Fundamentals EAQ Questions
A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what? - Double the intake of Vitamin C - Remove loose rugs from the environment - Avoid taking showers until the cast is removed - Increase weight bearing on the injured leg gradually
Remove loose rugs from the environment Loose rugs can interfere with crutch walking and cause a fall; they should be removed to prevent further injury. Calcium rather than vitamin C is encouraged to enhance bone healing; vitamin C minimizes capillary fragility. It is not within the legal role of the nurse to encourage the client to increase the dose of any medication without a healthcare provider's prescription. The client may shower if the cast is protected from becoming wet. Decisions regarding weight bearing are a medical, not a nursing, responsibility.
A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? - Don an N95 respirator mask before entering the room - Put on a permeable gown each time before entering the room - Implement contact precautions and post appropriate signage - After finishing with patient care, remove the gown first and then remove the gloves
Don an N95 respirator mask before entering the room A N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions are required, not contact precautions. When finished with care, gloves should be removed first because they are the most contaminated.
A nurse is caring for a client whose mobility is restricted to a wheelchair following a motor vehicle accident. The client has been prescribed physiotherapy as a part of rehabilitation care. What interventions should the nurse consider when the client is discharged from the healthcare facility? - Focus firmly on the challenges faced by the client - Refrain from including children in the support system - Assist the family in identifying community support systems - Encourage the primary caregiver to set a routine time for respite - Consider the primary caregiver's experience in the discharge plan
Assist the family in identifying community support systems Encourage the primary caregiver to set a routine time for respite Consider the primary caregiver's experience in the discharge plan The nurse should assist the family in identifying support within the community. The family may need assistance with meals, physiotherapy exercises, and care for younger children. The nurse should encourage the primary caregiver to set a routine time for respite. The nurse should consider the primary caregiver's experience and abilities with nursing care while planning client discharge. The nurse should not only focus on the weaknesses and challenges faced by the client, but also the client's strengths. Children should be included in the support system, and the client and family should spend time sharing their stories with each other.
A nurse is changing the dressing of a postoperative client. The nursing assistant informs the nurse that another client has fallen down near the nursing station after losing consciousness. What is the best nursing action in this situation? - Attend to the client who lost consciousness - Delegate the dressing change to the nursing assistant - Delegate the care of the unconscious client to the nursing assistant - Complete the dressing as the open wound may increase infection risk
Attend to the client who lost consciousness Loss of consciousness may pose a threat to the client's safety and survival, and is a high-priority need. Therefore, the nurse should attend to the unconscious client. The nursing assistant may not have the required knowledge and skills to perform a dressing change. The care of an unconscious client may need critical nursing assessments and clinical decision-making, and should not be delegated to the nursing assistant. Risk of infection is not a threat to survival, and is considered an intermediate need.
Which nursing interventions would be beneficial for providing safe oxygen therapy? . - Check tubing for kinks - Run wires under carpeting - Post "no smoking" signs in clients' rooms - Place oxygen tanks flat in the carts when not in use - Make sure the client is familiar with the phrase "stop, drop, and roll"
Check tubing for kinks Post "no smoking" signs in clients' rooms Oxygen tubing should be checked for kinks during oxygen use. "No smoking" signs should be posted in the clients' rooms. Wires should not be kept under carpeting because heat buildup or friction can cause a fire. Oxygen tanks should be placed in an upright position in their carts or flat on floors. Being familiar with the phrase "Stop, drop, and roll" helps to describe when clothing or skin is burning.
When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? - Mask - Clean gloves - Sterile gloves - Shoe covers
Clean gloves Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Mask, sterile gloves, and shoe covers are not required for this situation.
The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? - Airborne precautions - Droplet precautions - Contact precautions - Protective Environment
Contact Precautions Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as methicillin-resistant Staphylococcus aureus (MRSA), stool infected with Clostridium difficile, draining wounds where secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller than 5 mcg, such as measles, chickenpox (varicella), or pulmonary tuberculosis (TB). Droplet precautions are used for droplets larger than 5 mcg and when within 3 feet (0.9 m) of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immune system to protect them from incoming pathogens
A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? - Assess the strength of the affected leg - Explain the transfer procedure step by step - Instruct the client to bear weight evenly on both legs - Encourage the client to keep the affected leg elevated
Explain transfer procedure step by step The client should understand the steps in the transfer to assist appropriately and avoid injury. Assessing strength in the affected leg is not advisable because it may disrupt the repair of the affected hip; also, weight bearing initially is not permitted on the operative leg. Bearing weight on the affected leg is contraindicated initially. The client may touch the floor with the foot of the affected leg, but may not bear weight on the affected leg. Elevating the leg will cause hip flexion, which is contraindicated initially because it may precipitate hip dislocation.
Which positioning should be avoided while assessing a client with a history of asthma? - Sitting - Supine - Dorsal recumbent - Lateral recumbent
Lateral recumbent The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.
A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where? - In the axillae - On the hands - On the right side - On the side the client prefers
On the hands Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side or the side the client prefers.
A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? - Place a surgical mask on the client - Other than standard precautions, no additional precautions are needed - Minimize close physical contact - Cover the client's leg with a blanket
Place a surgical mask over the client Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.
What does the nurse recognize as the reason the faucet handles on the sinks in a client's room are considered contaminated? - They are not in sterile areas - They are touched by dirty hands when turning the water on - There are a large number of people who use them each day - Water encourages bacterial growth
They are touched by dirty hands when turning the water on Unwashed hands are considered contaminated and are used to turn on sink faucets. Recontamination of washed hands may be prevented by using foot pedals or a paper towel barrier when closing the faucets. They are not considered contaminated because they are not in sterile areas; areas cannot be sterile. It is unrelated to the number of people, but rather to being touched by contaminated hands. Although bacterial growth is facilitated in moist environments, this is not why sink faucets are considered contaminated
The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? - Place the client in the semi-Fowler position - Stand behind the client during transfer - Turn the chair so it faces away from the bed - Instruct the client to dangle the legs
Instruct the client to dangle the legs The nurse should place the client in high-Fowler position, or 80 to 90 degrees, and then assist the client to the side of the bed. Next, the nurse helps the client sit on the edge of the bed and then instructs the client to dangle the legs. The nurse then faces the client and places the chair next to and facing the head of the bed. The semi-Fowler, or 30 to 45 degrees, position is not high enough to get the client in a sitting position.
A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning? 1. "I should examine the client in noise-free areas" 2. "I should use latex gloves during a physical examination" 3. "I should preform a physical examination in a cool room" 4. "I should leave a combative client alone during a physical examination" 5. "I should wear eye shields while examining a client with excessive drainage"
1. "I should examine the client in noise-free areas" 5. "I should wear eye shields while examining a client with excessive drainage" Clients should be examined in noise-free areas to prevent interruptions. Wearing eye shields while examining a client with excessive drainage helps to reduce contamination. Latex gloves should be used with caution because they may cause allergy in clients who are allergic to latex. A physical examination should be performed in a warm room to minimize discomfort. Combative clients should never be left alone during physical examinations.
When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? - Airborne - Contact - Droplet - Hazardous wastes - Standard
Airborne Contact Standard Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Contact precautions are used for patients with known or suspected infections transmitted by direct contact or contact with items in the environment. Varicella can be transmitted by airborne and contact routes. Droplet precautions are used for patients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods. Nurses should treat all body excretions, secretions, and moist membranes/tissues, excluding perspiration, as potentially infectious and thus as hazardous wastes. Contact and airborne precautions must be used. Standard precautions are used with every client.
Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? - Have the prescription renewed every 48 hours - Assess the client's position every hour - Provide rang of motion to the client's elbow every shift - Document output from the tube and catheter every 2 hours
Assess the client's position every hour A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? - Bending and then straightening their knees - Bending at the waist and then straightening the back - Placing one foot in front of the other and leaning back - Placing pressure against the client's axillae and then raising their arms
Bending and then straightening their knees The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs, the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomic structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.
A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? - Feeces - Blood - Semen - Urine - Sweat - Tears
Blood & Semen HIV, which is the virus that causes acquired immunodeficiency syndrome (AIDS), is transmitted through infected blood, semen, and bloody bodily fluids. HIV is not spread casually. Although HIV may be found in other bodily secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted.
A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? . - Assessing vital signs - Assessing wound drainage - Administering injections - Bringing equipment to the client's room - Transport the client to a diagnostic test
Bringing equipment to the client's room Transport the client to a diagnostic test The nursing assistive personnel can bring equipment to a client's room and transport the client from one place to another. Because the client is on isolation precautions, the registered nurse should assess vital signs, administer injections, and assess wound drainage.
The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? - Soap - Time - Water - Friction
Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.
The nurse is caring for a nonambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included in the client's plan of care? - Risk for pressure ulcer - Risk for impaired skin integrity - Impaired skin integrity, related to infrequent turning and re-positioning - Impaired skin integrity, related to the effects of pressure and shearing force
Impaired skin integrity, related to the effects of pressure and shearing force The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force. This is supported by the data provided that the client is nonambulatory and has a reddened sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's problem is not being "at risk" because the client already has an actual problem. Not enough information is provided to make the assumption that the impaired skin integrity is related to infrequent turning and repositioning.
The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? - Pregnancy - Inactivity - Aerobic Exercise - Tight Clothing
Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.
While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take? - Initiate an agency incident report - Report the fall to the state (provincial) health department - Write a brief description of the incident to be kept by the nurse manager - Determine that no documentation is needed because the visitor is not a client in the hospital
Initiate an agency incident report Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event, along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.
A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? - Picks up the walker and carries it for short distances - Uses the walker only when someone else is present - Moves the walker no more than 12 inches (30.5 cm) in front of client during use - States that the walker will be purchased on the way home from the hospital
Moves the walker no more than 12 inches (30.5 cm) in front of client during use
Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? - Instruct the client to position one arm on each shoulder of the nurses - Direct the client to extend the legs and remain still during the procedure - Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed (HOB), and then move the client - Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed
Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed (HOB), and then move the client Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.
The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? - Prevent a client from pulling out an IV when there is concern that the client cannot follow instructions or is confused - Prevent an adult client from getting up in the night when there is insufficient staffing on the unit - Maintain immobilization of a client's leg to prevent dislodging a skin graft client from falling out of bed after a surgical procedure
Prevent an adult client from getting up in the night when there is insufficient staffing on the unit Restraints are not used for staff convenience. An older adult client who is unable to sleep should be assessed for physiological reasons for this and for safety needs before consideration of any restraint device. Various forms of restraint devices are indicated for client protection from injury and to maintain essential medical therapies, such as pulling out an IV, dislodging a skin graft, or preventing falls.
A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? - Weak upper arm strength and impaired stamina - Weight bearing as tolerated and unilateral paralysis - Partial weight bearing on the affected extremity & kyphosis - Strong upper arm strength and non-weight bearing on effected extremity
Strong upper arm strength and non-weight bearing on effected extremity A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? - To avoid strain on incision - To promote drainage of wound - To provide stimulation for the client - To reduce edema at the operative site
To reduce edema at the operative site This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.
The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction? - To the client from outside sources - From the client to others - From the client by using special techniques to destroy infectious fluids and secretions - To the client by using special sterilization techniques for linens and personal items
To the client from outside sources Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.
A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? - Maintain head of bed at 35 degrees or less - Use draw sheets to pull up, transfer, and position client - Re-position the client every 2 hours propping with pillows - Perform passive range of motion exercises every 8 hours of extremities
Use draw sheets to pull up, transfer, and position client Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a draw sheet or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing tearing of the skin. Using a draw sheet can reduce and minimize friction and shearing force. Limiting head of bed elevation, repositioning, and range of motion are interventions that may prevent pressure related injury verses shear injury.