Fundamentals NCLEX

A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures should the nurse reinforce in the teaching plan?

-Balance activity, rest, and avoid stress. -Keep skin on arms and legs well lubricated -Wash any breaks in the skin with soap and water. -Receive recommended vaccines against influenza and pneumonia.

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client?

-Check temperature at least every 4 hours. -Monitor white blood cell count daily as prescribed. -Remove fresh flowers or plants from the client's room.

The nurse reinforces instructions to a client diagnosed with impetigo. Which statements by the client indicate a need for further teaching? Select all that apply.

-I can wash my laundry with other household members' items." -"I should not wash the lesions of the infection once the skin lesions have scabbed over".

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

-Open the distal flap of a sterile package first. -Prepare the sterile field just before the planned procedure. -Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)?

-Perform hand hygiene after removal of PPE. -Perform hand hygiene before donning any PPE. -When removing PPE, always remove gloves first. -Protective eyewear and face shield are indicated if there is risk of splatter.

The nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action?

Wash the hands and go to the linen room to obtain another towel.

The nurse prepares the client for irrigation of an abdominal wound. Refer to video. Click on the Question Video button to view a video showing preparation procedures. After preparation, the nurse should appropriately don which article(s) to perform the procedure?

Gloves, gown, and goggles

The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?

Gloves, mask, gown, and goggles

A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the primary health care provider's office because the leukemic child has never had chickenpox. The nurse should make which response to the mother?

"Bring the child to the office for an injection called immune globulin."

A child is diagnosed with bacterial conjunctivitis and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse should make which response to the parent?

"The child should be kept home until the antibiotic eye drops have been administered for 24 hours.

A client with tuberculosis, whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. What should the nurse tell the client?

"Three sputum cultures must be negative before returning to work."

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action?

Obtaining the specimen from the urinary drainage bag

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse use during the bathing of this client?

gown and gloves

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching?

"I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

The nurse is changing a dressing on the wound of a postsurgical client who is receiving contact precautions because of a history of methicillin-resistant Staphylococcus aureus (MRSA) from a previous surgery. Which interventions should the nurse follow?

-Observe the incision line for redness and drainage. -Change gloves between removal of the old dressing and applying the new.

In developing a plan of care for a client hospitalized with tuberculosis (TB), the nurse should place emphasis on which intervention?

The strict adherence to following airborne precautions

The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus?

Using personal protective equipment appropriately

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

wear gown and gloves

The nurse should plan to reinforce instructions to which clients about the risk for transmission of disease through blood and sexual contact?

-A client diagnosed with hepatitis B virus -A client diagnosed with hepatitis C virus -A client diagnosed with human immunodeficiency virus (HIV)

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations?

-Open the distal flap of a sterile package first. -Prepare the sterile field just before the planned procedure. -Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse is working with an unlicensed assistive personnel (UAP) to care for clients. While observing the UAP's delivery of care, the nurse notes which actions by the UAP that indicates the need for further teaching regarding standard precautions?

-Removes gloves and immediately uses computer to document care -Uses soap and water to wash hands for 5 seconds and then dries hands -Empties collection bag of an indwelling urinary catheter without wearing gloves

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teaching is necessary when the client makes which statement?

"I need to breastfeed my baby."

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?

Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax?

Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching?

"I do not need to be concerned about spreading this infection to others in my family."

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?

"I should use disposable plates, forks, and knives."

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?

Determining what common food item was ingested by those affected

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which items when performing this care?

Particulate respirator, gown, and gloves

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves?

Pick up right glove at cuff with left thumb and forefinger.

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test?

Place a surgical mask on the client for transport and for contact with other individuals.

The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

Proper hand-washing technique

When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution should the nurse institute before making contact with the client?

Put on a gown and gloves.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply.

Put on mask Don gown and gloves Wear a pair of protective goggles

The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery?

Reviewing hand-washing techniques and pericare with the client

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which should be the appropriate form of isolation to use to prevent the spread of infection to others?

Standard precautions

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity should the nurse question if observed while caring for this client?

The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple.

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection?

Wear a mask when in contact with people outside of the family until medications are effective.

A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?

Wears a gown when caring for the client and removes the gown immediately after leaving the client's room

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?

Change the IV tubing

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure?

Discard used tissues in a plastic bag.

A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions should be instituted immediately by the nurse?

Droplet precautions

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus?

Mask and gloves

The nurse is preparing to comb the hair of a child client who has been treated for pediculosis (lice) at a clinic. Which additional instructions should the nurse give the parents of the child? Select all that apply.

-All head wear and bed linens should be washed in hot water. -A parent should observe all persons in the household for presence of lice or nits -If others in the household are found to have pediculosis, they all must be treated and have the nits removed from their hair.

A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care?

-Change dressing as needed. -Change infusion tubing every 24 hours. -Use strict aseptic technique when caring for the catheter.

The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observations, found in the audit, pose a risk for a health care-associated infection?

-Drainage bag port touching the floor -Dependent loop in the catheter tubing -Use of one measuring container between two clients with the same pathogen in the urine

A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means?

-Get plenty of sleep and rest -Take all medications as prescribed. -Wash your hands frequently with antibacterial soap. -Contact the primary health care provider (PHCP) if even a low-grade fever develops.

A hospitalized child with leukemia has received chemotherapy by the intravenous (IV) route, and a discharge to home is being planned. Laboratory values indicate that the child is neutropenic. The child is being treated daily by cleansing and the application of a topical antibiotic on an open area from an old IV site. The nurse reinforces instructions to the mother regarding the signs of infection at this affected site. Which statement by the mother indicates that the mother understands the instructions?

"I will clean the site and apply the topical ointment every day."

A health care worker who signed a waiver and never received the hepatitis B vaccine receives a needle stick from a client who has hepatitis B. Which treatments are indicated for the health care worker under this situation?

-Hepatitis B immune globulin -Initiate hepatitis B vaccine series -Cleanse needlestick site with soap and water

Following a cleft lip repair, the nurse reinforces instructions to the parents of the infant. Which of the instructions should be given to the parents of the infant? Select all that apply.

-Monitor frequency of diaper changes. -Cleanse the surgical site with normal saline -Apply prescribed antibiotic ointment to the surgical site.

The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review?

-Needle-stick injuries -Transmission by breast milk -Inconsistent use of protective equipment

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV?

-Perform hand hygiene before and after contact with the client.

The nurse receives the culture test results for a client who developed a bloodstream infection from a central venous device. The culture report indicates that the infection is exogenous. The client asks the nurse how she could have contracted this infection. Which should the nurse include in the explanation of potential sources of infectious organisms?

-The health care facility -The nurse caring for the client -The use of contaminated intravenous fluids

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections?

-Use indwelling urinary catheters judiciously. -Remove indwelling catheters when no longer needed. -Use strict aseptic technique when inserting all urinary catheters.

A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce?

-Wash soiled clothes in hot water -Use gloves when handling body fluids. -Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.

-Where gloves and a gown while in the room carrying for the client -Use soap and water not alcohol base hand rub, for hand hygiene

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?

"The flowers from your garden are beautiful, but they should not be placed in the child's room at this time."