PART ONE

The nurse caring for a 3-year-old client notices that he is attempting to pull at his surgical incision site. What would be the best type of restraint to prevent him from doing this? A) Elbow restraint B) Wrist restraint C) Mummy restraint D) Extremity restraint

A) Elbow restraint

What does the 'A' stand for in AIDET?

Acknowledge

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? A) Once the wound is clean, gently dry the wound with an absorbent cloth. B) Clean the wound in a circular pattern, beginning on the perimeter of the wound C) Use clean technique to clean the wound D) Clean the wound from the top to the bottom and from the center to the outside.

D) Clean the wound from the top to the bottom and from the center to the outside.

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which of the following actions? A) Place the client in prone position to apply restraint. B) Remove the client's upper body clothing and reapply it over the restraint. C) Asses the client at least every two hours or according to the facility policy as required. D) Insert a fist between the restraint and the client to ensure the her breathing is not constricted.

D) Insert a fist between the restraint and the client to ensure the her breathing is not constricted.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this specimen, the nurse should do which of the following? A) Apply a topical anesthetic to the wound 30 min before collecting the specimen to prevent pain. B) Apply a small amount of normal saline to a swab after the collection to prevent drying. C) Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. D)Rotate the swab several times over the wound surface to obtain an adequate specimen.

D)Rotate the swab several times over the wound surface to obtain an adequate specimen.

A client who has a bacterial infection develops an abscess that needs to be drained? What drainage system would most likely be used in this situation?

Penrose Drain

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; Visible subcutaneous fat; no bone, tendon, or muscle visible. The nurse should recognize what stage of pressure ulcer?

Stage III

What are the two identifies REQUIRED for adult and pediatric inpatients?

patient name and medical record number/identification number

A health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. Which prescription should the nurse question? A) Restrain all four extremities. B) Diazepam (anti-seizure meds) 5mg IV now C) Neurologic assessment every five minutes D) Oxygen 2/L via nasal cannula

A) Restrain all four extremities.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which of the following interventions will best preserve this client's safety and could be used as an alternative to restraints? A) Increase the resident's physical activity to reduce evening restlessness. B) Investigate the possibility of discontinuing his catheter. C) Limit the resident's fluid intake in order to reduce his urge to void. D) Collaborate with the resident's physician to have is diuretics discontinued.

B) Investigate the possibility of discontinuing his catheter.

A nurse has been exposed to urine while changing the linens of a client's bed. Which of the following is a guideline for performing hand hygiene following this client encounter? A) Remove all jewelry, including wedding bands, before handwashing. B) Keep hands lower than elbows to allow water to flow toward fingertips. C) Pat dry with a paper towel, beginning with the forearms and moving down to the fingertips. D) Use an alcohol-based hand rub to decontaminate the hands?

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

A primary care provider orders the application of a warm, sterile compress to reduce edema in a client's wound. Which of the following is a recommended step in this procedure? A) Placing a heating compress directly on the wound. B) Keep the compress in place for the prescribed amount of time or up to 30 min. C) Cover the site with three layers of gauze and with a clean dry bath towel. D) Apply pressure to the compress to mold it around the wound site.

B) Keep the compress in place for the prescribed amount of time or up to 30 min.

An older adult client has been admitted to the hospital and the nurse is preparing to provide hygiene to the client. The nurse brings a tooth brush and toothpaste and the client's daughter laughs, stating "She doesn't actually have a tooth left!" What should the nurse do? A) Explain to the client's daughter that her absence of teeth was not documented on admission. B) Use the toothbrush as planned, despite the client having no teeth. C) Use a 4x4 gauze soaked with normal saline to cline the client's tongue and gums. D) Offer the client mouthwash instead of a toothbrush and toothpaste.

B) Use the toothbrush as planned, despite the client having no teeth.

The application of cold therapy is appropriate for which client? A) promotion of circulation B) muscle sprain C) phantom leg pain D) decreased pulses distal to site

B) muscle sprain

A recommended guideline for moving and lifting patients includes which of the following? A) Attempt to move the patient even when sufficient staff is not available and present. B) Plan carefully what you will do while moving or lifting a patient. C) Assess the patient's ability to understand instructions and cooperate with the staff to achieve the movement. D) Consider the patient to be fully dependent and use assistive devices for the transfer if any caregiver is required to life more the 25 pounds of a patient's weight.

C) Assess the patient's ability to understand instructions and cooperate with the staff to achieve the movement.

A physician orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? A) Remove the restraint at least every four hours, or according to the agency policy. B) Apply restraints to the hands or wrists, never to the ankles. C) Ensure that two fingers can be inserted between the restraint and the client's extremity. D) Use a quick release knot to tie the restraint to the side rail.

C) Ensure that two fingers can be inserted between the restraint and the client's extremity.

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. Which of the following nurse's actions was not appropriate? A) Performing hand hygiene and putting on goggles before emptying the drain. B) Administering analgesia before changing the dressing around the drain, if needed. C) Leaving the drain open for 5 to 7 minutes to ensure full drainage. D) Fastening the drain to the client's gown using a safety pin after emptying and recompressing it.

C) Leaving the drain open for 5 to 7 minutes to ensure full drainage.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which of the following guidelines promotes safe use of this device? A) The client should stand with as much weight as possible placed on the feet, using the cane for balance. B) When taking a step, the client should advance the stronger leg forward ahead of the cane and follow with the weaker leg. C) When taking a step forward, the heel of the foot should be slightly beyond the tip of the cane. D) The client should hold the cane in the hand on the same side as the leg with the most severe deficit.

C) When taking a step forward, the heel of the foot should be slightly beyond the tip of the cane.