Exam 1 -171 review

A nurse is preparing to administer an intramuscular injection at the ventral gluteal site. Which of the following needle lengths should the nurse select for an adult of an average size

1 1/2 in

A nurse is obtaining health history from a client who has cost me. The client reports frequent episodes of loose stools over the last month but has no signs of infection orbowel obstruction. The client tell the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following to the nurse recommend

Consume foods that are low in fiber content

Which of the following actions should the nurse take after witnessing a breach of Client confidentiality in a providers office?

Complete a health information privacy complaint form

Which of the following is an example of a best practice strategy to prevent fraud, waste, and abuse?

Establish procedures for maintaining and distributing medication samples

A nurse is providing teaching to an assistive personnel about the use of sterile gloves. Which of the following instructions regarding the open gloving method should the nurse give

Grasp only the inside of the glove with your ungloved hand

Which of the following pieces of legislation mandated the establishment of the joint healthcare fraud and abuse control program

Health insurance portability and accountability act

Well opening a sterile pack which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack?

Holding the steroid pack below waist or table level

A nurse over here's a provider refer a client who has Medicare to a durable medical equipment company owned by the providers father-in-law. The nurse should identify that which of the following statues has been violated?

Starks law

Which of the following methods of information exchange can occur without client authorization?

Walking around that involve two nurses discussing in a signed client at the clients bedside in a private room

A nurse is administering an enema medicated with sodium polystyrene sulfonate To an adult client who has hyper kalemia. To which of the following link to the nurse insert the rectal tube

7.5 cm to 10 cm or 3 to 4 inches

A nurse is caring for a group of newly admitted clients for which of the following clients are the nurse expect to receive a prescription for urinary catheterization

A client who is in the ICU for gastrointestinal bleed

A nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field?

A cotton ball dampened with sterile normal Celine is placed on the field, the nurse turns to address the clients question concerning the procedure, the procedure is postponed for 30 minutes to accommodate the client

A nurse is about to irrigate her clients open wound. Besides gloves, which of the following personal Protective equipment should the nurse wear?

A face shield

A nurse is assessing a client and dwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake which of the following actions should the nurse take first

Check the catheter for kinks

A nurse is caring for a client who has a healthcare associated infection HAI. Which of the following describes an exogenous HAI?

A salmonella infection that occurs after eating contaminated food from the cafeteria

A nurse obtained the capillary blood glucose results of 180 mg per DL from a client has diabetes Molite us which of the following actions should the nurse take

Administer insulin according to the patient sliding scale orders

A nurse is providing perineal care for a female client was in a dwelling urinary catheter. Which of the following areas should the nurse cleans last

Anus

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations

At least 30 minutes

A nurse is preparing to answer in and dwelling urinary catheter for a client which of the following actions should the nurse instructed client to reform during the insertion procedure

Bear down

A nurse is preparing to remove a clients indwelling urinary catheter. Which of the following actions should the nurse take?

Deflate the balloon completely before removal

What should the nurse do to maintain standard precautions

Disinfect hands immediately after removing gloves

To decontaminate their hands with an alcohol-based Joe, the nurse should rub your hands together until all the Joe has evaporated and their hands are dry. Which of the following is the correct rationale for why hand should be rub together until dry?

Drying provide the full anti-septic affect

The health insurance portability and accountability act mandates that healthcare entities employment which of the following strategies to help reduce the Medicare fee-for-service error rate and prevent payment for potentially fraudulent activity?

Electronic health records

A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal Skin after they have returned home. Which of the following instructions to the nurse include?

Empty the pouch when it is less than half full

A nurse in the emergency department is caring for a client following a motor vehicle crash. The client is unresponsive and the client spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client surgery?

Inform the provider of the spouse's contact information so consent can be obtained over the phone

Which of the following is an advantage of using alcohol-based gel?

It takes less time to use and washing with soap and water

A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse informed the client that which of the following options will allow them to have some control over urinary elimination

Kock's pouch

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take

Leave a space between the penis and sheath portion tip

A nurse is preparing an adult client for an enema. The nurse should assist the client in to which of the following positions

Left lateral with the right leg flexed

A nurse is caring for a client who has a suspended UTI. Which of the following urinalysis results to the nurse identify as a manifestation of a UTI

Leukocyte esterase

A nurse is preparing a male client for intermediate urethral catheterization. Which of the following actions should the nurse take

Lift the penis perpendicular to the body

A nurse is a ministering a return flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take?

Lower the container to allow the solution to flow back out

Well the nurse is a ministering a cleansing enema, the client reports of Abdominal cramping. Which of the following actions should the nurse take?

Lower the enema fluid container

A nurse is teaching a client about home collection of a stool specimen for fecal occult blood testing. Which of the following instruction should the nurse include

Obtain specimens from three different stools

A can't tell the nurse that they feel her privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instructed client to file the complaint?

Office for civil rights

Which of the following agencies of the US government has the authority to exclude individuals in entities from participating in federal healthcare programs?

Office of Inspector General

Which of the following terms indicates that the medication is given via an injection

Parenteral

Which of the following products can affect the permeability of latex gloves?

Petroleum based hand lotion

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take

Place the client and dorsal recumbent position on a bed pan

A nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse to perform the following steps

Position the tray so that the top flap is farthest away from their body, open the flat for this from the body, open the side slabs, open the flap closest to the body

A nurse is teaching a client about collecting stool specimenfor for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period

Poultry

A nurse is teaching a client about extended where skin barriers. Which of the following strategies to the nurse instructed client to use for maximal adherence

Press gently around the barrier for 30 seconds to one minute

A nurse is caring for a client has mycoplasma pneumonia. The client has been placed on droplet precautions. Which of the following actions should the nurse take one caring for the client?

Protect the eyes

Prior to entering the surgical scrub area, which of the following PPE items should a nurse put on

Protective eyewear, hair cover, mask, and shoe covers

A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following technique should the nurse suggest?

Push the skin away from the barrier while removing it

A client who's post operative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas

Return flow

A nurse is caring for a client has stage III pressure injury on a sacral area. Which of the following actions should the nurse take one obtaining a wound culture specimen from the pressure injury

Rotate a sterile swab in the area of drainage

A nurse is preparing to administer an insulin injection to a client. Which of the following actions should the nurse take

Rotate the injection sites

A nurse is collecting a blood specimen for culture from a client which of the following actions should the nurse take

Rub the clients arm at the site prior to Venti puncture

Employee in a providers office suspects fraudulent activity. Which of the following actions should the employee take after contacting the office of Inspector General hotline to report the fraudulent activity?

Stop filing the suspicious bills and claims, Pursue knowledgeable legal counsel, disengage professionally with a suspected perpetrator, report in return over payments.

A group of nurses on a clinical unit are planning to research the incidence of falls among clients falling joint replacement surgery. Which of the following actions should the nurse is take to ensure the study complies with the Hippa privacy rule?

Submit the proposal to the institutional review board for review and describe how they will De-identify client information

A nurse should identify which of the following areas of the hands require a special attention during the pre-scrub wash

The area under each finger nail

An AP is collecting a 24 hour specimen from a client. Which of the following statements by the AP indicates that the specimen collection has to be restarted

The client just told me that they forgot to put the urine in the container

After completing a procedure that required donning personal protective equipment consisting of a gown, an N 95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately?

The gloves

When donning Sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand?

The inner edge of the cuff will lie against the skin and will not be sterile

A nurse is preparing to flush and change the dressing on a client central venous catheter. Which of the following should the nurse identify as a primary purpose for performing this intervention using surgical asepsis

To control the introduction of micro organisms at a catheter site

A nurse should identify that which of the following is the goal of surgical asepsis?

To create and maintain in micro organism free environment

A nurse is preparing to wash their hands prior to surgery. For which of the following reason should the nurse keep their hands above their elbows?

To encourage water and soap to flow away from the clean hands

A nurse is preparing to administer the first of two large volume, cleansing enemas prescribe for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take?

Warm the enema solution prior to installation

A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedures, it is important to take which of the following actions?

Wash for at least 15 seconds

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notice is what appears to be soiled or grime on their hands. Which of the following actions should the nurse take?

Wash their hands with soap and water

A nurse is planning to obtain a urine specimen from a client close urinary system. Identify the correct sequence of steps of the nurse should take

Why is the port with an alcohol swab or agency specified anti-septic, attach a syringe to the collection port of the indwelling catheter, withdraw 3 to 30 mL of urine, transfer the urine to a sterile specimen container, and transport the specimen to the lab

While waiting for a sterile procedure to begin, how should the nurse position their hands and arms?

With hands together in front of the body above waist level

Others caring for a client who has diabetes Molite us is having difficulty obtaining a capillary fingerstick blood sample for point of care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the clients finger?

Wrap the finger in a warm cloth

A nurse and a pediatricians office is speaking on the telephone with the guardian of a school age child who will become a new client at the office. The nurse should instruct the guardian to call the child to previous providers office to request which of the following?

A form authorizing release of copies of the child's medical records to be signed by the guardian

A nurse is caring for a client who needs to collect a midstream urine specimen which of the following actions should the nurse take

Have a client urinate a small amount of urine before starting the collection

A nurse is replacing the ostomy appliance for a client who is newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take?

Cleanse the stoma and the peristomal skin

A newly hired nurse is reviewing information about the Hippa privacy rules during facility orientation. Which of the following statements by the nurse indicates an understanding of the privacy rule

I can give information about a client over the phone if the client gives permission

A nurse is teaching a newly licensed nurse about using a computer to document in the clients health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I should remain aware of my surroundings when documenting in the computer

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following to the nurse assess first

If the client has allergies to the medication

A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestines and rectum. The nurse should reinforce with a client that they are scheduled for which of the following types of ostomy procedures

Ileostomy

Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?

Infectious diarrhea

A nurse caring for a group of clients and an ambulatory care clinic is collecting urine for several prescribe diagnostic test. For which of the following test is a random sample voided into a clean cup appropriate

Routine urinalysis

According to recent estimate which of the following sources of healthcare Waze has the largest financial impact

Unwarranted use a medical resources or services

A nurse is preparing to administer and intradermal injection. Which of the following actions should the nurse take to ensure proper technique

Use a tuberculin syringe with a 5/8 inch, 25 gauge needle

A nurse is providing pre-operative teaching for a client who is scheduled for creation of sigmoid colostomy. Which of the following information should the nurse include in the teaching

Use irrigation to help establish a regular bowel pattern

A nurse is preparing to give an intramuscular injection into the left ventricle gluteal muscle. Which of the following actions should the nurse take to locate the side of injection

Use the heel of the hand and index finger to locate the vastus lateralis muscle