NUR311 Exam 1

three point gait

-patient moves affected leg and both crutches forward about 12 in -then patient moves stronger leg forward to the level of the crutches

swing to gait

-patient moves both crutches forward about 12 in -the patient lifts the legs and swings them to the crutches, supporting his or her body weight on the crutches

four point gait

-patient moves right crutch forward 12 in and then moves the left foot forward to the level of the right crutch -then patient moves the left crutch forward 12 in and then moves the right foot forward to the level of the left crutch

two point gait

-patient moves the left crutch and the right foot forward about 12 in -then patient moves the right crutch and left leg forward to the level of the left crutch at the same time

b

A client has a peripheral access IV infusion running via an electronic infusion device. While monitoring the infusion, the nurse notices that the electronic infusion device is not running. What should the nurse do? a. Lower the height of the pole. b. Check the electronic device for proper functioning. c. Check the IV connector to ensure the clamp is closed. d. Attempt to flush the IV with 5 to 10 mL saline in a syringe.

c, e

A client has been out of bed, sitting in the chair for the past hour. The nurse is preparing to apply knee-high length graduated compression stockings as prescribed by the client's health care provider. Which action would be appropriate for the nurse to do? Select all that apply. a. Remove any excessive hair from the legs with a depilatory b. Apply liberal amounts of lotion to the feet and legs. c. Assist the client back to bed. d. Have the client flex and extend the legs several times. e. Elevate the client's feet and legs for about 15 minutes.

a, d, e

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply. a. Choose a walker with wheels on the front legs if you have a faster gait. b. When going down stairs with the walker, move slowly. c. Pull on the walker for leverage when getting up from a chair. d. Wear nonskid shoes or slippers. e. Check the walker for signs of damage, frame deformity, or loose or missing parts before use. f. Choose a walker without wheels if you have difficulty lifting a walker.

a, b, d, e, f

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply. a. Toothpaste b. Emesis basin c.Lip lubricant d. Disposable gloves e. Towel f. Toothbrush

c

A client has undergone surgery and has a Hemovac drain in place. When providing care to this client, the nurse would monitor the drain status at which frequency? a. Every 2 hours b. Every 8 hours c. Every 4 hours d. Every hour

c

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse? a. Rinse the cut with warm water to remove shaving cream. b. Apply pressure with a towel to the area for 7 to 8 minutes. c. Apply pressure with a gauze pad for 2 to 3 minutes. d. Place a transparent dressing over the cut to enhance visualization.

c

A client wearing bilateral pneumatic compression devices reports pain and tingling in the left leg. After removing the pneumatic compression device, what is the next intervention by the nurse? a. Encourage the client to ambulate to increase both venous and arterial circulation. b. Administer a PRN dose of pain medication to the client. c. Assess the extremities for peripheral pulses, edema, changes in sensation, and movement. d. Vigorously massage the affected extremity.

a

A client who is recovering from surgery is beginning to ambulate. This client is strong enough to walk without assistance but has poor balance. Which type of mobility aid would be most appropriate for this client? a. A cane with four prongs on the end (quad cane) b. A walker with four fixed legs c. A single-ended cane with a straight handle d. A single-ended cane with a half-circle handle

c

A client who is wearing soft contact lenses is unable to remove the lenses before bedtime. What action should the nurse take? a. Contact the health care provider to assist with the removal of the lenses. b. Assist the client to remove the lenses using a small suction cup. c. Assist the client to remove the lenses using a small pair of rubber grippers. d. Allow the client to sleep with the contact lenses in place.

d

A client with a history of diabetes is demonstrating nail care to the nurse. Which action by the client requires teaching by the nurse? a. Using a cuticle stick to push cuticles back b. Filing the nail straight across and then rounding in a gentle curve c. Using a towel to dry between toes d. Using a nail clipper to cut the nail straight across

a

A client with diabetes asks the nurse what should be done for a large callus on the right great toe. What is the best response by the nurse? a. "I encourage you to see your podiatrist to get a recommendation for your callus." b. "Soak your foot in warm water for 30 minutes and then gently file the callus." c. "Rub lotion on your callus for 20 minutes and then use a clipper to cut the callus away." d. "You could try an over-the-counter callus remover and then call your health care provider."

b, f

A client's health care provider has prescribed the use of knee-high graduated compression stockings. To ensure that the correct size is obtained for the client, the nurse would measure which area? Select all that apply. a. Around the upper and lower aspects of the foot b. From the bottom of the heel to the gluteal fold c. Around the widest part of the thigh d. From the toes to the mid-calf e. From the bottom of the heel to the back of the knee f. Around the widest part of the calf

c

A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? a. "Any items coming into contact with a sterile field must be sterile." b. "Items below waist level are considered contaminated." c. "Turning a back to a sterile field maintains the sterility of the field." d. "Reaching over a sterile field contaminates the sterile field.

c

A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching? a. The students keep their hands lower than their elbows throughout the skill. b. The students rub their hands firmly with soap using a circular motion. c. The students wash their hands for 15 seconds prior to drying them. d. The students use warm water to complete the hand washing skill.

5, 3, 4, 6, 1, 2

A nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed to a stretcher. Place the following steps in the correct order. Use all options. 1. Roll the client away from the stretcher and place a transfer board across the space between the stretcher and the bed. 2. Pull the client across the transfer board using the friction-reducing transfer sheet to the stretcher. 3. Raise the bed to a height even with the transport stretcher. 4. Place a friction-reducing transfer sheet under the client's midsection. 5. Consult client handling algorithm. 6. Position the stretcher next to the bed and lock the wheels.

a

A nurse delegates the application of graduated compressions stockings to a licensed practical nurse. A while later, the client's spouse pulls the nurse aside and says, "I think the other nurse put the stockings on backwards. The opening is facing up." Which response by the nurse would be most appropriate? a. "The opening is face up to prevent any interference with the circulation." b. "It doesn't matter if the opening is up or down, as long the stocking is smooth." c. "I'm sure they are on correctly. I trust the nurse who put them on." d. "Yes, you are correct. Let me take them off and put them on again."

a, b, d

A nurse demonstrates the correct use of hand hygiene using an alcohol-based handrub for which situation? Select all that apply. a. Before entering a client's room b. After applying a clean, dry dressing c. Before eating a meal d. After removing gloves e. After using the restroom

d

A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long should the nurse have the client apply the bag before the nurse removes it? a. 10 minutes b. 25 minutes c. 15 minutes d. 20 minutes

b, d, e

A nurse is assessing a client's intravenous (IV) site while changing the dressing. Which signs would indicate fluid infiltration into the tissue around the IV catheter? Select all that apply. a. Redness b. Coolness c. Warmth d. Swelling e. Pallor

d

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures? a. Apply gentle pressure with a tongue blade to remove the denture plate. b. Ask the client to take a deep breath and exhale while grasping the denture plate. c. Use sterile gloves to apply gentle pressure and grasp the denture plate. d. Apply gentle pressure with a 4 × 4 gauze to grasp the denture plate.

d

A nurse is assisting a surgeon who will be placing a hollow, open-ended rubber tube in a client with an abscess to drain the wound. This drain will be placed such that one end will be in the abscess and the other will pass through an opening in the skin known as a stab wound. The nurse recognizes that which type of drain is needed? a. Jackson—Pratt drain b. Hemovac drain c. T-tube drain d. Penrose drain

d

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? a. Contact the client's caregiver and ask if the client wears contacts. b. Ask the unlicensed assistive personnel (UAP) to remove the contact lenses. c. Contact the health care provider for a prescription to remove the contact lenses. d. Assess both eyes for contact lenses.

d

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? a. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. b. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. c. Permit the client to remove the stockings indefinitely and speak to the health care provider about the necessity of having the client wear them. d. Tell the client he can remove them for 20 or 30 minutes during this shift.

d

A nurse is caring for a client who will be undergoing removal of the gall bladder. Which type of drain should the nurse expect the surgeon to place in the client's common bile duct to drain bile while the surgical site is healing? a. Penrose drain b. Jackson—Pratt drain c. Hemovac drain d. T-tube drain

c

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? a. Transparent semipermeable membrane dressing b. Sealed IV dressing c. Gauze dressing d. Occlusive dressing

a, b, d

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. a. Press and rotate the swab several times over the wound surfaces. b. Place the swab in the culture tube when done. c. Tap the outside of the culture tube with the swab before placing it in the tube. d. Insert a swab into the wound. e. Use the same swab for both wound sites. f. Touch the swab to the intact skin at the wound edges.

b

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? a. The client would like the spouse to assist with shaving. b. The client should use an electric razor. c. The client prefers shaving gel over shaving cream. d. The client likes to shave while in the shower.

c

A nurse is directed to apply a pneumatic compression device for a client, after surgery. What postoperative complication would this device help to prevent? a. Pneumonia. b. Hemorrhage. c. Venous thrombus. d. Infection.

a

A nurse is explaining to a client's caregiver the purpose of antiembolism stockings, which the client has received a prescription to wear. Which best explains their purpose? a. They promote venous blood return to the heart. b. They eliminate peripheral edema. c. They reduce the risk for impaired skin integrity. d. They provide a nonslip foot surface to help prevent falls.

b

A nurse is gathering the necessary equipment to empty a client's Hemovac drain. Which personal protective equipment (PPE) would be most essential for the nurse to use at a minimum? a. Face shield b. Clean gloves c. Gown d. Mask

a

A nurse is preparing a sterile field using a pre-packaged kit. The nurse opens the outside cover and removes the kit, placing it in the center of the work surface. The nurse places the kit so that the topmost flap is positioned in which direction? a. On the far side of the package b. To the right of the client c. Toward the nurse's body d. To the left of the nurse

b

A nurse is preparing to apply a pneumatic compression device for a client. Which statement accurately describes a contraindication for this device? a. Do not use the device in combination with anticoagulant therapy. b. Do not place the sleeves of the device above the knee. c. Do not use the device in combination with antiembolism stockings. d. Do not use the device if skin integrity is altered.

5, 2, 4, 1, 3

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. Place the following steps in the correct order. Use all options. 1) Rub the hands together, covering all surfaces of the hands and fingers 2) Check the product label for the correct amount to use 3) Ensure that the hands are dry 4) Apply the product 5) Remove jewelry

b

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. When applying the product, the nurse would place the product at which location? a. On the back of the non-dominant hand b.In the palm of one hand c. Between each finger d. On each of the fingertips

c

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading? a. 130oF (54.4oC) b. 89oF (31.7oC) c. 105oF (40.6oC) d. 98oF (36.7oC)

1, 3, 6, 4, 2, 5

A nurse is preparing to shampoo a client's hair while the client is in bed. Place the steps below in the order that the nurse would perform them? Use all the steps listed. 1) Place a protective pad under the client's head and shoulders after removing the pillow. 2) Put on gloves and give the client a folded washcloth to hold over the forehead. 3) Fill the pitcher with water at an appropriate temperature. 4) Position a drain container underneath the drain of the shampoo board. 5) Saturate the client's hair with water from the pitcher. 6) Place the shampoo board under the client's head.

a

A nurse is preparing to use an alcohol-based handrub for hand hygiene. After applying the appropriate amount of product, the nurse would rub the hands together for at least how long? a. 15 seconds b. 120 seconds c. 90 seconds d. 45 second

a

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first? a. Warm the cap in the microwave. b. Add water to the cap to create a lather. c. Wet the client's hair with water. d. Apply the cap to the client's head.

a

A nurse is providing care to several clients who are extremely weak and need to have their hair shampooed while remaining in bed. When gathering the necessary supplies, the nurse would anticipate needing to adapt the shampoo board for the client with which condition? a. Acute spinal cord injury b. Septic shock c. Diverticulitis d. Postoperative coronary artery bypass graft

a, c, e, f

A nurse is providing nail care for an older adult client. Which actions should the nurse take? Select all that apply. a. Cut the nail straight across b. Trim the nail far down on the sides c. Gently clean under the nails using an orangewood stick d. Leave hangnails alone e. File the nail straight across f. Round the tips of the nails in a gentle curve using a file

a

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? a. Every two hours. b. Every hour. c. Every four hours. d. Every shift.

d

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? a. Place a drain container underneath the drain of the shampoo board. b. Close curtains around the bed and close the door to the room, if possible. c. Place a protective pad under the client's head and shoulders. d. Raise the bed to elbow height.

c

A nurse is shaving a male client's face. Which should the nurse do? a. Let the skin hang loose and shave in long downward strokes. b. Shave against the direction of hair growth, using short strokes. c. Pull the skin taut and shave in the direction of hair growth using short strokes. d. Pull the skin taut and use short, upward strokes.

c, e, f

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply. a. Grasp the mattress and shift it down to the foot of the bed. b. Secure clean top linens under the head of the mattress. c. Put on gloves before removing soiled linens. d. Place soiled linen on the floor. e. Place a bath blanket over the client. f. Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible.

b

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth? a. Three times a day b. Twice a day c. Four times a day d. Once a day

a

A nurse would perform additional monitoring of the IV site and infusion according to facility policy for which client? a. A client who is receiving IV medications. b. A client who has fluid imbalances. c. A client who is unconscious. d. A client who is dehydrated.

b

After 30 minutes, the nurse comes to remove the warm compress from a client's wound site. The client requests to leave the warm compress on a little longer. What is the best response by the nurse? a. "Since it is making you feel better, I will call the health care provider and ask to leave it on longer." b. "Leaving it on for more than 30 minutes can cause complications such as tissue injury." c. "Ok, we can leave it on for about 10 more minutes then I will return to remove it." d. "I cannot do that because your health care provider only prescribed it for 30 minutes at a time."

a

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? a. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. b. Assist the client to get out of bed and sit up in a chair for a short while. c. Leave the therapy on for 10 more minutes and return to remove it after that time. d. Explain to the client that this is not possible because of the health care provider's prescription.

5, 1, 3, 2, 4

After assessing a client's Hemovac drain, the nurse prepares to empty it. After emptying the contents into a graduated container, the nurse completes the next steps. Place the steps below in the order in which the nurse would perform them. Use all options. 1. Compress the chamber. 2. Check the patency of the equipment. 3. Apply the cap. 4. Secure the device to the client's gown. 5. Wipe the outlet with a gauze pad.

c

After assisting a bed-bound client with oral care, what action does the nurse take? a. Inspect the oral cavity for dryness, erythema, or bleeding. b. Dispose of the used toothbrush, basin, and cups. c. Assist the client to a comfortable position in the bed. d. Place the supplies on the edge of the overbed table.

a

After emptying a client's Hemovac drain, the nurse re-establishes suction and closes the cap. Which action would the nurse do next? a. Secure the drain to the client's gown below the level of the wound. b. Perform hand hygiene. c. Measure the amount of drainage in the graduated container. d. Change the dressing at the drain site.

c

After emptying the drainage from a Jackson-Pratt drain, how will the nurse re-establish suction to the drain? a. This type of drain does not use suction. b. Reapply the cap and fully compress the bulb. c. Fully compress the bulb and reapply the cap. d. Turn the suction back on at the wall unit.

d

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed? a. To the nondominant side of the client, with legs together and one foot near the head of the bed. b. Near the client's hip, with legs together. c. To the dominant side of the client, with legs together and one foot near the head of the bed. d. Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed.

d

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: a. side to side using a new gauze for each wipe. b. distal to proximal using a new gauze for each wipe. c. outside to center using a new gauze for each wipe. d. top to the bottom using a new gauze for each wipe.

d

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? a. Respiratory infection b. Sexually transmitted infection c. Droplet infection d. Health care-associated infection

d

Assisting the client out of bed, the nurse is helping to lower a client into a wheelchair. What would the nurse ask the client to do at this point? a. Fold arms across the chest while being guided to a sitting position. b. Hold on to the bed railing to steady self while lowering to a sitting position. c. Use both arms to hold onto the nurse's shoulders while lowering to a sitting position. d. Use an arm to steady self on one chair arm while lowering to a sitting position.

a

During sitz bath therapy, a client reports feeling dizzy and lightheaded. What is the most likely rationale for this occasional effect from sitz bath therapy? a. The warm water caused vasodilatation. b. The client's blood pressure has increased. c. The client's wound has begun bleeding. d. The cool water has caused the client to become cold.

a

How often should skin integrity be assessed for a client who is using pneumatic compression devices? a. every 8 hours b. every 12 hours c. every 24 hours d. every 4 hours

b, d

How often will the nurse empty a Jackson-Pratt drain? Select all that apply. a. Only when the drain is full b. At least every 4 hours c. Once every 24 hours d. When the drain is one-half to two-thirds full e. At least every shift

c

How should the nurse open the bottom sheet when making an unoccupied bed? a. Fold in thirds to the side b.Fanfold to the side c. Fanfold to the center d.Fold in half in the center

b

How should the nurse teach the client who is ambulating with a cane? a. Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the weaker leg and the cane, advance the stronger foot forward, parallel with the cane. b. Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane. c. Instruct the client to advance the 4 to 12 in (10 to 30 cm) and then, while supporting weight on the weaker leg and the cane, advance the weaker foot forward, parallel with the cane. d. Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the stronger foot forward, parallel with the cane.

a

How would the nurse remove the top linens when making an occupied bed? a. Have the client hold onto the bath blanket and reach under it to remove the linens. b. Fanfold the linens at the bottom of the bed and remove them to the chair. c. Arrange the client's gown for privacy and roll the linens to the bottom of the bed. d. Have the client hold onto the bath blanket and reach under it to remove all linens except the top sheet.

a

How would the nurse secure a Jackson-Pratt drain after emptying it? a. With a safety pin, secure the drain to the client's gown below the wound. b. With a safety pin, secure the drain to the side of the bedding. c. With a safety pin, secure the drain to the client's gown above the wound. d. With tape, secure the drain to the client's gown above the wound.

d

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned? a. directly beside the client with opposite hand on gait belt b.in front of the client with near hand on gait belt c. directly behind the client with both hands on the gait belt d. to either side and slightly behind the client with near hand on gait belt

a

In which client would the application of an external heating pad be contraindicated? a. Client who has a wound that is bleeding. b. Client who has muscle spasms from tension. c. Client who has chronic arthritic pain. d. Client who has a wound that is infected.

c

Inspection of a client's peripheral venous access site reveals signs of phlebitis. Which action by the nurse would be most appropriate? a. Keep the IV in place until the solution has been infused, and then discontinue it and notify the health care provider. b. Keep the IV in place, notify the health care provider, and start treatment for phlebitis. c. Notify the health care provider, discontinue the IV, and start it at another site. d. Discontinue the IV and start it at another site. If phlebitis worsens, notify the health care provider.

c

Personal protective equipment (PPE) is used in health care facilities for primarily which reason? a. To protect staff members from becoming infected by clients b. To protect clients from becoming infected by staff members c. To protect both the staff and clients from becoming infected by one another d. To protect the hospital from legal liability

3, 4, 2, 1, 5, 6

Place in correct order the steps for removing a gown. Use all options. 1) Turn gown inside out. 2) Keeping hands on the inner surface of the gown, pull gown from arms. 3) Unfasten the ties. 4) Touching only the inside of the gown, pull away from the torso. 5) Fold or roll the gown into a bundle. 6) Discard the gown.

4, 1, 3, 5, 2

Place in order, from first to last, the actions the nurse will perform when applying a warmed moist compress. Use all options. 1. Remove the compress from the warmed solution. 2. Cover the site with a dry, clean bath towel. 3. Squeeze out any excess solution. 4. Assess the application site. 5. Gently mold the compress to the intended site.

2, 6, 5, 3, 4, 6

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options. 1. Time and date the dressing. 2. Put on clean gloves. 3. Open dressing materials. 4. Irrigate the wound bed. 5. Assess the wound bed. 6. Remove old dressing.

b

Proper application of a pneumatic compression device includes which step? a. Apply each sleeve with the cotton liner facing down. b. Place a sleeve under the client's leg with the tubing toward the heel. c. Wrap the tubing around client's bedrail to ensure that it stays in place. d. Apply the sleeve tightly so that fingers cannot fit in between the tube and client's leg

passive ROM

ROM exercises performed by a nurse without participation by the patient

erythema

Redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries

a

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate? a. "Let me assess the patches. They may indicate the development of a fungal infection." b. "Is this the first time you noticed them? These types of patches are a normal finding in most adults." c. "The patches are probably the result of ineffective brushing. I'll get you a new toothbrush." d. "What type of milk did you drink during your last meal? These patches often occur after drinking whole milk."

a

The charge nurse confronts a new nurse about not wearing gloves into a client's room. The client is not on transmission-based precautions. How does the new nurse best respond? a. "Can you show me the hospital policy for when to wear gloves?" b. "It is not necessary to wear gloves for all client interactions." c. "The client is not on any precautions for infectious organisms." d. "I don't think gloves are needed to care for this particular client."

d

The charge nurse notices that when caring for a client, some nurses are wearing personal protective equipment and other nurses are not. Which action would be most appropriate for the nurse to take? a. Check with the other staff nurses on the unit. b. Ask the health care provider about the client's condition. c. Review the medication record for use of antibiotics. d. Consult the agency's infection control manual.

d

The charge nurse observes a new nurse not wearing personal protective equipment (PPE) entering and exiting a client's room. The client is on transmission-based precautions. What is the charge nurse's best response? a. Ensure that the correct PPE is stocked by the room. b. Report the occurrence to the unit's hiring manager for additional action. c. Document the observations in an incident report in the hospital's computer system. d. Reinforce teaching that transmission-based precautions must be observed.

a

The client asks the nurse why the nurse wears a disposable gown every time she enters the client's room. What is the nurse's best response? a. "I am required to wear a gown for certain infections that are easily passed to others." b. "You have a sign on your door indicating that you have a transmissible infection." c. "I have to protect my other hospitalized clients from getting an infection." d. "The hospital says that I have to wear this gown to enter your room."

c

The client has decreased strength in the left leg. How should the nurse instruct the client to hold a cane for assistance? a. toward the front b. on the left side c. on the right side d. toward the back

c

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse? a. "Let me get you a wheelchair for your safety." b. "You seem unsteady, please slow down." c. "Allow me to show you how to use your walker again." d. "Press your nurse call light whenever you get up with your walker."

c

The client is 1 day postsurgery with a figure-eight bandage in place after an open reduction internal fixation (ORIF) of a left wrist fracture. How often should the nurse check the neurovascular status of the left wrist and hand? a. every 2 hours b. every 60 minutes c. every 4 hours d. every 30 minutes

d

The health care provider has prescribed application of total-leg pneumatic compression device sleeves to a client's legs. Where would the nurse place the opening in the sleeve? a. At the space in front of the knee. b. Where the upper thigh meets the groin muscle. c. the ankle. d. At the popliteal space behind the knee.

b

The new nurse notes a health care provider enter a client's room without the correct personal protective equipment (PPE). What does the nurse say to the health care provider? a. "You have to observe policies like we all do." b. "I notice you did not wear the required PPE." c. "Can you tell me why you did not observe policy?" d. "Why did you enter the room without putting on a gown?"

a

The nurse adjusts a client's bed to a comfortable working height to turn a client. What would be the nurse's next action? a. Move the client to edge of the bed opposite the side that client will be turning. b. Push the client to the opposite side of the bed. c. Push the client to the edge of the bed to which the client will be turning. d. Pull the client to the edge of the bed to which the client will be turning.

a

The nurse and an unlicensed assistive personnel (UAP) are moving a client up in bed. What position should the nurse instruct the client to take prior to the move? a. knees bent and chin tucked toward chest b. legs straight and chin tucked toward chest c. knees bent and head pointed upward toward ceiling d. legs straight and head turned toward left side

1, 3, 5, 2, 4, 6

The nurse and an unlicensed assistive personnel (UAP) are preparing to move a client up in bed. Place the following steps in the correct order. Use all options. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Remove all pillows from under the client. 4. Ask the client to bend the legs and place the chin on the chest. 5. Position the UAP on the side opposite the nurse. 6. Grasp the sheet and move the client on the count of three.

a

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? a. alongside the bed at the same height b. alongside the bed 2 in (5 cm) higher c. alongside the bed 2 in (5 cm) lower d. alongside the bed 1 in (2.5 cm) either lower or higher

a

The nurse applies a gait belt to a client prior to ambulation. For what reason might the nurse use a gait belt when ambulating certain clients? a. To improve grasp and help provide more stability and balance. b. To provide them with a better center of gravity. c. To increase the client's activity tolerance. d. To provide added weight for increased client exercise and endurance.

a

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? a. Reinforce the dressing and assess site frequently b. Call a rapid response and stay with the client c. Notify the health care provider of the bleeding d. Change the dressing using sterile technique

a

The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? a. The nurse drops the item from the wrapper into the side of the sterile field. b. The nurse grasps the remaining flap of the wrapper and pulls back toward wrist. c. The nurse keeps hands and wrists on the outside of the wrapped sterile item. d. The nurse holds wrapped item in dominant hand to open, opening top flap away from body.

c

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms? a. instructing the client not to share the use of the walker with anyone else b. assisting the client to wash the hands upon return to the bed c. wiping down the handles of the walker once the client has returned to bed d. requiring the client to wear gloves when using the walker

a

The nurse changes a client's peripheral venous access dressing. Which nursing action is correct? a. Press the chlorhexidine applicator against the skin using a back-and-forth motion. b. Apply an antibacterial ointment to all the skin area that will be covered with the dressing. c. Loop the intravenous tubing near the entry site and secure it under the access dressing. d. Label the new dressing with the client's name, date of birth, and initials.

a

The nurse cleans the client after a bowel movement and notes stool on the gloves. The nurse has not finished cleaning the client. What action should the nurse take? a. Change into a new pair of gloves. b. Continue to complete care. c. Avoid touching clean linen. d. Use a wipe to clean gloves.

c

The nurse determines that the sterile field has been contaminated when which action occurs? a. A sterile object falls within the 1-in (2.5-cm) border of the field. b. The nurse reaches around the sterile field. c. The nurse turns his or her back to the field. d. The field is above waist level.

d

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client's large abdominal wound. The nurse uses the extra gloves for what purpose? a. To remove the existing dressing from the abdominal wound b. To leave in the room with additional supplies for the next change c. To be able to change gloves if the wound has copious draining d. To use if the first pair of sterile gloves gets contaminated

c

The nurse has created a sterile field with sterile dressings in preparation for a client's wound care. While getting ready to apply a dressing, the client moves his arm and touches the sterile field. Which action by the nurse would be most appropriate? a. Ask the client if he touched anything. b. Add new sterile dressings to the sterile field. c. Set up an entirely new sterile field. d. Replace any items that moved with new ones.

d

The nurse has delegated contact lens removal to the unlicensed assistive personnel (UAP) for a client in the preoperative area. Which action by the UAP requires intervention by the nurse? a. The UAP is donning clean gloves. b. The UAP has placed the storage case on the overbed table. c. The UAP is using the pads of the thumb and index finger to grasp the lens. d. The UAP has placed the client in a side-lying position.

b

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: a. has bright red granulation tissue in the wound bed. b. has black brown eschar covering the top. c. has redness with partial thickness loss of dermis. d. has exposed bone, tendon, or muscle visible.

c

The nurse has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction? a. Turn the suction back on at the wall outlet. b. Recap the drain and keep tubing to gravity. c. Fully compress the drain and reapply the cap. d. Milk and then clamp the drain tubing.

c

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? a. Allow the wound to air dry for 2 minutes. b. Measure the length, depth, and width of the wound. c. Pat the wound dry with a sterile gauze sponge. d. Position the client to promote drainage of the solution.

c

The nurse has gathered several individually packaged dressings for a sterile dressing change. When adding these dressings to the sterile field, which action would the nurse take? a. Pull the top cover off at an angle. b. Cut the package open with sterile scissors. c. Peel the edges apart with both hands. d. Tear open the package across the top.

b

The nurse has instructed the client with a knee injury on how to perform crutch walking with a four-point gait. Which statement clarifies client understanding? a. "The four-point gait uses both crutches and the affected leg at the same time, then followed by the unaffected leg." b. "The four-point gait uses one crutch, then one leg, followed by the other crutch, and then the other leg." c. "The four-point gait uses both crutches and allows the client to move both legs up past the crutches at the same time." d."The four-point gait uses the left crutch and right leg, then the right crutch and left leg."

c

The nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site. Which action is most appropriate? a. Attempt to flush the catheter again. b. Remove the dressing, ensure that all connections are tight, and apply a new dressing over the insertion site. c. Remove the IV catheter and restart the venous access site in a new location. d. Reinforce the original dressing and notify the health care provider.

a, c, d, e, f

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. a. Rate of the IV solution b. Manufacturer of the IV catheter c. Type of IV solution d. Gauge and length of the IV catheter e. Location of the IV catheter access f. Client's reaction to the procedure

c

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action? a. Replace soiled gloves with new ones. b. Place the clean bottom sheet in center of bed. c. Remove gloves, unless indicated for transmission precautions. d. Scrub the mattress with antimicrobial cleaner.

b

The nurse has prepared a sterile field using a pre-packaged kit. Which would be important for the nurse to keep in mind? a. Sterile gloves are not needed to obtain any items from the field. b. The field is contaminated if it is out of the nurse's site. c. No other sterile items can be added to the sterile field at this point. d. The items contained in the kit are considered clean.

c

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing. What action would be appropriate? a. Skip the part of the care that requires the missing item. b. Leave the client and the room to obtain the missing item. c. Call someone to bring in the necessary item to the client's room. d. Complete the care right up to the step of the missing item, then go get it.

d

The nurse has put on one sterile glove and is preparing to put on the other. What is the next step in donning the second glove? a. Use the fingers to grasp the edges of the cuff of the second glove. b. Hold the second glove in the palm of the gloved hand. c. Use the thumb and index finger to grasp the cuff. d. Slide the gloved fingers under the cuff of the second glove.

d

The nurse has transferred a client out of bed into a chair using a powered full-body sling lift. How would the nurse know when the client has been lowered far enough into the chair? a. The straps will fall to the floor. b. The client's buttock will touch the chair. c. The straps will be taut. d. The straps will be slightly loosened.

d

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that wearing contact lenses. What is the priority action by the nurse? a. Irrigate the eyes with 0.9% normal saline to aid in removal of the contact lenses. b. Remove the contact lenses and place in a storage case marked L and R. c. Ask the client to remove the contact lens from the unaffected eye and place in a storage case marked L and R. d. Notify the emergency department health care provider the client is wearing contact lenses.

d

The nurse is applying a pneumatic compression device to a client's legs. Where would the nurse place the inflation pump? a. On the side railing. b. At the head of the bed. c. On the side table. d. On the bottom of the bed.

a

The nurse is assessing a client with a figure-eight bandage on the right ankle. The client has returned from the bathroom and the bandage is loose and has migrated over the tips of the toes. What action does the nurse perform next? a. Discard the bandage and replace with a new bandage following the figure-eight pattern b. Apply medical tape to hold the figure-eight bandage in place c. Remove the bandage washing the bandage to restore elasticity d. Pull the bandage proximally back to the original applied position

d

The nurse is assessing a client's peripheral venous access site and notes redness and inflammation at the site. What is the best action by the nurse at this time? a. Change the site dressing using aseptic technique. b. Document the findings and continue to closely monitor the site. c. Notify the health care provider of the findings and request prescription for an antibiotic. d. Discontinue current IV and relocate to new site.

b

The nurse is assisting a client from bed into a wheelchair. Before asking the client to swing his or her legs over the side of the bed, what position would the nurse ask the client to assume? a. Supine. b. Side-lying. c. Knee-to-chest. d. Sitting.

b

The nurse is assisting a client from the bed into a wheelchair. After helping the client to a sitting position, what would be the nurse's next action? a. Ask the client to slide the buttocks to the end of bed until the feet touch the floor. b. Wrap the gait belt around the client's waist. c. Encourage the client to use the stand-assist device. d. Stand facing the client with feet shoulder-width apart and flex the hips and knees.

d

The nurse is assisting a client from the bed into a wheelchair. Which is a recommended guideline for this procedure? a. Make sure the bed brakes are unlocked. b. Place the bed in the highest position. c. Put the chair at the foot of the bed. d. Raise the head of the bed to a sitting position.

b, c, d, f

The nurse is assisting a client with a sitz bath. Which actions should the nurse perform? Select all that apply. a. Hang the bag of tepid to warm water at the client's chest height on an IV pole. b. Fill the bowl of the sitz bath about halfway full with tepid to warm water. c. Insert tubing into the infusion port of the sitz bath. d. Ensure that the call bell is within reach. e. Have the client soak for about 50 to 60 minutes. f. Slowly unclamp the tubing and allow the sitz bath to fill.

b

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? a. Under the client's head. b. Supporting the client's back. c. Under the client's feet. d. In front of the client's abdomen.

c

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client? a. Head of the bed at 45 degrees b. Head of the bed at 10 degrees c. Sitting at the edge of the bed d. Head of the bed at 30 degrees

d

The nurse is assisting with range-of-motion exercises for a client who is on bed rest following surgery. How often would the nurse perform each range-of-motion exercise? a. Eight times. b. One time. c. Ten to twelve times. d. Two to five times.

b

The nurse is capping a client's IV line for intermittent use in preparation for the administration of an antibiotic. After inspecting the site, what will the nurse do next? a. Remove the primary IV tubing from the access cap. b. Close the clamp on the current administration set. c. Cleanse the access cap with an alcohol swab. d. Open the short extension tubing and prime with normal saline.

d

The nurse is capping an existing IV line for intermittent use. Which action by the nurse follows correct procedure? a. attempting to aspirate for a blood return after flushing the extension tubing b. flushing the extension tubing with a heparin solution to maintain patency c. loosely wrapping the extension tubing over the insertion site and tapes it in place d. cleaning the end cap of the extension tubing with an antimicrobial swab

4, 2, 1, 5, 3

The nurse is capping an intravenous (IV) line for intermittent use. Place in order how the nurse will perform these actions. Use all options. 1. Aspirate the catheter for positive blood return by gently pulling back on the syringe. 2. Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. 3. Reclamp the extension tubing and loop it near the entry site, securing it with tape. 4. Scrub the needleless connector or end cap on the extension tubing with an antimicrobial swab. 5. Flush the tubing slowly, over one minute, with a sterile saline filled syringe.

5, 2, 1, 3, 4, 6

The nurse is caring for a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options. 1. Empty the bulb's contents into the collection chamber. 2. Remove the cap from the bulb. 3. Wipe the outlet of the bulb with a sterile gauze pad. 4. Fully compress the bulb. 5. Place the graduated collection container under the drain outlet. 6. Replace the cap on the bulb.

c

The nurse is caring for a client in the postanesthesia care unit (PACU) who has just undergone a third foot surgery. Which gate is best for the nurse to teach this client? a. four-point gait b. two-point gait c. swing-to gait d. three-point gait

d

The nurse is caring for a client wearing a pneumatic compression device. The nurse has set the device properly when the pressure is in what range? a. 55 to 65 mm Hg b. 30 to 35 mm Hg c. 65 to 75 mm Hg d. 35 to 55 mm Hg

c

The nurse is caring for a client who has a Penrose drain. On assessment, the nurse notes that there is a safety pin on the drain just outside the wound incision area. What action should the nurse take related to this finding? a. Obtain a wound culture to test for possible infection. b. Notify the health care provider of the finding at the incision site. c. Document the presence and location of the safety pin. d. Remove the safety pin and clean with an antiseptic preparation.

c

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? a. Assure that the packing material is completely saturated when placed in the wound. b. Use less packing material. c. Reduce the time interval between dressing changes. d. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

d

The nurse is caring for a client who has been diaphoretic and observes that the dressing on the peripheral venous access site has become loose and needs changing. Which type of dressing would be best for this client? a. 2 × 2 gauze with foam tape b. clear non-permeable occlusive dressing c. a transparent semi-permeable membrane dressing d. a sterile gauze dressing

a

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new prescription for the client to sit in the chair three times a day. Which action will be most effective to transfer the client safely into the chair? a. Have the client sit on the side of the bed for several minutes before moving to the chair. b. Position a friction-reducing sheet under the client. c. Obtain a quad cane for the client to use as a transfer aid. d. Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair.

a

The nurse is caring for a client who has had colon surgery. The client asks the nurse "How do pneumatic compression devices decrease risk of thromboemboli?" What is the best response by the nurse? a. "They increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart." b. "They provide points of muscle massage when you are ambulating." c. "They increase fluid volume improving venous return." d. "They stimulate blood flow improving arterial circulation to the lower extremities."

b

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity? a. Cover the client with the bed linens. b. Pull the shoulder blade forward and out from under the client. c. Assess for pain. d. Place the call bell within reach.

d

The nurse is caring for a client with a Jackson-Pratt drain. Which intervention by the nurse is priority before beginning the dressing change? a. Gathering the needed supplies b. Checking the client's latest laboratory values c. Assessing the client's need to void d. Assessing the need for analgesia

a

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? a. To promote moist wound healing and protect the wound from contamination and trauma. b. To prevent the dressing from sticking to the wound. c. To fill the wound with saline to dissolve wound secretions. d. To soften the dressing to prevent trauma to the wound bed.

a

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? a. Teach the client ways to relieve the pressure on the heel. b. Teach the client to reposition every 4 hours. c. Prescribe the client a high carbohydrate diet to promote healing. d. Remove the eschar by irrigating with sterile saline.

a

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? a. Obtain a sterile wound culture b. Consult dietician to assist client with meal choices c. Assist client up to chair three times daily d. Give ciprofloxacin 1gram IV every 12 hours

b

The nurse is caring for a client's wound that has a Jackson-Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container? a. Fully compress the chamber. b. Use a gauze pad to clean the outlet. c. Put on clean gloves. d. Replace the cap on the chamber.

b

The nurse is caring for a client, after hip replacement, and receives a prescription to apply a pneumatic compression device. On what part of the body would the nurse place this device? a. Feet b. Legs c. Chest d. Arms

d

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why he or she needs to ambulate in halls three times a day. What is the correct response by the nurse? a. "Ambulation helps prevent anesthesia related tachycardia." b. "Ambulation helps prevent surgical wound infection." c. "Ambulation helps prevent hypoglycemia after surgery." d. "Ambulation helps prevent thromboembolism."

a, c, e

The nurse is caring for a postsurgical client. The client asks the nurse why he needs to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factors? Select all that apply. a. increase joint flexibility b. decrease risk of wound infection c. aid gastrointestinal motility d. help pain control e. improve respiratory function

c

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens? a. Fold the bedding in half on the bed and then place them at the bottom of the bed b. Fold the bedding in fourths on the bed and place them on the overbed table. c. Fold the linens in fourths on the bed and then hang them over a clean chair. d. With the assistance of another nurse, fold the linens in fourths on the bed and then place them on a clean chair.

b

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? a. Use a skin barrier on the wound itself prior to applying a dressing. b. Use Montgomery straps instead of adhesive tape to hold the dressing in place. c. Cleanse the area with an antimicrobial wipe prior to applying the new dressing. d. Cleanse the area with an alcohol wipe prior to applying the new dressing.

a

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? a. Use small amounts of sterile saline to help loosen and remove the dressing. b. Wipe the area with an alcohol wipe and pull the dressing from the skin. c. Wipe the area with an antimicrobial swab and pull the dressing from the skin. d. Soak the area with sterile water using gauze pads.

a

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? a. Replace the dressing with a smaller one. b. Replace the dressing with a larger one. c. Notify the health care provider for further instructions. d. Allow the wound to air dry.

b

The nurse is changing the figure-eight bandage on the client's hand after hand surgery. In addition to the gauze bandage, a small gauze pad is placed in between each finger to prevent what complication? a. To keep fingers in a straight position. b. To pad between fingers so there is no skin to skin contact under the bandage. c. To prevent bleeding upon removing the bandage. d. To decrease risk of wound infection.

c

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client? a. Do not change the bed linens until the client is experiencing less pain. b. Change the bed linens from the bottom to the top. c. Change the bed linens from the top to the bottom. d. Change the bed linens from the left to the right side.

a

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action? a. Provide client comfort b. Remove soiled linens c. Prepare the client to receive visitors d. Tidy up the client's room

c

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? a. Identify the client using two client identifiers. b. Twist and break the seal on the culture tube. c. Remove gloves and perform hand hygiene. d. Assess and clean the wound per orders.

b

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? a. Obtain the wound culture. b. Clean the wound. c. Dress the wound. d. Document the procedure.

b

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment? a. vital signs b. cognitive function level c. medication allergies d. lower extremity muscle strength

c

The nurse is demonstrating proper ambulation technique with crutches to a child with a fractured ankle. What is priority assessment should the nurse perform? a. neurovascular status b. neuromuscular status c. weight bearing status d. pain status

b

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? a. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. b. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. c. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. d. Don a second pair of sterile gloves over the first pair.

a, d, e

The nurse is explaining the benefits of cold therapy to a client. What should the nurse include in the teaching plan? Select all that apply. a. Slows the transmission of pain stimuli b. Increases perfusion to the wound site c. Causes blood vessels to dilate d. Reduces bleeding and hematoma formation e. Reduces swelling and inflammation

b

The nurse is helping a client perform range-of-motion exercises on the hand and fingers. Which exercise would be performed first? a. Make a fist and relax it. b. Flex the hand down and backward and relax. c. On both hands, touch the thumb to each finger. d. Spread the fingers out and relax them.

b, c

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate? Select all that apply. a. Ask the client, "When was the last time you ate?" b. Firmly grasp the client's gait belt. c. Support the client's body against the nurse and gently slide the client onto the floor. d. Apply oxygen and wait several minutes for the weakness to pass. e. Ask the client to lean against the wall while the nurse obtains a wheelchair.

a

The nurse is helping a client with a weak left leg to a standing position for an assist into a wheelchair. What action would the nurse take to accommodate this weak extremity? a. Brace the front knee against the client's left leg. b. Position the right leg on the floor with the left leg flexed. c. Place a brace on the client's left leg. d. Brace the front knee against the client's right leg.

d

The nurse is helping a client with musculoskeletal alterations to perform range-of-motion exercises. In what order would the nurse perform the exercises for the client? a. From the head, to the arms, to the legs. b. From the feet, to the arms, to the head. c. From the arms, to the head, to the legs. d. From the head and down one side of the body at a time.

a

The nurse is instructing a client to perform range-of-motion exercises on the head. Which statement accurately describes a recommended movement? a. Move the chin down to rest on the chest. b. Roll the head around in a clockwise motion. c. Move the head backwards as far as it will go. d. Move the head around in a counter-clockwise direction.

b

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? a. When all the irrigation solution is finished b. When the solution from the wound flows out clear c. When the solution from the wound flows out a pink color d. When the solution from the wound flows out a red color

b

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution? a. Used wound dressing b. Sterile basin c. Waterproof pad d. Gauze

b

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens? a. Sitting up b. Lying on one side c. Lying prone d. Lying flat

b

The nurse is monitoring a client receiving an IV infusion to replace fluids lost during surgery and notices air bubbles in the tubing above the roller clamp. Which action would be most appropriate? a. Disconnect the tubing from the client to purge the air from the tubing. b. Remove the bubbles by closing the roller clamp, stretching the tubing downward and tapping the tubing with a finger. c. Change the IV solution administration set immediately. d. Make sure the flow clamp is open and that the drip chamber is approximately half full.

d

The nurse is monitoring an IV site for a client who reports that the needle feels "funny." What should the nurse do first? a. Discontinue the IV infusion and notify the health care provider. b. Reassure the client that this is a normal feeling associated with an IV infusion. c. Remove the catheter and apply a gauze dressing. d. Check the integrity of the IV system, IV solution and tubing, and flow rate.

b

The nurse is moving a client from bed to a wheelchair using a powered full-body sling lift. Where would the nurse position the frame of the lift? a. At the head of the bed. b. Centered over the client. c. To the working side of the bed. d. At the foot of the bed.

a

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? a. Sterile drape positioned with the moisture-proof side facing up b. Sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field c. Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field d. Sterile drape hanging off the work surface

a

The nurse is observing the client's caregiver apply a figure-eight bandage to the client's ankle. The caregiver begins wrapping the elastic bandage around the ankle and unrolls the entire bandage before wrapping the ankle in figure-eight fashion. What should the nurse instruct the caregiver? a. Re-roll the bandage, wrap twice around the ankle, and then alternate with the bandage rolled ascending and descending with every turn. b. Re-roll the bandage, wrap twice above the ankle, and then alternate with the bandage rolled ascending and descending with every turn. c. Continue wrapping the ankle alternating ascending and descending with every turn. d. Re-roll the bandage, wrap twice around the foot, and then alternate with the bandage rolled ascending and descending with every turn.

c

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next? a. Dry the wound bed using a sterile sponge. b. Open the culture tube and apply the swab to the wound bed. c. Cleanse the wound with a nonantimicrobial cleanser. d. Assess the drainage for amount, type, color, and odor.

b

The nurse is opening a package containing a sterile drape to establish a sterile field. Which occurrence would indicate that the nurse had contaminated the sterile drape? a. The nurse places the shiny side of the drape facing down. b. The nurse allows the drape to touch his or her body. c. The nurse touches the sterile drape by its corners. d. The nurse allows the drape to unfold gently.

c

The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves? a. The nurse touches one glove to the other glove. b. The nurse picks up a sterile dressing from the sterile field. c. The nurse touches the client's skin with one hand. d. The nurse keeps both hands above waist level.

d

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? a. Notify the health care provider of the findings. b. Document the findings in the client's medical record. c. Gently rub and massage the area to warm it up. d. Discontinue the therapy and assess the client.

d

The nurse is performing hand washing using soap and water after providing client care. The nurse has performed hand hygiene using soap and water. What action would the nurse take next? a. Apply an oil-free lotion to both hands. b. Use an alcohol-based handrub. c. Turn off the water at the faucet. d. Dry the hands with a paper towel.

a

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate? a. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. b. Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing. c. Fill the wound with sterile saline gel and cover with a large transparent dressing. d. Instill 50 mL of normal saline into the wound and loosely cover with packing material.

a

The nurse is planning to use a pre-packaged kit to prepare a sterile field. Which would be of least importance in ensuring the sterility of the kit? a. The outer wrapper is disposed in an appropriate receptacle. b. The kit is dry. c. The kit is unopened. d. The expiration date is not yet reached.

a

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound? a. From the upper end of the wound to the lower end b. From the lower end of the wound to the upper end c. From the right side of the wound to the left side d. From the left side of the wound to the right side

b

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? a. Sitting up. b. Lying flat. c. Lying prone. d. Lying flat with feet raised slightly.

c

The nurse is preparing a client to move from the bed into a wheelchair. What motion would the nurse use when assisting the client to sit up on the side of the bed? a. Twist the back and lift the client's trunk and shoulders. b. Pivot on the front leg to lift the client's trunk and shoulders. c. Pivot on the back leg to lift the client's trunk and shoulders. d. Pivot on the front leg and pull the client forward to the edge of the bed.

d

The nurse is preparing a sterile field using a pre-packaged kit. After performing hand hygiene, which action would the nurse take next? a. Remove the outer wrapper from the kit b. Place the package in the center of the work surface c. Place the work surface at waist height d. Confirm the client's identity

c

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, what temperature range will the nurse set the pad? a. 100°F to 104°F (37.7°C to 40°C) b. 110°F to 115°F (43.3°C to 46.1°C) c. 105°F to 109°F (40.5°C to 43°C) d. 90°F to 99°F (32.2°C to 37.2°C)

d

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens? a. Sit the client up and roll the soiled linens from the top of the bed until they meet the client's backside. b. Help the client to a supine position in the bed and pull the sheets from the top to the bottom of the bed. c. Raise the client's legs and roll the linens from the bottom of the bed to the client's buttocks. d. Keep the blanket in place over the client to provide privacy and remove the top sheet.

a

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? a. The client's comfort and effectiveness of pain medication b. Any physical limitations the client may have c. The client's temperature and pulses d. Color of drainage on the wound dressings

c

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure? a. Identify the client. b. Perform hand hygiene. c. Check the client's chart. d. Provide for privacy.

b

The nurse is preparing to move a client up in bed with the assistance of another nurse. In what position would the nurse place the client, if tolerated? a. Reverse Trendelenburg. b. Supine. c. Semi-Fowler's. d. Sitting.

c

The nurse is preparing to move a client using a powered full-body sling lift. Which action is recommended in this procedure? a. Lower the side rail on the opposite side of the bed being worked on. b. Place the sling evenly on top of the client. c. Lower the side rail on the side of the bed being worked on. d. Roll the client to the middle of the bed.

5, 6, 3, 2, 1, 4

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. 1) Pat the hands dry with a paper towel. 2) Wash the palms and backs of the hands for at least 20 seconds. 3) Apply soap. 4) Turn the faucet off with a paper towel. 5) Turn on the faucet and adjust the force and temperature of the water. 6) Wet the hands and wrists.

b, c, d,

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply. a. After cleaning, insert the lower denture followed by the upper denture. b. Use a toothbrush and paste to gently brush all surfaces. c. Provide privacy while the client removes dentures from the mouth. d. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. e. Use a sterile 4 × 4 gauze to remove debris from the gums and mucous membranes. f. Rinse the dentures with normal saline if the client is dehydrated.

a

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? a. Raise the bed to elbow height. b. Gather all necessary equipment. c. Position the client. d. Maintain a sterile field.

b

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? a. Thumb and fifth finger b. Thumb and forefinger c. Index and second finger d. Second, third, and fourth fingers

d

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure? a. Use a rinse to clean the dentures, not a toothbrush and toothpaste. b. Store the dentures in a cup filled with mouthwash. c. Place the removed dentures on a paper towel. d. Apply gentle pressure with a piece of gauze to remove the upper dentures.

b, c, d, e

The nurse is providing nail care to a client. Which assessment findings require notification of the client's health care provider? Select all that apply. a. Chipped and cracked nail polish present to all toes b. Red and swollen skin around the great toe c. Nails curled around the tip of the toes d. Bleeding under the nail bed and from the sides of the toes e. Blackened great toe nail

d

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client? a. Semi-Fowler's b. Supine c. Prone d. Side-lying

d

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority? a.Preventing dental caries b. Preventing deterioration of the oral cavity c. Promoting the client's sense of well-being d. Decreasing the incidence of hospital-acquired pneumonia

a

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client? a. Suction toothbrush b. Emesis basin c. Toothpaste d. Towel

2, 4, 1, 6, 3, 5

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Place the following instructions in the correct order. Use all options. 1)"Place your unaffected leg on the first stair tread." 2)"Place both crutches under your left arm." 3)"Move up onto the stair tread." 4)"Grasp the stair railing with your right arm." 5)"Move your crutches and the affected leg up onto the stair tread." 6)"Transfer your weight to the unaffected leg."

c

The nurse is putting on sterile gloves. Which principle would be important to keep in mind? a. The cuffs of the gloves should be adjusted as each glove is applied. b. The outer edge of the cuff is used to pick up the glove to be put on. c. The hands should remain above waist level at all times. d. The inner package should be placed on the surface with the cuff side away from the body.

c

The nurse is removing a gown after providing care to a client. Which action would the nurse take first? a. Pull the gown away from the torso. b. Allow the gown to fall away from the shoulders. c. Unfasten the ties at the neck and back. d. Turn the gown inside out.

b

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? a. Tell the client that this is a life-threatening situation and that the health care provider will be called. b. Assess for pain, shortness of breath, and abdominal pressure. c. Leave the wound open and notify the health care provider. d. Place the client in a sitting position to reduce pressure on the abdomen.

b

The nurse is required to wear a gown, gloves, goggles, and mask as personal protective equipment (PPE) when caring for an assigned client. What should the nurse put on first? a. Goggles b. Gown c. Mask d. Gloves

a

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? a. Remove the IV catheter and reinsert another in a different location. b. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. c. Apply a new dressing and observe for signs of infection over the next several hours. d. Decontaminate the visible portion of the catheter, and then gently reinsert.

a

The nurse is talking to a client who has been using crutches for ambulation. The client reports intermittent numbness of the upper arms. What should the nurse instruct the client to avoid? a. leaning for prolonged periods by the axilla on the crutches b. using non-padded crutches c. using a four-point gait d. re-adjusting the height of the crutches

d

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching? a. "I will use a special denture cleaner to remove food that does not come off with brushing." b. "I will store my dentures in cold water when I sleep." c. "I will never place my dentures beside me in bed." d. "When I eat, I will remove my dentures and place them in a napkin."

c

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching? a. "I will use warm water and shave cream to soften the hair." b. "I will shave in smooth, short strokes to prevent discomfort." c. "I will pull the skin taut to reduce the risk for ingrown hairs." d. "I will shave in the direction of hair growth to prevent discomfort."

c

The nurse is teaching a client how to perform range-of-motion exercises on the toes. What motions would be accomplished by curling the toes downward, spreading the toes apart, and then bringing them together? a. Rotation, dorsiflexion, and plantar flexion. b. Flexion, inversion, and eversion. c. Flexion, extension, abduction, and adduction. d. Rotation, extension, abduction, and adduction.

b, c, d, e

The nurse is teaching a client the purpose of using an external heating pad. What should the nurse include in the teaching plan? Select all that apply. a. It promotes healing by decreasing perfusion to the site and decreasing edema. b. It promotes healing by accelerating the body's natural inflammatory response. c. It can be used to treat inflammation, chronic pain, and surgical wounds. d. It reduces the discomfort of muscle tension and muscle spasms. e. It helps to relieve pain from arthritis and joint stiffness.

a, d, e

The nurse is teaching a client with peripheral vascular disease about foot care. What will be included in the teaching plan? Select all that apply. a. Schedule foot exams with podiatrist at least once per year. b. Dry feet thoroughly and apply lotion between the toes. c. Inspect feet once a week and report any problems to the podiatrist for early intervention. d. Wear appropriate footwear. e. See a podiatrist for treatment for bunions.

d

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development? a. Keep the head of the bed elevated 35 degrees. b. Pull the client up in the bed very gently. c. Gently massage any reddened areas for several minutes. d. Turn and reposition the client every 2 hours.

a

The nurse is teaching proper cane use to a client who has had ankle surgery. The client has been cleared to begin bearing weight on the affected leg. What outcome would be unexpected? a. The client reports increased strength in the weaker leg. b. The client demonstrates proper use of the cane. c. The client uses the cane to ambulate safely without falls. d. The client demonstrates increased independence.

a

The nurse is transferring a client from the bed into a wheelchair. Where would the nurse be positioned when assisting the client to stand? a. As close to client as possible, with a foot positioned on the outside of the client's foot. b. As close to client as possible, with both feet positioned on the inside of the client's feet. c. As close to client as possible, with a foot positioned one foot away from the client's foot. d. As far away from client as possible, with a foot positioned on the outside of the client's foot.

a

The nurse is transferring a client out of bed using a powered full-body sling lift. How high above the bed should the nurse use the lift to raise the client? a. 6 in (15 cm) b. 24 in (60 cm) c. 18 in (45 cm) d. 3 in (7.5 cm)

c

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse? a. Quickly pivot the client into the wheelchair to prevent client fall. b. Have the client stand without moving to see if the dizziness will pass. c. Firmly grasp the gait belt and gently lower the client into bed. d. Apply oxygen 2L via nasal cannula to the client.

c

The nurse is turning a client in bed. Where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed? a. At the client's feet. b. At the client's head. c. Opposite the center of the client's body. d. At the center of the client's body.

a

The nurse is wearing a gown and gloves as part of using personal protective equipment. The gown is tied in the front at the waist and at the neck. Which action would the nurse take first? a. Unfasten the gown at the waist. b. Pull off both gloves at the cuff area. c. Remove the glove from the dominant hand. d. Untie the gown at the neck.

a

The nurse is wearing a gown as part of using personal protective equipment and is preparing to put on clean disposable gloves. Which placement indicates that the nurse has put on the gloves properly? a. The glove ends extend to cover the gown's cuffs. b. The edges of the gloves are under the gown's cuffs. c. There is a 1-in (2.5-cm) space between the gown's cuffs and the gloves' edges. d. The ends of the gloves are folded over onto the glove.

d

The nurse knows that monitoring the infusion rate and IV site is a nursing responsibility. When does the nurse routinely monitor client IVs? a. End of the work shift. b. Upon admission. c. Upon discharge. d. Beginning of the work shift.

b

The nurse making an occupied bed. Under which body part of the client would the nurse place the drawsheet? a. Buttocks b. Midsection c.Head d. Feet

d

The nurse moves a client's leg laterally away from the client's body and then crosses it over the other leg. What joint or muscle is the nurse exercising? a. Knee b. Toes c. Ankle d. Hip

b

The nurse need to place a dressing under and around a Penrose drain. Which dressing would be best for the nurse to obtain? a. Nonadherent petrolatum dressing gauze b. A precut 4 × 4 sterile drain sponge c. Roll of sterile prewoven gauze d. Sterile 2 × 2 gauze sponge

d

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? a. Remove the gauze from the package with one sterile hand. b. Lay the item in an open package on the 1-in (2.5-cm) border. c. Extend the sterile field by laying the open package beside it. d. Drop the item from 6 in (15 cm) above the sterile field.

d

The nurse notes an unexpected decrease in the amount of drainage in a client's T-tube drain. What action should the nurse take next? a. Change the dressing surrounding the drain. b. Increase the suction to the drain. c. Document the decrease in drainage. d. Assess for any kinks in the tubing.

b

The nurse notes that a health care provider failed to observe transmission precautions in a client's room and is entering another client's room. What is the nurse's next action? a.Ask the charge nurse to speak with the health care provider. b. Remind the health care provider about the transmission precautions. c. Report the health care provider to the unit supervisor or manager. d. Insist the health care provider observe additional hand hygiene.

b

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated? a. Limited range of motion b. Active range of motion c. Passive range of motion d. Active assistive range of motion

a

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need? a. "Place all four feet of the walker on the ground before stepping forward." b. "Place the front two feet of the walker on the ground as you step forward." c. "Drag the rear feet of the walker with you as you step forward." d. "When stepping forward, always lead with your left leg."

a

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? a. Stage 1 pressure injury b. Stage 2 pressure injury c. Unstageable, skin intact d. Deep tissue injury

c

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take? a. Slide the gloves out of the package. b. Reach under the package folds to open. c. Open the top and bottom folds completely. d. Obtain a new pair of sterile gloves.

a

The nurse performs hand hygiene using an alcohol-based handrub after exiting a client's room. The nurse does not touch another surface or client until what has occurred? a. The antiseptic has evaporated from the skin. b. Twenty to thirty seconds of hand rubbing has occurred. c. Hand hygiene performance has been documented. d. The hands have been dried with a paper towel.

a

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take? a. Take a few steps around the table to pick up the additional supplies. b. Reach toward the other end of the table and pick up the supplies. c. Prepare a second sterile field to cover the entire table surface. d. Discard the current sterile field and supplies and begin again.

b

The nurse prepares for a sterile procedure. What action does the nurse perform first? a. Identify the client the procedure is prescribed for. b. Perform hand hygiene with alcohol-based handrub. c. Put on personal protective equipment, if required. d. Place all the necessary supplies in the room.

c

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next? a. Begin cleansing the meatus with antiseptic. b. Dispose of the catheter kit and begin again. c. Change into a new pair of sterile gloves. d. Position the catheter kit closer to the client.

a

The nurse prepares to enter a client's room where goggles are required but are not available. Which action by the nurse is best? a. Wear a face shield as part of the protective equipment. b. Wait until material management sends more goggles to the unit. c. Wear a surgical mask and stay 3 ft (1 m) from the client. d. Wait to administer client care until goggles can be located.

c

The nurse prepares to wear personal protective equipment (PPE) when entering a client's room. What action does the nurse take first? a. Open the door to the room. b. Verify the type of precautions. c. Perform hand hygiene. d. Ensure the gown is closed.

c

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client? a. Place pillows behind the client's back. b.Use a client hydraulic lift. c. Ask for help from a staff member. d. Pull the client from side to side.

d

The nurse puts on sterile gloves in preparation for a sterile central line dressing change. The nurse realizes that the bed is too low to complete the procedure adequately. What action does the nurse take? a. Raise the bed using one finger. b. Place clean gloves over the sterile gloves. c.Take off the sterile gloves. d. Ask someone to raise the bed.

b

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct? a. Remove respirator at the doorway of the client's room. b. Touch the inside of the gown and pull it away from the torso. c. Slide one gloved hand under the other glove for removal. d. Remove the goggles before removing other equipment.

b

The nurse should document the time, date, and location of the figure-eight bandage when applied or changed in the nursing record. What other information should the nurse record in the procedure documentation? a. client position b. size of bandage c. informed consent d. medication allergies

a

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? a. Pour the liquid into a sterile container within the sterile field. b. Pour the liquid into the cap of the bottle and dip the gauze as needed. c. Pour the liquid into the palm of a sterilely gloved hand for use. d. Pour the liquid onto gauze on the sterile field until the gauze is moist.

a

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take? a. Change to a clean wipe after each stroke. b. Use multiple wipes to create a thicker wipe. c. Alternate wipes with reusable wash cloths. d. Flush cleansing wipes after perineal care is complete.

c

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing? a. Washing to 1 in (2.5 cm) below the elbows b. Drying the hands, then fingers c. Using a rubbing, circular motion d. Keeping the hands above the elbows

c

The nurse wears personal protective equipment (PPE) when entering the client's room. What is the nurse's goal in wearing PPE? a. To prevent the client from touching the nurse b. To adhere to facility policy c. To prevent infection transmission d.To protect the client from the nurse's organisms

b

The nurse wraps the sleeves of a pneumatic compression device around the legs of a client. How would the nurse determine if the fit is correct? a. Three fingers should fit between the leg and the sleeve. b. Two fingers should fit between the leg and the sleeve. c. The nurse's fist should fit between the leg and the sleeve. d. One finger should fit between the leg and the sleeve.

b

The nurse, who is monitoring the IV site of a client receiving peripheral venous fluid therapy, checks for bleeding at the site. The nurse understands that bleeding at an IV site is most likely to occur at which time? a. When the IV is initiated. b. When the IV is discontinued. c. When the IV solution is changed. d. When the IV is infusing.

b

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? a. The student rolls gloves into each other during removal for disposal in the waste can. b. The student pulls the gloves off starting with the fingertips prior to removal. c. The student uses one gloved hand to grab the outside surface of the other glove. d. The student reaches under the glove on one hand to peel the glove off of the other hand.

a

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond? a. "Mouth care during this time helps prevent complications." b. "It is comforting to have moist oral mucosa during this time." c. "Without swallowing, bacteria get trapped in the mouth." d. "Dental care is still important, even when not chewing."

d

Three nurses are following guidelines for safe client handling and are transferring a client from bed to a stretcher. Which description is correct, once the stretcher is placed next to the bed? a. One nurse stands beside the stretcher, one nurse stands on the opposite side of the bed, and the third nurse stands at the client's feet. b. One nurse stands beside the stretcher, one nurse stands on the opposite side of the bed, and the third nurse helps support the client as needed. c. One nurse stands on the side of the bed with the stretcher; two nurses stand on the opposite side of the bed. d. Two nurses stand beside the stretcher; one nurse stands on the opposite side of the bed.

d

Three nurses are transferring a client from the bed to a stretcher. Which action by the nurse is appropriate once the client is transferred to the stretcher? a. Turn the client on the side, against the side rails, until transfer is complete. b. Keep the transfer board in place for the return transfer. c. Cover the client with a bath blanket and remove the friction-reducing sheet. d. Leave the friction-reducing sheet in place for the return transfer.

a, c, d, e

To assess for circulatory compromise, what assessments will the nurse perform at the site of application before applying a warm compress? Select all that apply. a. Evidence of edema b. Respiratory rate c. Skin color d. Distal pulses e. Presence of sensation

d

To ensure the early detection of problems, at a minimum, how often should the nurse check the T-tube drain? a. Every shift b. Every hour c. Every day d. Every 4 hours

b

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? a. Shift their weight back and forth from the legs to the back muscles. b.Shift their weight back and forth, from back leg to front leg. c.Turn the client from side to side while pushing upward. d. Rock the client back and forth to raise the client up in bed.

b

What action does the nurse perform to remove gloves after performing a sterile procedure? a. Pull the glove off starting at the fingers. b. Invert the glove as it is removed. c. Place the first removed glove in the waste. d. Lay the first removed glove in the sterile field.

b

What action should the nurse take when changing a sterile dressing on a central venous access device? a. Position the sterile dressing supplies on the table between the nurse and client. b. Cleanse the central venous access device site while wearing sterile gloves. c. Place sterile gloves on before removing the existing dressing. d. Leave the bed in a low position if the side rail will need to be lowered.

a, b, c, e

What are the expected outcomes when caring for a T-tube drain? Select all that apply. a. The client does not experience pain or discomfort. b. The drain will remain patent. c. Care is accomplished without causing trauma to the wound. d. The client is able to get out of bed without assistance. e. Care is accomplished without contaminating the wound.

c

What is the best source for the nurse to determine the type of transmission precautions a client needs? a. Charge nurse's report b. Sign on the client's room c. Client's medical record d. Health care provider

b

What is the best way for the nurse to clean the wound site in a client with a Penrose drain? a. in an up-and-down pattern beginning on left side of pin and then to right side b. in a circular motion beginning at the pin site and moving outward toward the edge of the wound c. in a wedge pattern from pin site to outer edge of wound and repeat d. in a circular motion beginning at the outer edge of the wound and moving in toward the pin site

a

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? a. Secure the drain to the client's gown with a safety pin below the level of the wound. b. Allowed the Jackson—Pratt drain to hang freely to avoid any kinks in the tubing. c. Tape the drain to the dressing material securely below the level of the wound. d. Apply an abdominal binder over the entire wound and drain to support the site.

c

What motion is being provided for the shoulder when the nurse raises a client's arm at the side until the upper arm is in line with the shoulder, bends the elbow at a 90-degree angle, moves the forearm upward and downward, and returns the arm to the side? a. Flexion b. Adduction c. Rotation d. Abduction

a, b, d, e

What should the nurse assess before application of sitz bath therapy? Select all that apply. a. client's ability to sit for 15 to 20 minutes b. client's ability to ambulate to the bathroom c. client's serum sodium levels d. client's need to void e. client's perineal/rectal area

c

What should the nurse teach the client about climbing stairs with a cane? a. The client should place the cane one step above and use the weaker leg to pull the stronger leg upward. b. The client should advance the weaker leg up the stair first, followed by the cane and stronger leg. c. The client should advance the stronger leg up the stair first, followed by the cane and weaker leg. d. The client should place the cane one step above and use the stronger leg to pull the weaker leg upward.

d

What would be most important to document after shaving a client? a. Time shaving was completed b. That aftershave lotion was applied c. Type of shaving cream used d. That the chin was nicked with the razor

c

What would the nurse do with the sling of a full-body sling lift once the client has been lowered into a chair? a. Remove the sling and clean it according to manufacturer's directions. b. Remove the sling and fold it for later use. c. Leave the sling in place under the client. d. Remove the sling and dispose of it in appropriate manner.

a

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed? a. Ease the clean linens under the client, from the top to the bottom of the bed. b. Fold two bottom linens in half and place one at the top of the bed and one at the bottom. c. Apply the bottom sheet, securing it at the bottom of the bed. d. Pull the clean linens under the client from the bottom to the top of the bed.

b

When adding sterile items to a sterile field, the nurse would drop the sterile items from which height? a. 10 in (25 cm) b. 6 in (15 cm) c. 14 in (35 cm) d. 2 in (5 cm)

a

When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who: a. requires that the heat penetrate deeply into the tissues. b. has a wound with inflammation. c. has chronic arthritic joint pain. d. needs relief from muscle tension and occasional spasms.

c

When applying an external heating pad, which prescription from the health care provider would the nurse question? a. Maintain the temperature between 105°F to 109°F (40.5°C to 43°C). b. Assess site frequently during application of the heating pad. c. Leave heating pad on for 40 to 45 minutes, then off for 2 hours. d. Use gauze to secure the heating pad to the site of application.

b

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? a. Stage 2 pressure injury b. Deep tissue injury c. Stage 1 pressure injury d. Unstageable, skin intact

a

When assessing the area of application of a warm compress, the nurse observes skin maceration of the surrounding area, and the client reports increased discomfort. What should the nurse do first? a. Stop the heat application and completely remove the compress. b. Document the event in the client's medical record. c. Notify the health care provider of the client's report of increased discomfort. d. Administer the prescribed PRN analgesic.

d

When assisting a client from bed to a chair, the nurse counts to three prior to assisting the client to a standing position. What muscle group would the nurse use to assist? a. Back b. Gluteal c. Abdominal d. Leg

b

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client? a. Circulatory alterations. b. Orthostatic hypotension. c. Hypertension. d. Deep vein thrombosis.

d

When assisting a client from the bed into a wheelchair, the nurse assesses the client when standing up and notices that the client is weak and unsteady. What would be the recommended nursing intervention in this situation? a. Use the call bell to summon the assistance of another nurse. b. Allow the client to keep standing for several minutes until balance returns. c. Place the client into the wheelchair. d. Return the client to the bed.

c

When assisting a client into a wheelchair, what action would the nurse take to ensure the client is properly positioned before sitting down in the wheelchair? a. Have the client hold on to the nurse's shoulders and turn. b. Using the back and arm muscles, assist the client to turn toward the wheelchair. c. Pivot on the back foot and assist the client to turn until the client feels the wheelchair against the legs. d. Pivot on the front foot and assist client to turn until the client appears to be near the wheelchair.

d

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results? a. Pushing motion b. Back-and-forth motion c. Up-and-down motion d. Rolling motion

c

When evaluating the effectiveness of sitz bath therapy, what outcome will the nurse expect? a. increased comfort of client b. decreased need for dressing changes c. increased drainage from wound site d. decreased anxiety of client

c

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure? a. Shake the bottle of irrigating solution before pouring. b. Discard any irrigation solution remaining in the bottle. c. Date and reuse leftover irrigation solution within 24 hours. d. Pour the chilled irrigating solution into the irrigation container.

b

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe? a. Cleaning the tip of the syringe with an alcohol wipe after each use b. Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound c. Directing the flow of irrigating solution from the top of the wound d. Positioning the client to face away from the sterile supplies

b

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action? a. Remove the old linens out from under the client. b. Raise the side rail. c. Push the client to the other side of the bed. d. Move to other side of bed.

a

When monitoring the peripheral access IV sites of various clients receiving IV therapy, the nurse would assess closely for which finding as the most common complication related to IV therapy? a. Phlebitis b. Infection c. Thrombus d. Sepsis

a

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position? a. To prevent hyperextension of the neck. b. To prevent pressure on the arms. c. To decrease the effort needed to move the client. d. To lower the client's center of gravity.

c

When opening a pre-packaged kit to prepare a sterile field, which would be important to keep in mind? a. The outside surface of the outer wrapper becomes the sterile field. b. The edges of the wrapper are positioned to hang below the edges of the work surface. c. The inner surface of the outer wrapper is considered sterile. d. The outer 2-in (5-cm) border of the wrapper is considered contaminated.

c

When preparing a sterile field, which action would be appropriate for the nurse to take first? a. Open any sterile items to be used. b. Put on sterile gloves. c. Check the packages for expiration date. d. Place the work surface at chest height.

a

When providing oral care to an unconscious client, the nurse takes which action? a. Ensure there is a towel and basin positioned for drainage. b. Have endotracheal suction supplies at the bedside. c. Brush the tongue and each tooth surface multiple times d. Place the head of the client's bed in high-Fowler's position.

c

When putting on the second sterile glove, the nurse places the gloved thumb at which location? a. Adjacent to the fifth finger b. Under the fingers, as in a fist c. Outward away from the gloved hand d. Close to the palm of the gloved hand

d

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? a. Ecchymosis. b. Sinus tract. c. Undermining. d. Dehiscence.

b

When removing soiled gloves, which action should the nurse take? a. Grab the gloved dominant hand at the wrist using the fingers of the non-dominant hand to invert the glove. b. Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside. c. Pull on the fingertips of the gloved non-dominant hand using the fingers of the gloved dominant hand. d. Slide the fingers of the gloved non-dominant hand between the skin and glove of the dominant hand.

a

When removing soiled gloves, which should the nurse do first? a. Grasp the outside of one glove with the opposite gloved hand. b. Slide the fingers under the glove at the wrist. c. Turn the glove inside out as it is being pulled off. d. Peel the glove off over the other glove

a

When removing the old dressing from the site of a Penrose drain, the nurse notes that some of the dressing material has stuck to the client's skin. What action should the nurse take next? a. Apply sterile saline to loosen the dressing material from the skin. b. Use an alcohol based adhesive remover to aid in the removal of the dressing. c. Administer an analgesic to the client and warn the client this may be a little painful. d. Gently pull the dressing material off the client's skin and observe for irritation.

d

When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which action would the nurse take first? a. Pull the corners of the wrapper back toward the wrist. b. Hold the package in the non-dominant hand. c. Reach over the package to open the side flaps. d. Unfold the top flap away from the body.

b

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure? a. To lift the client off the bed. b. To reduce friction as the client is pulled laterally onto the stretcher. c. To protect the client's head from hitting the headboard. d. To slide the board with the client onto the stretcher.

c

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? a. Arm b. Chest c. Leg d. Back

a

When turning a client in bed, what positioning instructions would the nurse give the client before using the friction-reducing sheet to turn the client? a. Cross the arms across the chest and cross the legs. b. Keep the arms at the sides and the legs crossed. c. Cross the arms across the chest and keep the legs straight. d. Keep the arms folded loosely at the abdomen and the legs straight.

c

When washing the hands with soap and water what is an appropriate action for the nurse to perform? a. Rub each hand with soap individually. b. Lean as close to the sink as possible. c. Keep the hands below the elbows. d. Remove jewelry prior to turning on water.

c

Where should the nurse position the drain collection bag for the T-tube drain to facilitate proper drainage? a. Anywhere on the bedside rails. b. Below the client's heart level. c. Below the level of the wound. d. Above the client's waist.

d

Where should the nurse roll soiled linens when removing them from an unoccupied bed? a. Inside the top sheet b. On the bedside table c. On the floor d. Inside the bottom sheet

d

Which action by the nurse is most important to ensure the client's safety when changing a peripheral venous access device dressing? a. inspecting the access site for redness and inflammation b. gathering all equipment before entering the client's room c. using a semi-permeable dressing to cover the site d. placing the bed in the lowest position before leaving the room

a, c, e, f

Which are basic principles of surgical asepsis? Select all that apply. a. Only a sterile object can touch another sterile object. b. Forceps soaked in disinfectant can be used to add items to a sterile field. c. Never turn the back on a sterile field. d. Hold sterile objects at hip level or above. e. Avoid talking, coughing, sneezing, or reaching over a sterile field. f. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated.

a

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Brushing the dentures b. Planning when denture care will be implemented c. Assessing the oral cavity for inflammation d. Teaching the client about importance of denture care

b, c, e

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. a. Skin around injury is red and warm to touch b. Visible subcutaneous fat c. No bone, tendon, or muscle visible. d. Drainage is foul smelling and green in color e. Full-thickness tissue loss

d

Which client is a greatest risk of developing a pressure injury? a. 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance b. 25-year-old client on bed rest for 24 hours following a procedure c. 17-year-old client postoperative for fracture of the upper extremity d. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness

a, b, d

Which client will the nurse expect to be prescribed sitz baths? Select all that apply. a. client who had surgery to the perineum b. client after childbirth c. client after repair of a femur fracture d. client who had rectal surgery e. client who had a hip replacement surgery

c

Which client would be at greatest risk for developing a pressure injury? a. Client who is delirious after taking pain medications b. Older adult client who has chronic obstructive pulmonary disease (COPD) c. Adult client who is comatose d. Adolescent client with a cast on the left leg

b

Which client would be at highest risk for experiencing fluid overload as a complication of IV therapy? a. An adult injured in a car accident receiving medication via an IV infusion. b. An older adult client receiving an IV infusion for pneumonia. c. A teenager receiving an IV infusion for dehydration. d. An infant receiving an IV infusion for bronchitis.

b, c, d, e

Which clients will the nurse recognize are at an increased risk of thermal injury when using an external heating pad? Select all that apply. a. Client who is experiencing joint pain. b. Client who has peripheral neuropathy. c. Client who has diabetes. d. Client who is an older adult. e. Client who has a spinal cord injury.

a

Which describes an accurate step taken by the nurse when applying a pneumatic compression device on a client? a. Unfold the sleeves and place them on the bed with the inner lining facing up. b. Put on sterile gloves and remove the sleeves from the packaging. c. Place the sleeve on top of the client's leg with the tubing toward the heel. d. For knee-high sleeves, place the end of the sleeve above the back of the ankle.

b, d, e

Which hospitalized clients are good candidates for capping of an existing intravenous line for intermittent use? Select all that apply. a. Client who is solely receiving normal saline at 60 mL/hour. b. Client who is only receiving fluids at a keep-vein-open rate. c. Client who is tolerating the clear liquid diet without complication. d. Client who needs infusions of an antibiotic only every 12 hours. e. Client who no longer requires intravenous infusions.

b

Which includes practices used to render and keep objects and areas free from microorganisms? a. Medical asepsis b. Surgical asepsis c. Clean technique d. Hand hygiene

b

Which item would the nurse remove first when removing personal protective equipment? a. Face shield b. Gloves c. Gown d. Mask

a, d

Which methods can be used to remove a client's soft contact lenses? Select all that apply. a. Use the pads of the index finger and thumb to gently pinch and remove the lens. b. Apply gentle pressure to the lower eyelid until the lens pops out. c. Use a commercially available tool with a small suction cup. d. Ask the client to remove them, if able. e. Use two cotton-tipped applicators to gently grasp the lens.

c

Which question by the nurse, to the client, will best help evaluate the outcome of having applied cold therapy? a. "Have you noticed any increase in the wound drainage?" b. "Can I help you get up to the chair now?" c. "Do you feel your muscle spasms have decreased?" d. "Does your dressing feel like it is too tight?"

c

Which should be documented by the nurse? a. The fact that the nurse washed her hands before a procedure. b. The specific items that the nurse transferred into a sterile field. c. The fact that sterile technique was used for a given procedure. d. The fact that the nurse donned gloves two different times during a procedure.

a

Which situation would warrant the need for the nurse to change a client's venous access dressing? a. The skin around the site is wet. b. The tubing is looped near the site of entry. c. The IV infusion rate has slowed. d. The client is complaining of pain at the site.

c

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure? a. If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. b. An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection. c. If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair. d.Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant.

a

While assessing a client receiving peripheral IV therapy as part of the treatment plan for hypovolemia, the nurse suspects that the client is experiencing fluid overload based on which finding? a. Shortness of breath. b. Pounding headache. c. Change in the level of consciousness. d. Deceased blood pressure.

a

While assessing the IV site of a client who has had abdominal surgery, the nurse suspects infiltration. Which finding would help support the nurse's suspicions? a. Pallor b. Heat c. Redness d. Edema

d

While donning sterile gloves for a client's dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action? a. Continue with the dressing change. b. Use the ripped glove for nonsterile actions. c. Place a new sterile glove over the ripped glove. d. Obtain a new pair of sterile gloves.

d

While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse would be most appropriate? a. Apply a new pair of sterile gloves over the current ones. b. Continue the procedure using only the left gloved hand. c. Cover the contaminated glove with a non-sterile disposable glove d. Replace the current gloves with a new set of sterile gloves.

a

While removing gloves after performing client care, what action does the nurse take? a. Ensure the skin of the hands does not touch the outside surface of the glove. b. Discard each glove separately into the waste receptacle. c. Wrap the discarded gloves inside the sterile field for waste disposal. d. Use hand sanitizer on the surface of the gloves prior to glove removal.

c

Why would the nurse lower the arms of a full-body sling lift when attempting to transfer a client? a. To keep the client from falling out of bed. b. To allow the client to grasp the arms. c. To attach the sling's hooks. d. To keep the client from rolling to the side.

short

________ straps of a lift attach behind the patients back

long

________ straps of a lift attach to the bottom end of the sling

thrombophlebitis

a blood clot that accompanies vein inflammation

autologous transfusion

a blood transfusion donated by the patient in anticipation that he or she may need the transfusion during a hospital stay

fracture

a break in the continuity of a bone

sinus tract

a cavity or channel underneath the wound that has the potential for infection

peripheral venous access device

a short, less than 3 inches peripheral catheter placed in a peripheral vein for ST therapy. This device is not appropriate for certain therapies such as vesicant chemotherapy, drugs classified as irritants or TPN.

aseptic

a sterile field is created to provide a surgically __________ workspace and is considered to be a restricted area

eschar

a thick, leathery scab or dry crust composed of dead cells and dried plasma

tunneled percutaneous central venous catheter

a type of CVAD intended for long-term use -implanted into the internal or external jugular or subclavian vein -length of the catheter is more than 8cm depending on the patient size

nontunneled percutaneous central venous catheter

a type of CVAD that has a short dwell time (3 to 10 days); may have double, triple, or quadruple lumens; are more than 8 cm, depending on patient size; introduced through the skin into the internal jugular, subclavian, or femoral veins and sutured into place; and are mainly used in critical care and emergency settings

implanted port

a type of CVAD; subcutaneous injection port attached to a catheter -distal catheter tip dwells in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium, and the proximal end or port is usually implanted in the subcutaneous pocket of the upper chest wall

central venous access device

a venous access device in which the tip of the catheter terminates in the central venous circulation, usually in the superior vena cava just above the right atrium

dehiscence

accidental separation of wound edges, especially a surgical wound

edema

accumulation of fluid in the interstitial tissues

visibly

alcohol based hand rubs may be used if hands are not ____________ soiled or have not come in contact with blood or blood products

medical technique

also known as clean technique

goniometer

an apparatus to measure joint movement and angles

vasodilation

an increase in the diameter of a blood vessel

contusion

an injury in which the skin is not broken - a bruise

NAP, UAP

assisting a patient to turen in bed may be delegated to a ________ or an ________

flexion

bending of a joint so that the angle of the joint diminishes

medical asepsis

clean technique; involves procedures and practices that reduce the number and transfer of pathogens

jaundice

condition characterized by yellowness of the skin, whites of eyes, muscous membranes, and body fluids as a result of deposition of bile pigment resulting from excess bilirubin in the blood

venous stasis

decrease in blood flow in the venous system related to dysfunctional valves or inactivity of the muscles of the effected extremity

blood typing

determining a person's blood type (A,B,AB, or O)

crossmatching

determining the compatibility of two blood specimens

ecchymosis

discoloration of an area resulting from infiltration of blood into the subcutaneous tissue

pathogen

disease-producing microorganism

approximated wound edges

edges of a wound that are lightly pulled together; epithelialization of wound margins; edges touch, wound is closed

Personal Protective Equipment

equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear

hypervolemia

excess isotonic fluid (water and sodium) in the extracellular space

hyperextension

extreme or abnormal extension -angle greater than 180 degrees

back

for knee high sleeves, make sure the _______ of the ankle is over the ankle marking

popliteal

for total leg sleeves, place the behind the knee opening at the _______ space to prevent pressure there

shearing force

force created by the interplay of gravity and friction on the skin and underlying tissues -shear causes layers to slide over one another and blood vessels to stretch and twist, and disrupts the microcirculation of the skin and subcutaneous tissue

4, 12

have the patient advance the cane _____ to ____ in and then advance the weaker foot forward with weight on the stronger side of the body

hypertonic

having a greater concentration of solutes than solution with which it is being compared

isotonic

having about the same concentration as the solution with which it is being compared

1, 2

if stockings are knee-length make sure each stocking top is ____ to ____ in below the patella

1, 3

if stockings are thigh-length make sure each stocking top is ______ to _____in below the gluteal folds

health care associated infection

infection not present on admission to a health care agency; acquired during the course of treatment for other conditions

healthcare associated infections

infections caused by a wide variety of common and unusual bacteria, fungi, and viruses during the course of receiving medical care

3

initiate ROM exercises as soon as possible because body changes can occur after only _____ days of impaired mobility

ischemia

insufficient blood supply to a body part due to obstruction of circulation

abduction

lateral movement away from the center or median line of the body

adduction

lateral movement toward the center or median line of the body

pressure injury

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

necrosis

localized tissue death

pathogens

microorganisms that can harm humans

vasoconstriction

narrowing of the lumen of a blood vessel

granulation tissue

new tissue that is deep pink/red composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal; characterized by irregular surface-like raspberries

compartment syndrome

occurs when there is increased tissue pressure within a limited space -leads to compromises in the circulation and the function of the involved tissue

tunneling

passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin

undermining

passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin

cannot

patient teaching regarding the use of crutches ___________ be delegated to and NAP

pain

perform a _______ assessment before turning a patient in bed

contracture

permanent shortening or tightening of a muscle due to spasm or paralysis

waterproof

place the ____________ side of the sterile drape facedown on the workspace

trendelenburg

place the bed in slight _______________________ position when moving a patient to the head of the bed

transmission based precautions

precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes

standard precautions

precautions used in the care of all hospitalized patients regardless of their diagnosis or possible infection status

rotation

process of turning on an axis -twisting or revolving

debridement

removal of devitalized tissue and foreign material from a wound

maceration

softening of tissue due to excessive moisture

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

surgical staples

stainless-steel wire (shaped like a staple) used to close a surgical wound

surgical asepsis

sterile technique - involves practices used to render and keep objects and areas free from microorganisms

sterile technique

strategies used in patient care to reduce exposure to microorganisms and maintain objects and areas as free from microorganisms as possible.

nonsterile technique

strategies used in patient care to reduce overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another

ahtroplasty

surgical formation or reformation of a joint

pronation

the act of lying face downward -the act of turning the hand so the palm faces downward or backward

range of motion

the complete extent of movement of which a joint is normally capable

deep vein thrombosis

the formation or development of a blood clot in a blood vessel originating in the large veins of the legs

dehydration

the loss or deprivation of water from the body or tissues

patient care ergonomics

the practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care -it provides a means for adjusting the work environment and work practices to prevent injuries before they occur and is part of best practices for providing safe patient care

extension

the return of movement from flexion -the joint ankle is increased

35, 55

the usual pressure used with a pneumatic compression device is usually between _____ and 55 mmHg

surgical sutures

thread or wire used to hold tissue and skin together

supination

turning the palm or food upward

4

when applying a figure eight bandage assess the distal circulation of the extremity after the bandage is in place at least ever _______ hours thereafter

15, 30

when applying a figure eight bandage elevate the wrapped extremity for ____ to _____ minutes after application of the bandage

1/2, 2/3

when applying a figure eight bandage overlap each turn of the bandage by ______ to _____ the width of the strip

twice

when applying a figure eight bandage wrap the bandage around the limb __________, below the joint, to anchor it

dangle

when assisting a patient from the bed into a chair allow the patients legs to _____________ for a few minutes while sitting on the edge of the bed before continuing with any more steps

stronger

when assisting a patient to ambulate with a cane have the patient place the cane on his or her __________ side close to the body

6, 8

when assisting a patient to ambulate with a walker have them place the walker _____ to _____ in out in front of them making sure all 4 legs of the walker are on the ground

tripod

when assisting a patient to ambulate with crutches make sure the patient is standing erect, face forward in the _________ position

head

when beginning ROM exercises start at the _________

6

when lifting a patient with a lift device raise the patient _____ in above the bed

center

when lifting a patient with a lift place the lift with the ___________ frame over the patient and lock the wheels of the lift

head

when moving a patient up to the head of the bed make sure to remove all pillows, but keep one pillow placed at the _______ of the bed

2

when placing pneumatic compression devices wrap the sleeve snugly around the patient so that _____ fingers fit between the leg and the sleeve

cooling

when pumping up a pneumatic compression device turn on the ____________ setting

15

when putting on graduated compression stockings check if the patient has been sitting or walking, if so have them lie down with feet or legs elevated for at least _____ minutes before applying stockings

active ROM

when the patient does the ROM exercise for themselves

even

when transferring a patient from a bed to a stretcher raise the bed to an _________ height to the stretcher

friction-reducing sheet

when turning a patient in bed place a __________-___________ ____________ underneath the patient

first

when using pneumatic compression devices observe the patient for the __________ cycle then check the sleeves and pumps at least once per shift