Fundamentals Final

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open C. Rinse the client's mouth with an alcohol-based mouthwash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges

A. Place the client in a lateral position with the hand turned to the side before beginning the procedure

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restraints within 24 hr B. Secure the restraint with the buckle side next to the client's skin C. Ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hr

A. Renew the prescription for the use of restraints within 24 hr

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A. Test for the presence of the client's gag reflex B. Place the client in the supine position C. Use a firm toothbrush for tooth and gum care D. Use a 2 gauze-wrapped fingers to hold the mouth open

A. Test for the presence of the client's gag reflex

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the solid linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold

B. Hold the linens away from the body and clothing

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed B. Tie the restraint with a quick-release knot C. Allow a fingerbreadth between the restraint and the client's chest D. Place the restraint under the client's clothing

B. Tie the restraint with a quick-release knot

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required? A. "I should not leave all 4 side rails up unless there is a prescription for restraints." B. "An alert client will be safest if I raise the 2 upper side rails at the head of the bed." C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." D. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed."

C. "If a client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A. Select a vein in the client's dominant arm B. Choose the most proximal vein in the extremity C. Choose a vein that is soft on palpation D. Select a site distal to previous venipuncture attempts

C. Choose a vein that is soft on palpation

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

C. Remove the IV catheter

A nurse is caring for an older client who is violent and attempting to disconnect her IV lives. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails B. Perform range-of-motion exercises to the wrists every 3 hr C. Remove the restraints one at a time D. Obtain a PRN prescription for the restraints

C. Remove the restraints one at a time

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Wear a gown when in the client's room D. Dispose of all bed linens used by the client

C. Wear a gown when in the client's room

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure knot with the restraint straps B. Attach the restraints' straps to the bedside rails C. Make sure 3 fingers fit beneath the restraints D. Remove the restraints at least every 2 hr

D. Remove the restraints at least every 2 hr