because it describes the function of removing disease-causing organisms by loosening and removing dirt and grime to which the organisms are attached. Antiseptic agents are used to inhibit the growth of microorganisms on living tissues, while chemical disinfectants are used to kill or inhibit the growth of microorganisms on inanimate objects. Sterilizing agents are used to completely eliminate all forms of microbial life. Therefore, the most appropriate term for an agent that removes disease-causing organisms by loosening and removing dirt and grime is a cleansing agent.

Which position places a patient at the greatest risk for pressure on the popliteal space? A. Prone B. Supine C. Contour D. Trendelenburg

Correct Answer C. Contour Explanation(a) In the prone position, there is pressure in front of, not behind, the knees.(b) In the supine position, the hips and legs are extended, which does not exert pressure on the popliteal space. (c) In the contour position, the head of the bed and the knee gatch are slightly elevated. The elevated knee gatch puts pressure on the popliteal spaces. (d) In the Trendelenburg position, the hips and knees are extended, which does not exert pressure on the popliteal space.

Which is a systemic adaptation to immobility? A.Plantar flexion contracture B.Hypostatic pneumonia C.Dependent edema D.Pressure ulcer

Correct Answer C. Dependent edema Explanation(a) Plantar flexion contracture (foot drop) is a localized response to prolonged extension of the ankle(b) Static respiratory secretions provide an excellent media for bacterial growth that can result in hypostatic pneumonia, which is a localized response to immobility(c) Decreased calf muscle activity and pressure of the bed on the legs allow blood to accumulate in the distal veins. The resulting increased hydrostatic pressure moves fluid out of the intravascular compartment into the interstitial compartment, causing edema. (d) Prolonged pressure on the skin over a bony prominence interferes with capillary blood flow to the skin, which ultimately can result in the localized response of a pressure ulcer.

Which motion occurs when in the supine position the ankle is bent so that the toes are pointed towards the ceiling? A. Supination B. Adduction C. Dorsal flexion D. Plantar extension

Correct Answer C. Dorsal flexion Explanation(a) Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward(b) Adduction occurs when an arm or leg moves toward and/or beyond the midline of the body(c) Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg. (d) There is no range of motion called plantar extension. Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.

When Raising the Patient, the base should be A. Closed B. Extended half way C. Extended to its widest D. Dose not matter

Correct Answer C. Extended to its widest ExplanationWhen raising the patient, it is important to extend the base to its widest position. This provides maximum stability and support, reducing the risk of the patient falling or being injured during the lifting process. By extending the base to its widest position, it ensures that the weight of the patient is evenly distributed and the lift is performed safely and efficiently.

Which assessment reflects a defining characteristic that would support the nursing diagnosis Impaired Physical Mobility? A. Exertional fatigue B. Sedentary lifestyle C. Limited Range of Motion D. Increase Respiratory Rate

Correct Answer C. Limited Range of Motion Explanation(a) This is a defining characteristic of the nursing diagnosis Activity Intolerance. (b) This is a contributing factor for the nursing diagnosis Activity Intolerance(c) Limited range of motion is a defining characteristic of the nursing diagnosis Impaired Physical Mobility(d) An increased respiratory rate would be an adaptation to activity, not a defining characteristic of the nursing diagnosis Impaired Physical Mobility.

An immobilized bedridden patient is placed on a 2-hour turning and positioning program primarily to: A. Support comfort B. Promote elimination C. Maintain skin integrity D. Facilitate respiratory function

Correct Answer C. Maintain skin integrity Explanation(a) Although turning a patient to a new position every 2 hours provides a variety and increased comfort, these are not the primary reasons for this intervention. (b) Although turning frequently promotes elimination, the upright positions, such as high-Fowler's and sitting, have the greater influence on elimination. (c) Compression of soft tissue greater than 32 mm Hg prevents capillary circulation and compromises tissue oxygenation in the compressed area. Turning the patient relieves the compression of tissue in dependent areas, particularly those tissues overlying bony prominences. (d) Although turning and positioning promotes respiratory functioning, other interventions such as sitting, deep breathing, coughing, and incentive spirometry, have a greater influence on respiratory status.

A drug is administered by inhalation using a metered dose inhaler (MDI) aerosol. which pathway will the drug follow A. Mouth trachea, aveoli, bronchioles B. Mouth, bronchioles, trachea, alveoli C. Mouth, trachea, bronchioles, alveoli D. Bronchioles, alveoli, nasal cavity, trachea

Correct Answer C. Mouth, trachea, bronchioles, alveoli ExplanationWhen a drug is administered by inhalation using a metered dose inhaler (MDI) aerosol, it is sprayed into the mouth and then inhaled. From the mouth, the drug travels down the trachea (windpipe) and enters the bronchioles, which are small airways in the lungs. Finally, the drug reaches the alveoli, which are tiny air sacs where gas exchange takes place. Therefore, the correct pathway for the drug in this case is mouth, trachea, bronchioles, alveoli.

Which is a local adaptation to immobility? A. Renal calculi B. Thrombophlebitis C. Muscle contractures D. Pathological fracture

Correct Answer C. Muscle contractures Explanation(a) Demineralization of bone is a systemic response to immobility. Without the stress of weight-bearing activity, the bones begin to demineralize and the urine becomes more alkaline. Calcium salts precipitate out as crystals to form calculi. (b) Thrombophlebitis results from the systemic responses of impaired venous return and hypercoagulability in conjunction with injury to a vessel wall. (c) A contracture is a localized response to immobility. When muscle fibers are not able to shorten or lengthen, eventually a permanent shortening of the muscles and subsequently of the tendons and ligaments occurs.(d) Immobility can cause the systemic response of demineralization of bone (disuse osteoporosis) that eventually can result in bone fractures.

The absorption of drugs throught the skin, often for a systemic effect A. PH B. Systemic effect C. Percutaneous absorption D. Ophthalmic Correct AnswerC. Percutaneous absorption ExplanationPercutaneous absorption refers to the process of drugs being absorbed through the skin and entering the systemic circulation, resulting in a systemic effect. This mechanism is commonly used in transdermal drug delivery systems, where drugs are formulated in patches or creams to be applied on the skin for slow and controlled absorption into the bloodstream. Ophthalmic refers to drugs or formulations that are specifically designed for use in the eyes, while pH refers to the measure of acidity or alkalinity of a substance.

Correct Answer C. Percutaneous absorption Explanation Percutaneous absorption refers to the process of drugs being absorbed through the skin and entering the systemic circulation, resulting in a systemic effect. This mechanism is commonly used in transdermal drug delivery systems, where drugs are formulated in patches or creams to be applied on the skin for slow and controlled absorption into the bloodstream. Ophthalmic refers to drugs or formulations that are specifically designed for use in the eyes, while pH refers to the measure of acidity or alkalinity of a substance.

Definition. It is a set of infection control practices that healthcare personnel use to reduce transmission of microorganisms in healthcare settings. A. Mechanisms of Infection B. Infection Prevention and Control C. Standard Precautions D. Mode of Transmission

Correct Answer C. Standard Precautions ExplanationStandard Precautions refer to a set of infection control practices that healthcare personnel follow to minimize the transmission of microorganisms in healthcare settings. These precautions include hand hygiene, the use of personal protective equipment (such as gloves, masks, and gowns), safe injection practices, safe handling and disposal of sharps, and respiratory hygiene/cough etiquette. By implementing these measures, healthcare workers can protect themselves and their patients from the spread of infections.

Which word is most closely associated with nursing care strategies to maintain functional alignment when patients are bedridden? A. Endurance B. Strength C. Support D. Balance

Correct Answer C. Support Explanation(a) Endurance relates to aerobic exercise that improves the body's capacity to consume oxygen for producing energy at the cellular level. (b) Strength relates to isometric and isotonic exercises, which contract muscles and promote their development. (c) The line of gravity passes through the center of gravity when the body is correctly aligned; this results in the least amount of stress on the muscles, joints, and soft tissues. Bedridden patients often need assistive devices such as pillows, sandbags, bed cradles, wedges, rolls, and splints to support and maintain the vertebral column and extremities in functional alignment. (d) Balance relates to body mechanics, and is achieved through a wide base of support and a lowered center of gravity.

A rasied blister-like area on the skin caused from an intradermal injection is called a A. Thrombus B. Pachyderma C. Wheal D. Phlebitis

Correct Answer C. Wheal ExplanationA raised blister-like area on the skin caused from an intradermal injection is called a wheal. This is a common reaction to injections where a small amount of fluid is injected just below the skin's surface. The wheal is typically red, swollen, and itchy. It is a localized immune response to the injection and usually resolves on its own within a few hours or days. Rate this question:

Pressure ulcers come in how many stages? A. 5 B. 8 C. 1 D. 4

Correct Answer D. 4 ExplanationPressure ulcers come in four stages. This means that there are four different levels of severity for pressure ulcers. The stages range from stage 1, which is the least severe, to stage 4, which is the most severe. Each stage has specific characteristics and symptoms that help healthcare professionals determine the appropriate treatment for the pressure ulcer.

Modified release tablets might be called A. Extended release B. Prolonged action C. Long acting D. All of the above

Correct Answer D. All of the above ExplanationThe term "modified release tablets" refers to tablets that are designed to release the medication into the body over an extended period of time. These tablets are also commonly referred to as "extended release" tablets because they provide a prolonged action by slowly releasing the medication. Additionally, they are considered "long acting" because they have a sustained effect compared to immediate release tablets. Therefore, all of the given options - extended release, prolonged action, and long acting - are correct ways to refer to modified release tablets.

Which is a localized adaptation to immobility? A. Orthostatic Hypotension B. Muscle Atrophy C. Osteoporosis D. Atelectasis

Correct Answer D. Atelectasis Explanation(a) A systematic response to immobility is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). (b) After 24 to 36 hours of inactivity, all the muscles begin to lose their contractile strength, the initial process of atrophy, which is a systemic response to mobility. (c) Osteoporosis, a systemic response to immobility, is demineralization of bone because of the lack of weight-bearing activity. (d) The pooling of respiratory secretions that block the bronchioles and the decreased production of surfactant associated with immobility cause the localized effect of ATELECTASIS (Collapse of all or part of a lung)

Sterile field set up A. Can be set up appromimately 3 hours prior to procedure B. Can be covered and monitored for 3 hours C. Prepared as soon as patient is ready D. Constantly monitored and sterility maintained.

Correct Answer D. Constantly monitored and sterility maintained. ExplanationThe correct answer is "constantly monitored and sterility maintained." This means that the sterile field should be continuously observed and kept free from any contamination throughout the procedure. The other options mentioned in the question are not appropriate because setting up the sterile field too early may increase the risk of contamination, covering and monitoring for only 3 hours may not be sufficient for the duration of the procedure, and preparing the sterile field as soon as the patient is ready does not guarantee constant monitoring and maintenance of sterility.

Which medical treatment is specific for a patient with a stage IV pressure ulcer with eschar? A. Heat lamp treatment three times a day B. Application of a topical antibiotic C. Cleansing irrigations every shift D. Debridement of the wound

Correct Answer D. Debridement of the wound Explanation(a) Heat lamp treatments should not be used because they can cause burns(b) Topical antibiotics are used only when the ulcer is infected, not to treat eschar(c) Cleansing irrigations are ineffective in removing the thick fibrin-containing cells of eschar covering the surface of the wound(d) Thick, leather-like necrotic devitalized tissue (eschar) must be removed surigally or enzymatically before wound healing can occur.

When an older adult is afraid of falling, the most common consequence is: A. Impaired skin integrity B. Occurrence of panic attacks C. Self-imposed social isolation D. Decreased physical conditioning

Correct Answer D. Decreased physical conditioning Explanation(a) A person who chooses not to ambulate still has the ability to assume many different sitting or lying down positions. (b) Anxiety and ultimately panic that is precipitated by a situation can be prevented by avoiding the situation.(c) A person who chooses not to ambulate still can socialize(d) Most falls occur when ambulating. Fear of falling results in the conscious choice not to place oneself in a position where a fall can occur. Disuse and muscle wasting cause a reduction of muscle strength at the rate of 5 to 10 percent per week so that within 2 months of immobility over 50 percent of a muscle's strength can be lost. In addition, there is a decreased cardiac reserve. These adaptations result in decreased physical conditioning.

Which motion occurs when the angle is reduced between the palm of the hand and forearm? A.Hyperextension B.Opposition C.Abduction D.Flexion

Correct Answer D. Flexion Explanation(a) hyperextension of the condyloid joint of the wrist is accomplished by bending the fingers and hand backwards as far as possible. (b) Opposition of the thumb, which is a saddle joint, occurs when the thumb touches the top of each finger on the same hand. (c) Abduction of the fingers (metacarpophalangeal joints - condyloid) occurs when the fingers of each hand spread apart. (d) flexion of the wrist, a condyloid joint, occurs when the fingers of the hand move toward the inner aspect of the forearm.

Nucrotic ulcers are A. Found on the back B. Found on or around the knee area C. A stage I ulcer D. Found on the foot

Correct Answer D. Found on the foot Explanation Necrotic ulcers are typically found on the foot. Necrotic ulcers refer to areas of dead tissue, which can occur due to various reasons such as poor circulation, pressure, or infection. The foot is particularly susceptible to developing necrotic ulcers because it is often subjected to pressure and friction while walking or standing. Additionally, the foot is prone to reduced blood flow, especially in individuals with diabetes or peripheral artery disease, further increasing the risk of developing necrotic ulcers in this area.

_____ injections are administered into the top layer of the skin at a slight angle using short needles A. Intraarterial B. Transcorneal C. Subcutaneous D. Intradermal

Correct Answer D. Intradermal ExplanationIntradermal injections are administered into the top layer of the skin at a slight angle using short needles. These injections are typically used for diagnostic tests, such as tuberculin skin tests or allergy tests, as well as for administering certain medications. The angle and depth of the injection allow for accurate placement of the medication just below the epidermis, where it can be easily absorbed into the bloodstream. This method is commonly used because it minimizes pain and discomfort for the patient while still delivering the medication effectively.

Which of the following routes is least likey to give a systemic effect? A. Oral B. Sublingual C. Rectal D. Intradermal

Correct Answer D. Intradermal ExplanationThe intradermal route is least likely to give a systemic effect because it involves injecting the medication into the dermis layer of the skin, which is a superficial layer. This route is commonly used for diagnostic tests, such as tuberculin skin tests, where the medication is intended to have a local effect rather than being absorbed into the bloodstream and distributed throughout the body. In contrast, the oral, sublingual, and rectal routes involve the medication being absorbed into the bloodstream, allowing for systemic effects to occur.

Which is not used to administer a drug by parenteral route? A. Syringe B. Elastomeric pump C. Infusion pump D. None of the above

Correct Answer D. None of the above ExplanationThe question asks which option is not used to administer a drug by the parenteral route. The parenteral route refers to the administration of drugs directly into the body, bypassing the digestive system. Syringe, elastomeric pump, and infusion pump are all commonly used methods for parenteral drug administration. Therefore, the correct answer is "none of the above" since all of the options listed can be used to administer drugs by the parenteral route.

When doing ROM exercises, moving the thumb so it touches each finger is called... A. Flexion B. Inversion C. Abduction D. Opposition

Correct Answer D. Opposition Explanation(a) Flexion of the metacarpophalangeal joints (condyloid joints) and the interphalangeal joints (hinge joints) occurs by making a fist, which decreases the angles of the joints. (b) Inversion is turning the sole of a foot medially, which is not a range-of-motion of the hand. (c) Abduction is moving an arm or a leg away from the midline of the body. (d) Opposition occurs when the thumb touches the top of each finger of the same hand.

The presence of which adaptation is most important to assess before administering passive ROM exercises? A. Weakness B. Flaccidity C. Atrophy D. Pain

Correct Answer D. Pain Explanation(a) Although the extent of weakness should be assessed, it is not the priority(b) Although the presence of flaccidity should be assessed, it is not the priority(c) Although the degree of atrophy should be assessed, it is not the priority(d) If the patient is experiencing pain, there will be reluctance to move. An analgesic administered before beginning these exercises will promote acceptance and tolerance of the exercises

Which action occurs when you turn the palm of the hand downward? A. External rotation B. Circumduction C. Lateral flexion D. Pronation

Correct Answer D. Pronation Explanation(a) External rotation of the shoulder, a ball-and-socket joint, occurs when the upper arm is held parallel to the floor, the elbow is at a 90-degree angle, and the fingers are pointing toward the floor and the person moves the arm upward so that the fingers point toward the ceiling. (b) Circumduction of the shoulder, a ball-and-socket joint, occurs when an extended arm moves forward, up, back and down in a full circle. (c) Lateral flexion of the hand occurs with both abduction (radial flexion) and adduction (ulnar flexion). With the hand supinated, radial flexion occurs by bending the wrist laterally toward the fifth finger. (d) Pronation of the hand occurs by rotating the hand and arm so that the palm of the hand is facing down toward the floor.

Which stage pressure ulcer would require the nurse to measure the extent of undermining? A. Stage 0 B. Stage I C. Stage II D. Stage III

Correct Answer D. Stage III Explanation(a) There is no Stage 0 in the classification system for staging pressure ulcers. (b) The skin is still intact and there is no undermining in a Stage I pressure ulcer. (c) Tissue damage is superficial and there is no undermining in a Stage II pressure ulcer.(d) IN a Stage III pressure ulcer there is full thickness skin loss involving damage to subcutaneous tissue that may not be undermining, which is tissue destruction underneath intact skin along wound margins.

A process that kills bacteria spores is A. Boiling B. Disinfection C. Isolation D. Sterilization

Correct Answer D. Sterilization ExplanationSterilization is the correct answer because it refers to the process of eliminating or destroying all forms of microbial life, including bacteria spores. This method ensures complete elimination of any potential pathogens or contaminants, making it a highly effective way to kill bacteria spores. Boiling, disinfection, and isolation may not necessarily achieve the same level of thoroughness and effectiveness in killing bacteria spores as sterilization does.

Under the Dongue A. Necrosis B. Systemic effect C. Wheal D. Sublingual

Correct Answer D. Sublingual ExplanationThe term "sublingual" refers to the area under the tongue. This answer is correct because it is the only term that is related to the location under the tongue. "Dongue" is likely a typographical error for "tongue" and does not have any medical significance. "Necrosis" refers to the death of cells or tissues, "systemic effect" refers to the effects on the entire body, and "wheal" refers to a raised, itchy area on the skin. None of these terms are specifically related to the area under the tongue.

Which intravenous dosage form requires the technician to consider syringeability and injectability? A. Emulsions B. Gels C. Solutions D. Suspensions

Correct Answer D. Suspensions ExplanationSuspensions require the technician to consider syringeability and injectability. Suspensions are heterogeneous mixtures in which solid particles are dispersed in a liquid medium. Due to the presence of solid particles, suspensions may have issues with syringeability, meaning that they may not easily pass through a syringe without clogging. Additionally, injectability refers to the ability of a formulation to be easily injected into the body. Suspensions may require careful consideration to ensure that they can be easily injected without causing harm or discomfort to the patient. Rate this question:

Which nursing action is most dependent on the principle: "the wider the base of support the greater the stability"? A. Carrying a heavy object B. Raising the side rails on a bed C. Repositioning a trochanter roll D. Transferring a patient from a bed to a chair

Correct Answer D. Transferring a patient from a bed to a chair Explanation (a) Carrying a heavy objectThis follows the principle "The closer an object is to the center of gravity, the greater the stability and the easier the object is to move" (b) Raising the side rails on a bedSide rails protect patients from falling out of bed and follow the principle "An object in motion stays in motion until it hits an opposing force"(c) Repositioning a trochanter rollTrochanter rolls placed lateral to the legs between the iliac crests and knees prevent external hip rotation when the patient is in the supine position. This follows the principle "An object in motion stays in motion until it hits an opposing force"(d) Transferring a patient from a bed to a chairWhen transferring a patient from bed to char both the nurse and the patient should have their feet spread the width of their shoulders and with one foot in front of the other. Appropriate body mechanics prevents falls.

Which action is specifically related to the principle, "the greater the base of support, the more stable the body?" A. Keeping the back straight when lifting an object B. Holding objects close to the body when walking C. Locking the wheels of a wheelchair D. Using a walker when ambulating

Correct Answer D. Using a walker when ambulating Explanation(a) This follows the principle: Balance is maintained and muscle strain is limited as long as the line of gravity passes through the base of support. (b) This follows the principle: The closer an object is held to the center of gravity the greater the stability and the easier the object is to move. (c) This follows the principle An object with wheels that are locked will remain stationery. (d) Walkers surround a person on three sides and provide 4 points of contact with the floor. This wide base provides the best support available for assisted ambulation.

Transmission can be through: A. Direct contact B. Blood C. Indirect contact D. Water

Correct Answer D. Water ExplanationTransmission can occur through water when infectious agents, such as bacteria or viruses, are present in the water source. This can happen when contaminated water is consumed or when it comes into contact with mucous membranes, such as the eyes or mouth. Waterborne diseases, such as cholera or giardiasis, can be spread through contaminated water. Proper sanitation and water treatment methods are essential in preventing the transmission of diseases through water.

What is the most effective way to help prevent the spread of organisms? A. Sterile technique B. Medical asepsis C. Use of ultraviolet properties D. Eliminating normal flora E. Hand hygiene

Correct Answer E. Hand hygiene ExplanationHand hygiene is the most effective way to help prevent the spread of organisms. Proper hand hygiene, including washing hands with soap and water or using hand sanitizers, can remove or kill harmful microorganisms that may be present on the hands. This helps to prevent the transmission of infections from person to person or from contaminated surfaces to individuals. Hand hygiene is a simple and cost-effective measure that can be practiced by healthcare professionals and the general public to reduce the risk of infections.

To comply with the principles of sterile technique it is necessary to create and maintain a sterile field, isolate the operative sit and prevent contamination of the open wound. It is the responsibility of ----------------to report any violation of sterile technique

Correct Answer every surgical team member ExplanationTo comply with the principles of sterile technique, it is necessary for every surgical team member to create and maintain a sterile field, isolate the operative site, and prevent contamination of the open wound. This means that it is the responsibility of every team member to report any violation of sterile technique. This ensures that any breaches or mistakes can be identified and corrected promptly, minimizing the risk of infection and promoting patient safety.

A ________________ ________________ is an infection acquired by a patient in a health care facility.

Correct Answer nosocomial infection ExplanationA nosocomial infection refers to an infection that is acquired by a patient while they are in a healthcare facility. This type of infection is often caused by bacteria, viruses, or other pathogens that are present within the healthcare environment. Nosocomial infections can be particularly dangerous as they can spread easily among patients who may already have compromised immune systems. It is important for healthcare facilities to have strict protocols in place to prevent and control the spread of nosocomial infections.

Scrubbing, please place this in the correct order A. Cleans nails B. Scrubs all sides of each digit. C. Uses knee to turn off water D. Rinses hands and arms so water flows off at elbows E. Wets hands and forearms

Correct Answer(s)A. Cleans nailsB. Scrubs all sides of each digit.C. Uses knee to turn off waterD. Rinses hands and arms so water flows off at elbowsE. Wets hands and forearms ExplanationThe correct order for scrubbing is to first clean the nails, then scrub all sides of each digit. After that, the person uses their knee to turn off the water. Following that, they rinse their hands and arms so that the water flows off at the elbows. Finally, they wet their hands and forearms.

Practices that are used to keep an area free of disease-producing microorganisms. A. Asepsis B. Sterilization C. Disinfection

Correct AnswerA. Asepsis ExplanationAsepsis refers to the practices that are used to keep an area free of disease-producing microorganisms. This includes techniques such as proper hand hygiene, wearing gloves, using sterile equipment, and maintaining a clean environment. Asepsis is important in healthcare settings to prevent the spread of infections and ensure patient safety. It is different from sterilization, which is the complete elimination of all microorganisms, and disinfection, which involves killing or reducing the number of microorganisms on surfaces or objects.

Plasters are generally used with the _______ route of administration A. Dermal B. Rectal C. Intranasal D. Vaginal

Correct AnswerA. Dermal ExplanationPlasters are generally used with the dermal route of administration because they are designed to be applied directly to the skin. The adhesive backing of the plaster allows it to stick to the skin and deliver medication or provide a protective barrier. This route is commonly used for topical medications, such as pain relievers or skin treatments, as it allows for localized and controlled absorption through the skin.

The orthopneic position is used primarily to A. Facilitate respirations B. Support hip extension C. Prevent pressure ulcers D. Promote urinary elimination

Correct AnswerA. Facilitate respirations Explanation(a) Sitting in the high-Fowler's position and leaning forward allows the abdominal organs to drop by gravity, which will promote contraction of the diaphragm. The arms resting on an over-bed table increases thoracic excursion. (b) the hips will be in extreme flexion, not extension.(c) Pressure ulcers can still occur on the ischial tuberosities(d) Ambulation is superior to any bed position for promoting urinary elimination.

What is a basic principle associated with transferring a patient from a bed to a chair using a mechanical lift? (p. 238) A. Hook the longer chains on the end of the sling closest to the patient's feet B. Ensure that there is a physician's order to use a mechanical lift C. Place a sheepskin inside the sling so that it is under the patient D. Lead with the patient's feet when existing the bed

Correct AnswerA. Hook the longer chains on the end of the sling closest to the patient's feet Explanation(a) The longer chains go in the holes for the seat support, which keeps the legs and pelvis below the upper body. Appropriate placement of the upper and lower chains creates a bucket seat in which a patient is moved safely. (b) Moving patients with a hydraulic life is within the scope of nursing practice and a practitioner's order is unnecessary. (c) This could result in the patient's sliding down and out of the sling during the transfer. Nylon, net or canvas slings are available. (d) it does not matter whether the feet or the head exits the bed first as long as functional alignment and safety are maintained.

Which motion occurs when the ankle is turned so that the sole of the foot moves medially toward the midline? A. Inversion B. Adduction C. Plantar Flexion D. Internal Rotation

Correct AnswerA. Inversion Explanation(a) Inversion, a gliding movement of the foot, occurs by turning the sole of the foot medially toward the mid line of the body(b) Adduction occurs when an arm or leg moves toward and beyond the midline of the body(c) Plantar flexion occurs when the joint of the ankle is in extension by pointing the toes of the foot downward and away from the anterior portion of the lower leg.(d) Internal rotation of a leg occurs by turning the foot and leg inward so that the toes point toward the other leg.

Which is the primary reason why immobilized people develop contractures? A. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles B. Muscle mass and strength decline at a rate of 5 to 10 percent per week C. Muscular contractures occur because of excessive muscle flaccidity D. Muscle catabolism exceeds muscle anabolism

Correct AnswerA. Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles Explanation(a) The state of balance between muscles that serve to contract in opposite directions is impaired with immobility. The fibers of the stronger muscles contract for longer periods that do those of the weaker, opposing muscles. This results in a change in the loose connective tissue to a more dense connective tissue and to fibrotic changes that limit range of motion. (b) Disuse and muscle wasting cause a reduction in muscle strength at the rate of 5 tp 10 percent a week so that within 2 months over 50 percent of a muscle's strength can be lost. (c) Contractures occur because of muscle spasticity and shortening, not muscle flaccidity. (d) This is unrelated to contractures. In unused muscles, catabolism exceeds anabolism, and the muscles decrease in size (disuse atrophy)

To best prevent pressure ulcers when a patient is on bed rest, the nurse should: A. Place an air mattress on the bed B. Massage bony prominences every shift C. Apply a moisture barrier to the sacral area D. Raise the head of the bed to the low-Fowler's position

Correct AnswerA. Place an air mattress on the bed Explanation(a) Air mattresses automatically and rhythmically inflate and deflate, which applies and relieves pressure on various body areas. Capillary beds close at between 12-32 mm Hg (capillary closing pressure). Any device that reduces pressure below capillary closing pressure is considered a pressure relief device. Any device that does not consistently reduce pressure below capillary closing pressure is considered a pressure reducing device. (b) A bedridden patient is at risk for skin breakdown, and therefore 3 back rubs a day are inadequate(c) Moisture barriers prevent skin breakdown when a patient is incontinent of urine or feces, they do not prevent pressure on the skin(d) This increases the risk of the patient's sliding down in bed, which may cause shearing force that can injure tissue. In addition, this position increases pressure on the vulnerable sacral area.

Risk of transmission is extremely low or nonexistent through feces, saliva, sweat, urine and tears? A. True B. False

Correct AnswerA. True ExplanationThe statement is true because the risk of transmission of diseases through feces, saliva, sweat, urine, and tears is extremely low or nonexistent. These bodily fluids do not typically contain high concentrations of pathogens that can cause infections. However, it is important to note that there may be exceptions in certain specific cases or with certain diseases. Overall, the likelihood of transmitting diseases through these bodily fluids is very low.

Most familiar of the microbes that infect humans; CAN be treated with antibiotics. A. Microorganisms B. Bacteria C. Virus

Correct AnswerB. Bacteria ExplanationBacteria are the most familiar microbes that infect humans and can be treated with antibiotics. Antibiotics are medications that specifically target and kill bacteria, helping to eliminate the infection. While other microbes such as viruses do not respond to antibiotics, bacteria can be effectively treated with these medications.

Tb is a blood borne pathogen? A. True B. False

Correct AnswerB. False ExplanationTb, also known as tuberculosis, is not a blood borne pathogen. It is primarily an airborne disease that spreads through the inhalation of infected droplets from the coughs or sneezes of an infected person. While it can affect various organs in the body, including the lungs, it is not transmitted through the blood. Therefore, the correct answer is False.

Germs that are found on skin, in the air, on surfaces, and even inside bodies. A. Asepsis B. Microorganisms C. Bacteria

Correct AnswerB. Microorganisms ExplanationMicroorganisms are tiny living organisms that can be found in various environments, including on skin, in the air, on surfaces, and even inside bodies. They can include bacteria, viruses, fungi, and other types of germs. These microorganisms can be harmless or harmful, and they play a crucial role in various biological processes. Understanding and controlling microorganisms is essential for maintaining asepsis, which refers to the absence of harmful microorganisms and preventing infections. Therefore, the given answer, microorganisms, accurately describes the germs that can be found in different places.

Which complication of immobility would be of most concern? A. Dehydration B. Incontinence C. Contractures D. Hypertension

Correct AnswerC. Contractures Explanation(a) Dehydration is not an adaptation to immobility(b) The decreased tone of the urinary bladder and the inability to assume the normal voiding position in bed promotes urinary retention, rather than urinary incontinence. (c) Contractures result from permanent shortening of muscles, tendons, and ligaments. Contractures are irreversible without surgical intervention.(d) With immobility, the increased heart rate reduces the diastolic pressure. In addition, there is a decrease in blood pressure related to postural changes from lying to sitting or standing (orthostatic hypotension). This situation is manageable with a priority on maintaining patient safety.

A basic principle associated with transferring a patient using a mechanical lift A. Lock the base lever in open position when moving the mechanical lift B. Keep the wheels of the mechanical lift locked throughout the transfer C. Ensure that the patient's feet are protected during the transfer D. Raise the lift so that the patient is 6 inches off the mattress

Correct AnswerC. Ensure that the patient's feet are protected during the transfer Explanation(a) The width of these depends on the configuration of the bed, objects in the room, and the ultimate destination. The base usually is locked open when lifting or lowering the patient and locked closed when moving the lift. (b) The wheels must be unlocked to move the lift from under the bed to its ultimate destination(c) The legs dangle from the sling and therefore may drag across the linens or hit other objects if not protected. (d) This is unsafe. The life should raise the patient high enough to clear the surface of the bed.

What should the nurse do to quickly assess a patient's tolerance to a change in position when transferring the patient from a bed to a wheelchair? A. Take the patient's blood pressure B. Monitor the patient for bradycardia C. Establish whether or not the patient feels dizzy D. Allow the patient time to adjust to the change in position

Correct AnswerC. Establish whether or not the patient feels dizzy Explanation(a) Although a blood pressure reading may indicate the presence of hypotension, the blood pressure should be obtained before and after a transfer to allow a comparison to conclude that the hypotension is orthostatic hypotension. (b) If the patient is experiencing orthostatic hypotension, the heart rate will increase, not decrease(c) Feeling dizzy is a subjective adaptation to orthostatic hypotension. Obtaining feedback from the patient provides a quick evaluation of the patient's response to the transfer. (d) This is not an assessment. This is a safe intervention for a patient who is experiencing orthostatic hypotension

When a patient with hemiparesis uses a cane, the nurse needs to teach the patient to: A. Advance up a step with the weak leg first followed by the strong leg and cane B. Adjust the can height 12 inches lower than the waist C. Hold the cane in the strong hand when walking D. Look at the feet when walkng

Correct AnswerC. Hold the cane in the strong hand when walking Explanation(a) The unaffected leg should be advanced first because the weight of the body is lifted to the next step on the leg with the greatest strength. (b) With the tip of the cane placed 6 inches lateral to the foot, the handle should be at the level of the patient's greater trochanter to ensure that the elbow will be flexed 15 to 30 degrees when using the cane(c) A cane is a hand-gripped assistive device; therefore, the hand opposite to the hemiparesis should hold the cane. Exercises can strengthen the flexor and extensor muscles of the arms and the muscles that dorsiflex the wrist. (d) This will cause flexion of the neck, hips, or waist that will move the center of gravity outside the line of gravity. Proper body alignment (posture) is essential for balance, stability, and safe ambulation.

When raising a patient from a hospital Bed , the bed should be in A. Its lowest position B. Half way raised C. Its highest position D. Any of the above

Correct AnswerC. Its highest position Explanation When raising a patient from a hospital bed, it is important to have the bed in its highest position. This allows for easier access to the patient and provides better leverage for the caregiver when lifting. Having the bed at its highest position also helps to prevent strain or injury to the caregiver's back and ensures the patient's safety during the transfer. Therefore, raising the bed to its highest position is the correct choice in this scenario.

Smallest of all the microorganisms; CANNOT be treated with antibiotics. A. Bacteria B. Microorganisms C. Virus

Correct AnswerC. Virus ExplanationViruses are the smallest of all microorganisms and cannot be treated with antibiotics because they are not living organisms. Antibiotics work by targeting the cellular processes of bacteria, which are living organisms. Viruses, on the other hand, are parasitic particles that require a host cell to replicate and survive. Due to their unique structure and replication process, antibiotics are ineffective against viruses.

In humans, which of the following is not a common portals of exit or escape routes: A. Respiratory tract B. Gastrointestinal tract C. Genitourinary tract D. Breaks in the skin E. Muscular system

Correct AnswerE. Muscular system ExplanationThe muscular system is not a common portal of exit or escape route for pathogens in humans. Pathogens typically exit the body through the respiratory tract, gastrointestinal tract, genitourinary tract, or breaks in the skin. The muscular system is responsible for movement and does not provide a direct pathway for pathogens to exit the body.

Signs of Tb: A. Productive cough greater than 2 weeks B. Extreme weight loss C. Persistent fever D. Night sweats E. Bloody sputum F. All the above

Correct AnswerF. All the above ExplanationThe given answer, "all the above," is correct because all of the mentioned signs - productive cough greater than 2 weeks, extreme weight loss, persistent fever, night sweats, and bloody sputum - are indicative of tuberculosis (TB). These symptoms are commonly associated with TB and are important diagnostic criteria for the disease.

Infections that can be spread to other people are called ___________________.

Correct Answercontagious ExplanationInfections that can be spread to other people are called contagious. This means that the infection can be easily transmitted from one person to another through various means such as direct contact, airborne particles, or contaminated surfaces. Contagious infections pose a higher risk of spreading and can result in outbreaks or epidemics if not properly controlled or treated. It is important to take necessary precautions and practice good hygiene to prevent the spread of contagious infections.

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: A. Keep splashes on the sterile field to a minimum. B. Cover the nose and mouth with gloved hands if a sneeze is imminent. C. Use forceps soaked in a disinfectant. D. Consider the outer 1 inch of the sterile field as contaminated.

D. Consider the outer 1 inch of the sterile fielda s contaminated

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? A. Place the bottle cap on the table with the edges down. B. Hold the bottle inside the edge of the sterile field. C. Hold the bottle with the label side opposite the palm of the hand. D. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

D. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? A. Imbalanced Nutrition: More Than Body Requirements related to immobility B. Impaired Physical Mobility related to pain and discomfort C. Chronic Pain related to immobility D. Risk for Infection related to altered skin integrity

D. Risk for Infection related to altered skin integrity

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? A. Only patients with diagnosed infections B. Only patients with visible blood, body fluids, or sweat C. Only patients with nonintact skin D. All patients receiving care in hospitals

D. all patients receiving care in hospitals

1. A nurse should wear a facemask within 3 to 6 feet of a hospitalized patient receiving _________ precautions for an infection.

DROPLET

According to the body mechanics guidelines, what is the first thing you should do when starting body mechanics with a patient? Get in the proper stance Put the patient as close to you as possible Determine how much help the patient needs to move Try to lift the patient alone to see how heavy they are

Determine how much help the patient needs to move

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, and nausea and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities Answer: 2

Explanation: Fever, malaise, anorexia, and nausea and vomiting are symptoms of a systemic infection.

TRUE OR FALSE 1. Vancomycin-resistant Enterococcus (VRE) is the most frequently isolated source of health care--associated infections in the United States.

FALSE

Which muscles should be used when lifting patients? Large arm muscles Large back muscles Large leg muscles Large stomach muscles

Large leg muscles

What part(s) of the body can be bent when lifting patients? Back and legs only Back and hips only Legs and hips only Legs only

Legs and hips only

1. The primary vector in North America that is responsible for transmitting several types of viruses that cause encephalitis is the _______________.

MOSQUITOS

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation? a. Wait a few minutes and then continue the move to the chair. b. Call for assistance and continue the move with the help of another nurse. c. Lower the patient back to the side of the bed and pivot her back into bed. d. Have the patient sit down on the bed and dangle her feet before moving.

c. Lower the patient back to the side of the bed and pivot her back into bed.

TRUE OR FALSE The first tier of isolation guidelines, called standard precautions, is designed for the care of all patients in the hospital and is the primary strategy for preventing health care--associated infections.

TRUE

Ambulation prevents _____, which is when muscles, tendons and ligaments shorten and become hard due to a loss of elasticity, leading to joint deformity. muscle weakness joint overextension contractures contractions

contractures

A 49-year-old who injured his spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for him correctly tells the aide not to place him in which position? a. Side-lying b. Fowler's c. Sims' d. Prone

d. Prone

Intravenous administration A. Deltoid B. 0.1 ml C. 20 seconds D. Implants

The correct answer is C. 20 seconds. This suggests that the given information, such as "intravenous administration," "deltoid," "0.1 ml," and "implants," is irrelevant to the answer. The only relevant information is the time duration of 20 seconds.

What is the term for the break down of skin tissue due to lack of oxygen supply? contracture decubitus ulcer constipation orthostatic hypotension

decubitus ulcer

________ occurs as a result of fluid retention in the lungs due to the chest muscles getting weak. orthostatic hypotension muscle weakness contractures hypostatic pneumonia

hypostatic pneumonia

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur.

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. Support weight on stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Do not use the cane to rise from a sitting position, as this is unsafe.

a. Support weight on stronger leg and cane and advance weaker foot forward.

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. A. The nurse removes all jewelry including a platinum wedding band. B. The nurse washes hands to one inch above the wrists. C. The nurse uses approximately two teaspoons of liquid soap. D. The nurse keeps hands higher than elbows when placing under faucet. E. The nurse uses friction motion when washing for at least 15 seconds. F. The nurse rinses thoroughly with water flowing toward fingertips.

all except D (keeping hands higher than elbows under faucet; dirty water would run down your arms) and A

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? a. Supination b. Dorsiflexion c. Hyperextension d. Abduction

b. Dorsiflexion

A nurse is caring for an 82-year-old woman in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation

b. Urinary stasis

A nurse is caring for a 73-year-old male patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. Lateral position c. Fowler's position d. Sims' position

c. Fowler's position

Which of the following is an effect of mobility? increased peristalsis poor circulation constipation low blood pressure

increased peristalsis

Which is a potential problem associated with the supine position? A. Flexion on the knees B. Pressure on the heels C. Pressure on the trochanters D. Internal rotation of the hips

orrect Answer B. Pressure on the heels Explanation(a) the knees are extended, not flexed, when in a supine position, (b) the supine position is a back-lying position that results in pressure in the heels (calcaneus), which have minimal tissue between the bone and skin, making them vulnerable to the development of pressure ulcers. (c) There is no pressure on either greater trochanter when in the supine position. Pressure on the greater trochanter occurs when the patient is in a lateral (side-lying) position. (d) External rotation, not internal rotation, of the hips tends to occur when a patient is in the supine position.

The process used to kill microbes and their spores. A. Antiseptics B. Sterilization C. Asepsis

orrect Answer B. Sterilization ExplanationSterilization refers to the process of killing microbes and their spores. It is a method used to completely eliminate all forms of life, including bacteria, viruses, and fungi. This process is commonly used in medical and laboratory settings to ensure the complete elimination of harmful microorganisms. Antiseptics, on the other hand, are substances used to kill or inhibit the growth of microorganisms on living tissues, while asepsis refers to the absence of harmful microorganisms. Therefore, sterilization is the most appropriate term to describe the process of killing microbes and their spores

_____ is body orientation and helps to maintain the correct curvature of the vertebral column. positioning range of motion stretching ambulation

positioning

Which body mechanics technique moves joints through the entire area through which they allow movement? range of motion positioning stretching ambulation

range of motion

What does the term 'body mechanics' mean? the movement of muscles and bones to change posture and create motion working on the body to fix what is wrong only movement of the joints to walk development of contractures to allow for movement

the movement of muscles and bones to change posture and create motion