Exam 4 Nursing 1

A client with psoriasis tells the nurse, "I finally found a remedy online that will cure my psoriasis." What is the appropriate nursing response?

"Advertised remedies that promise a cure may be a scam."

The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states which of the following?

"I do not need to wash my hands if I am using gloves."

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is

"I will set up your bath for you. I will come back and help you with your back."

Dehiscence

A separation of layers, usually of a surgical incision

An acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire code system and notify the appropriate person.

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

Adolescents

Which type of mobility aids would be most appropriate for a client who has poor balance?

A cane with four prongs on the end (quad cane)

hematoma

A localized swelling filled with blood

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which of the following clients?

An 84-year-old male with four recent driving violations

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse would recognize which of the following patients as being particularly susceptible to impaired wound healing?

An obese woman with a history of type 1 diabetes mellitus

bandage

Any material used to hold a dressing in place

A nurse visits an elderly client at home and assesses the safety of the client's environment. Which of the following articles can be a threat to the client's safety?

Area rugs kept on the stairs without carpet

Which of the following statements about glove use and hand hygiene is true?

Artificial fingernails should not be worn by staff involved in direct patient care.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

Assess both eyes for contact lenses.

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A. A 4-month-old infant who is unable to roll over B. A 6-month-old infant who is unable to hold his head up himself C. An 11-month-old infant who cannot walk unassisted D. An 18-month-old toddler who cannot jump

B

A nurse is explaining the need for bathing to an elderly client who has been avoiding her daily bath. Which of the following benefits of bathing should the nurse explain to the client?

Bathing reduces the possibility of infection.

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering room

The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering the client?s room

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development?

Braden scale

patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? A. Pain B. Impaired Skin Integrity C.Disturbed Body Image D. Disturbed Thought Processes

C

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. A. Notify the health care provider of the situation. B. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. C. Place the patient in the low Fowler's position.

C, B, A

The nurse is caring for a patient with human immunodeficiency virus (HIV). The patient currently has no signs or symptoms of the disease, but the nurse teaches the patient she may transmit this disease to another person. What term is used to describe an individual who is asymptomatic but can transmit the disease?

Carrier

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which of the following?

Client will participate in self-care measures by the end of the week.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

Skin with deep red maroon or purple discoloration that is non blanchable

Deep tissue injury

An acute medicine unit of a hospital currently has a number of patients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following measures should the nursing staff prioritize in preventing the spread of MRSA to patients who are currently MRSA-negative?

Diligent handwashing practices

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

Discard the sterile field and the supplies and start over.

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

Do you experience incontinence??

A nurse enters a patient's room and finds that the patient has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this patient?

Document the incident, assessment, and interventions in the patient's medical record

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment?

Encourage exercise that improves balance and muscle strength

The nurse is planning hygiene care for a client with self-care bathing deficit related to weakness. Which nursing intervention is appropriate?

Encourage the client to wash own face and hands.

Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges

Eschar

In order to maintain a healthy and hygienic integumentary system, a nurse is clipping the overgrown nails of an elderly client. Which other part should the nurse check to maintain the hygiene of the client's integumentary system?

Hair

Which nursing action is a component of medical asepsis?

Handwashing after removing gloves

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

Hold sterile objects above waist level to prevent inadvertent contamination.

Which of the following is a recommended guideline for maintaining a sterile field?

If the patient touches the sterile field, you should discard the supplies and prepare a new sterile field.

The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?

In a bag marked ?biohazards?

When the nurse cleanses the client's leg during a bed bath, it will allow for

Increased circulation

During range-of-motion exercises, the nurse turns the sole of a patient's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions?

Inversion and eversion of the ankle

A nurse working in a long-term care facility institutes interventions to prevent falls in the elderly population. Which intervention would be an appropriate alternative to the use of restraints for ensuring patient safety and preventing falls?

Involve family members in the patient's care.

When educating parents of preschoolers, what is most important to include in your presentation?

Keep chemicals in a locked cabinet

A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

What best describes the nurse's role in disaster preparedness?

Multiple roles including triage and the distribution of resources

The nurse observes the client for signs of Stage I pressure ulcer development, which is most likely to include which finding?

Nonblanchable redness

patient has been recently admitted to the hospital unit following a suspected stroke and a family member states that the patient's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the patient's lenses after removal?

Normal saline

During morning care, the nurse notices a glasslike appearance to the patient's eyes and prepares to perform eye care. What solution should the nurse use to perform basic eye care to remove the excessive secretions related to illness?

Normal saline solution

Which of the following is one of the most important benefits of a nurse helping with bathing?

Nurse-patient relationships are facilitated.

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What should the nurse do?

Open a new sterile dressing kit

A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of which of the following?

Pediculosis

When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. Which of the following is the appropriate action by the nurse?

Perform hand hygiene after removing the glove

The nurse is caring for a client with a latex sensitivity. Which of the following resources would be the most appropriate for the nurse to access when developing the client's plan of care?

Policy for clients with latex sensitivity

The nurse educator has just completed a lecture regarding the elderly and hazards in the home. The nurse educator recognizes that teaching was effective when the students state that common dangers in the home setting of an elderly adult include which of the following?

Polypharmacy and use of multiple extension cords

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Pour the liquid into a sterile container within the sterile field.

Which of the following is an indication for the use of negative pressure wound therapy?

Pressure ulcers

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

Providing a backrub before bed

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

A nurse is shaving a male client's face. Which should the nurse do?

Pull the skin taut and shave in the direction of hair growth using short strokes.

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following?

Recapping a needle

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

The nurse on a medical surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. Which of the following should be the nurse's first action?

Remove the client from the room.

A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action?

Removing dead or infected tissue to promote wound healing

The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action?

Repeat or read back the order.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which of the following drainage types should the nurse document?

Serosanguineous (Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color)

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which of the following stages should the nurse assign to this client's wound?

Stage 3 -Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, or muscle should be seen.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse?

Stop and obtain appropriate PPE

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline?

Store dentures in cold water when not in use.

A nurse is explaining the use and handling of dentures to an elderly client. Which of the following measures should the nurse mention to the client?

Store the dentures in water in a covered cup.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?

The importance of consistent seat belt use

A client's surgical wound dehisced when a nurse removed the staples before a health care provider prescription was given. Following root cause analysis, which organizational response is appropriate? Select all that apply.

The nurse will be found to have committed a human error. Systems around the documentation of prescriptions will be reviewed.

A team of inner city school nurses attends a community conference on child safety during the summer months. Which of the following would be the priority health outcome that these nurses would expect to achieve in summer school?

The students will demonstrate proper use of safety equipment while playing sports.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Disinfectants are used

To clean rooms between clients

You are caring for a female patient who is unconscious. You should pay special attention to cleaning which of the following areas of the body?

Underneath the breasts and in between skin folds

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should

Understand that his culture may influence his hygiene and ask him his preference

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers.

Which of the following modifications to bathing should be implemented for a patient who is incontinent?

Use special perineal skin cleaners and moisture barriers.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Vomiting Drowsiness Headache

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH-balanced soap.

A nurse who has finished cleansing and dressing the wound of a young client now needs to change the dressings of a client in the burn unit. Which of the following actions should the nurse perform, keeping in mind the importance of asepsis and client comfort?

Wash hands thoroughly and then wear sterile gloves

Which action should the nurse perform first after an exposure to a client's body fluids?

Wash the exposed area with soap and water

When is hand hygiene with an alcohol-based rub appropriate as opposed to using handwashing?

When hands are not visibly soiled

A nurse is providing perineal care for a female patient who has a decreased level of consciousness. Which of the following techniques should the nurse employ when providing this care?

Wipe from the pubic area toward the anal area.

A nurse is caring for a patient with long hair. The patient asks if something could be done about her hair to be more comfortable. How would the nurse respond?

Yes, I can braid it for you if you want me to."

Eschar

a thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

When providing oral care, what does the nurse recognize as the most important component of the oral care process?

a thorough, mechanical cleaning

paralysis

absence of strength secondary to nervous impairment

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

airborne precautions droplet precautions contact precautions

A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus?

alcohol consumption and smoking

Dressing offers effective protection for packing wounds and absorb excess liquid

alginate dressing

A woman is being treated for breast cancer with 5-FU and cisplatin in large doses. She should expect:

alopecia.

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

debridement

cleaning away devitalized tissue and foreign matter from a wound

Dressing acts as scaffolding for new cells to grow and can be highly effective for chronic wounds

collagen

abcess

collection of pus

range of motion

complete extent of movement of which a joint is normally capable

footdrop

complication resulting from extended plantar flexion

scar

connective tissue that fills a wound area

necrosis

death of cells, tissues, or organs

Atrophy

decrease in the size of a body structure

Flaccidity

decreased muscle tone; synonym for hypotonicity

ischemia

deficiency of blood in a particular area

desiccation

dehydration; the process of being rendered free from moisture

safety event report

documentation describing any injury or potential for injury suffered by a patient in a health care agency

intimate partner violence (IPV)

domestic violence or battering between two people in a close relationship

isometric exercise

exercise in which muscle tension occurs without a significant change in muscle length

isokinetic exercise

exercise involving muscle contractions with resistance varying at a constant rate

Pressure injuries take time to develop

false

exudate

fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells

Dressing that absorbs exudate from the wounds surface, creating an environment that promotes faster healing

foam

shear

force created when layers of tissue move on one another

wound bed that has pink or beefy red tissue with a shiny, moist grainy appearance

granulating tissue

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection?

handwashing

A child is learning to ride a bicycle. He should be instructed to use which of the following protective devices?

helmet

The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention?

hot water heater thermostat set at 130 degrees F (54.4 degrees C)

Non breathable dressing that are self adhesive and used on burns, wounds that are emittting liquid, necrotic wounds

hydrocolloid

Dressing used for a range of wounds that are leaking little or no fluid and are painful or necrotic wounds

hydrogel

Paresis

impaired muscle strength or weakness

spasiticity

increased muscle tone

passive exercise

manual or mechanical means of moving the joints

serosanguineous drainage

mixture of serum and red blood cells. light pink to blood tinged

isotonic exercise

movement in which muscles shorten (contract) and move

Health care workers may be exposed to a common occupational injury such as:

needle stick

granulation tissue

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

tonus

normal, partially steady state of muscle contraction

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

chemical emergency

occurs when a hazardous chemical has been released and the release has the potential to harm people's health

friction

occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?

one that remains in the client's room

dressing

protective covering placed over a wound

evisceration

protrusion of viscera through an incision

erythema

redness of the skin

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

The most common site for pressure ulcers in ICU patients are

sacrum and heels

A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is

semen

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk?

shearing force

maceration

softening through liquid; overhydration

Pressure injury is characterized by superficial reddening of the skin

stage 1

Pressure injury with partial thickness loss of dermis presenting as a shallow red pink wound bed

stage 2

epithelialization

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink

The nurse has been teaching the client about how to use a walker safely. The nurse knows the teaching has been effective when the client:

steps into the walker when walking.

Asphyxiation

stoppage of breathing or the lack of air reaching the lungs; synonym for suffocation

Epidermis

superficial layer of the skin

Biofilm

thick group of microorganisms

A strong correlation exists between poor nutrition and the development of pressure ulcers

true

Pressure ulcers are caused by unrelieved compression of the skin that results in damage to underlying tissues.

true

Shearing occurs when the skeleton and tissues slide while the skin remains still

true

subcutaneous tissue

underlying layer that anchors the skin layers to the underlying tissues of the body

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

You are caring for a patient who has an infection spread by respiratory droplets and is in Droplet Precautions. The patient asks, "Can my spouse visit me?" Which of the following responses is correct?

"Yes, as long as your spouse wears a mask and stays at least 3 feet away from you."

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?

/inform the UAP that she should be wearing gloves.

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

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? A.Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. B. Draw the shape of the wound and describe how deep it appears in centimeters. C. Gently insert a sterile applicator into the wound and move it in a clockwise direction. D. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

A

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? A. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. B. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. C. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. D. Children older than 6 years may be restrained using a car seat belt in the back seat.

A

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A. Carefully assessing the patient care environment B. Using two nurses to lift a patient who cannot assist C. Wearing a back belt to perform routine duties D. Properly documenting the patient lift

A

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? A. Document the findings and continue to monitor the patient. B. Administer antipyretics, as prescribed. C. Increase the frequency of assessment to every hour and notify the patient's primary care provider. D. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

A

When a fire occurs in a patient's room, what would be the nurse's priority action? A.Rescue the patient. B. Extinguish the fire. C. Sound the alarm. D. Run for help.

A

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

A commercially packaged surgical item is not considered sterile if past expiration date.

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces?

A patient sitting in a chair who slides down

For which of the following patients is foot care likely the highest priority?

A patient who is obese and has a diagnosis of type 1 diabetes

You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately?

A sterile, flexible applicator moistened with saline

Disaster

A sudden catastrophic event in which people are injured and killed and property is destroyed

Which of the following does the nurse recognize as the most important component of the oral care process when providing oral care?

A thorough mechanical cleaning

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. A. Serous drainage is composed of the clear portion of the blood and serous membranes. B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. C. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. D. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. E. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. F.Serosanguineous drainage can be dark yellow or green depending on the causative organism.

A, B, C, D

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. A. Use standard precautions or transmission-based precautions when indicated. B.Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. C. Clean the wound in full or half circles beginning on the outside and working toward the center. D. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. E. Clean to at least 1 in beyond the end of the new dressing if one is being applied. F. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

A, B, E

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. A. Hemostasis occurs immediately after the initial injury. B. A liquid called exudate is formed during the proliferation phase. C. White blood cells move to the wound in the inflammatory phase. D. Granulation tissue forms in the inflammatory phase. E. During the inflammatory phase, the patient has generalized body response. F. A scar forms during the proliferation phase.

A, C, E

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. A. Enhanced healing due to the presence of sugars and proteins B. Delayed healing due to dead tissue present in the wound C. Decreased effectiveness of antibiotics against the bacteria D. Impaired skin integrity due to overhydration of the cells of the wound E. Delayed healing due to cells dehydrating and dying F.ecreased effectiveness of the patient's normal immune process

A, C, E

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. A. Stop performing the exercises. B. Decrease the number of repetitions performed. C.Reevaluate the nursing care plan. D. Move to the patient's other side to perform exercises. E.Encourage the patient to finish the exercises and then rest. F. Assess the patient for other symptoms.

A, C, F

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. A. Instruct the patient to avoid sudden position changes that may cause dizziness. B.Recommend that the patient restrict fluid until after exercising is finished. C. Instruct the patient to push a little further beyond fatigue each session. D.Instruct the patient to avoid exercising in very cold or very hot temperatures. E. Encourage the patient to modify exercise if weak or ill. F.Recommend that the patient consume a high-carb, low-protein diet.

A, D

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The oncoming nurse receives in report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development?

Albumin 2.8 mg/dL

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

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

A nurse making a home visit for a client living in a high-crime area observes that the apartment building does not have outside lighting. The nurse understands this is an important assessment for which reason?

Assessment includes risk factors in the home including individual risk and unsafe environment

An 18-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following?

Automobile accidents

A nurse is caring for a patient 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

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

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A. 2 B. 4 C. 5 D. 6

B

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? A. Use the axillae to bear body weight. B. Keep elbows close to the sides of the body. C. When rising, extend the uninjured leg to prevent weight bearing. D. To climb stairs, place weight on affected leg first.

B

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

B

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? A. The nurse positions a patient in a supine position prior to applying wrist restraints. B. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. C. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. D. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

B

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? A. Irrigate the wound. B. Provide gentle cleansing of the wound. C. Debride the wound. D .Change the dressing frequently.

B

a nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. A. The patient takes time to think about responses to questions. B. The patient is 86 years old. C. The patient reports inability to control urine. D. The patient is scheduled for a hip arthroplasty. E. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). F. The patient reports increased pain in right hip when repositioning in bed or chair.

B, C, D, F

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A. Do full-body pushups in bed six to eight times daily. B.Breathe in and out smoothly during quadriceps drills. C. Place the bed in the lowest position or use a footstool for dangling. D. Dangle on the side of the bed for 30 to 60 minutes. E. Allow the nurse to bathe the patient completely to prevent fatigue. F. Perform quadriceps two to three times per hour, four to six times a day.

B, C, F

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes?

Breaks in skin integrity and fungal nail infection

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? A. A toddler playing with his 9-year-old brother's construction set B. A 4-year-old eating yogurt for lunch C. An infant covered with a small blanket and asleep in the crib D. A 3-year-old drinking a glass of juice

C

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 is the appropriate nursing action? 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

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? A. Have the patient extend his arms outward and cross his legs on top of a pillow. B. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. C. Have the patient cross his arms on his chest and place a pillow between his knees. D.Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

C

A nurse is caring for a 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

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? A. "I can expect to have more discomfort in the area where the cold is applied." B. "I should expect more drainage from the incision after the ice has been in place." C. "I should see less swelling and redness with the cold treatment." D. "My incision may bleed more when the ice is first applied."

C

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? A. The therapy is used to collect excess blood loss and prevent the formation of a scab. B. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. C. The therapy provides a moist environment and stimulates blood flow to the wound. D. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

C

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? A. Impaired gas exchange related to cigarette smoking B. Anxiety related to inability to stop smoking C. Risk for suffocation related to unfamiliarity with fire prevention guidelines D. Deficient knowledge related to lack of follow-through of recommendation to stop smoking

C

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. A. Sixty percent of U.S. fire deaths occur in the home. B. Most fatal fires occur when people are cooking. C. Most people who die in fires die of smoke inhalation. D. Fire-related injury and death have declined due to the availability and use of smoke alarms. E. Fires are more likely to occur in homes without electricity or gas. F. Fires are less likely to spread if bedroom doors are kept open when sleeping.

C, D, E

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? A. Keeping the head of the bed elevated as often as possible B. Massaging over bony prominences C. Repositioning bed-bound patients every 4 hours D. Using a mild cleansing agent when cleansing the skin

D

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? A. The nurse includes suggestions on how to prevent the incident from recurring. B. The nurse provides minimal information about the incident. C. The nurse discusses the details with the patient before documenting them. D. The nurse records the circumstances and effect on the patient in the medical record.

D

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response? A. Administer activated charcoal in tablet form and take child to the ED. B. Administer syrup of ipecac and take child to the ED. C. Bring the child into the primary care provider for gastric lavage. D. Call the PCC immediately before attempting any home remedy.

D

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? A. Using sterile dressing supplies B. Suggesting dietary supplements C. Applying antibiotic ointment D. Performing careful hand hygiene

D

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? A. Side-lying B. Fowler's C. Sims' D. Prone

D

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? A. Sitting him in a geriatric chair near the nurses' station B. Using the sheets to secure him snugly in his bed C. Keeping the bed in the high position D. Identifying his door with his picture and a balloon

D

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? A. Checking to make sure fire alarms are working properly. B. Preventing exposure to temperature extremes. C. Screening for partner or elder abuse. D. Making sure patient rooms are decluttered.

D

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused? A. They prevent confused patients from wandering. B. A history of a previous fall from a bed with raised side rails is insignificant. C. Alternative measures are ineffective to prevent wandering. D. A person of small stature is at increased risk for injury from entrapment.

D

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? A. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. B. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. C. Even small doses of radiation result in bone marrow depression and cancer. D. BLI is a serious consequence following detonation of an explosive device.

D

nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? A. Explain how to use the telephone. B. Introduce the patient to her roommate. C. Review the hospital policy on visiting hours. D. Explain how to operate the call bell.

D

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply an emollient as indicated.

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first?

Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."

A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. How should the nurse record the findings in the client's medical record?

Gingivitis

A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?

Help me understand your perspective about vaccinating."

The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select?

Hydrocolloid- The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement.-Telfa pads are non stick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

To eliminate needlesticks as potential hazards to nurses, the nurse should

Immediately deposit uncapped needles into puncture-proof plastic container

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning?

Keep cleaning solutions locked up.

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?

Keep hair off the face and wash hair daily.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

Launder gowns, linens, and towels separate from other clients' items

A school nurse is conducting a teaching session for the parents of elementary students. She is discussing the topic of head lice. Why is this age group more susceptible to transmission of head lice than other groups?

Lice are transmitted by head-to-head contact during play and by sharing of personal items.

Logrolling requires the nurse to use supportive devices in turning the client to

Maintain the natural alignment of the body

A school nurse is conducting a safety seminar with 6th-grade students. Which of the following teaching points is most important?

Make sure that you have smoke detectors in your house and that they're in working order."

The nurse would recognize which of these devices as an open drainage system?

Penrose drain A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.

Which of the following health problems is most clearly suggestive of a history of inadequate dental care?

Periodontitis

A nurse is preparing discharge teaching for a client being discharged with a newborn baby. What is the highest priority item that must be included in the teaching plan?

Restrain the baby in a car seat.

The nurse is performing range-of-motion exercises on a patient's arm. The nurse starts by lifting the arm forward to above the head of the patient. Which action would the nurse perform next?

Return the arm to the starting position at the side of the body.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?

Review the current infection control protocols.

After changing the bed linens for a client, the nurse uses an alcohol-based handrub to perform hand antisepsis. What is the proper way to use an alcohol-based handrub?

Rub the product between the hands until they are dry

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents?

Teaching nurses how to prevent falls

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's injury.

A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?

The nurse is caring for a client with a C. difficile infection.

outine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. The client is surprised at this finding, since he enjoys generally robust health. What should the client's nurse teach him about this diagnostic finding?

This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick."

A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room?

Thorough handwashing

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

Toothbrush Toothpaste Emesis basin Towel Disposable gloves

An unstageable pressure injury cannot be staged until enough slough or eschar is removed to expose the base of the wound

True

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

Use a sterile cotton-tipped applicator to apply the prescription to the site

the acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?

Your wound will heal slowly as granulation tissue forms and fills the wound."

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

restraint

a physical or chemical way to restrict voluntary movement or behavior

A nurse is caring for elderly clients. Which of the following is the most important safety issue in older clients?

accidental falls

poison control center

agency that handles poison exposure and provides poison prevention teaching to the general population

Which of the following medications do not contribute to pressure injuries

antibiotics

elder abuse

any knowing, intentional, or negligent act by a caregiver or any other person to an older adult; the act causes harm or serious risk of harm

The nurse performs neurological checks every 2 hours on a client who experienced an ischemic stroke. The nurse determines the client's neurological status is deteriorating. Which nursing action best prevents an adverse outcome in this client's care?

assessing the client's neurological status more frequently than prescribed

When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for

assessment of tissues

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. A. patient who is older than 50 B. patient who has already fallen twice C. patient who is taking antibiotics D. patient who experiences postural hypotension E. patient who is experiencing nausea from chemotherapy F. 70-year-old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: A. Grasp the gait belt. B.Stay with the patient and call for help. C.Place feet wide apart with one foot in front. D. Gently slide patient down to the floor, protecting her head. E. Pull the weight of the patient backward against your body. F. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b

serous drainage

composed of clear, serous portion of the blood and from serous membranes

purulent drainage

comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

The nurse is caring for a client with acute viral conjunctivitis. Which precautions will the nurse begin?

contact

sanguineous drainage

containing or mixed with blood

what is a common cause of underlying tissue not receiving an adequate blood supply

continuous pressure

The nurse is preparing to administer medication to a client. Which validation of client information is appropriate?

full name and date of birth

which of the following is NOT a term for a pressure ulcer

incontinence associated dermatitis

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increase circulation

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?

indwelling catheter

wound

injury that results in a disruption in the normal continuity of a body tissue

Nuclear terrorism

intentional dispersal of radioactive materials into the environment for the purpose of causing injury and death

active exercise

joint movement activated by the person

pressure injury

localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device

culture of safety

organizational environment where "core values and behaviors resulting from a collective and sustained commitment by organizational leadership, management, and workers emphasize safety over competing goals"

Contractures

permanently contracted state of a muscle

A client who has been staying at a health care facility for 2 months develops corns on his feet. A corn is a kind of inflammation on the feet. To which of the following people should the nurse send the client for relief?

podiatrist

patient care ergonomics

practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care

negative pressure wound therapy

promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria, and removal of excess fluid, while providing a moist wound healing environment

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

stage 2 -A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater.

Pressure injury involves the full thickness of the skin extending into the subcutaneous tissue

stage 3

orthopedics

the correction or prevention of deformities of the skeleton

Bioterrorism

the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic

Dermis

the layer of skin below the epidermis

Ergonomics

the practice of designing equipment and work tasks to conform to the capability of the worker

cyber terror

the use of high-tech means to disable or delete critical electronic infrastructure data or information

bullying

the use of threats or physical force to intimidate and control another person