QUIZ 3

A patient is diagnosed with a infection . What will the nurse most likely assess in this client ? A. Palpitations , irritability , and heat intolerance B. Fever , malaise , anorexia , nausea , and vomiting C. Tingling , numbness , and cramping of the extremities D. Edema , rubor , heat , and pain

B. Fever , malaise , anorexia , nausea , and vomiting

A nurse is admitting a client who has a wound infected with vancomycin - resistant enterococci ( VRE ) . Which of the following types of precautions should the nurse plan to initiate ? A. Airborne B. Droplet C. Contact D. Protective

C. Contact

A nurse is admitting a client who has a partial hearing loss . Which of the following is the priority action ( What should the nurse do first ) by the nurse ? A. Speak using his usual tone of voice . B. Rephrase statements the client does not hear . C. Determine the client uses hearing aids . D. Stand directly in front of the client

C. Determine the client uses hearing aids .

A nurse is reviewing the laboratory results of a client who has a pressure ulcer . The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection ? A. BUN B. RBC count C. WBC count D. Potassium

C. WBC count

A nurse is removing personal protective equipment ( PPE ) after giving direct care to a client who requires isolation . Which of the following PPE items should the nurse remove first ? A. Mask B. Gown C. Faceshield D. Gloves

D. Gloves

A nurse is caring for a group of clients on a medical surgical unit . Which of the following situations requires that the nurse wear gloves ? ( Select all that apply . ) A. Providing oral care B. Delivering a food tray to a client who has AIDS C. Placing oral medication tablets into a client's hand D. Emptying urine from an indwelling urine collection bag E.Changing an ostomy pouch

A D and E

A nurse on a medical - surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims . Which of the following clients should the nurse recommend for discharge ? ( Select all that apply . ) A. A client who has chronic hypertension and blood pressure 135/85 mm Hg . B. A client who has acute appendicitis and is scheduled for an appendectomy C. A client who is dehydrated and receiving IV fluid and electrolytes D. A client who is scheduled for elective surgery E. A client who has a nasogastric tube to treat a small bowel obstruction

A and D

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids . Which of the following statements should the nurse identify as an indication that the client understands the instructions ? A. " I take the batteries out of my hearing aids when I take them off at night . " B. " I keep the volume of my hearing aids turned up so I can hear better . " C. " I clean the ear molds of my hearing aids with rubbing alcohol . " D. I use a damp cloth to clean the outside part of my hearing aids . "

A. " I take the batteries out of my hearing aids when I take them off at night . "

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage . How should the nurse dispose of the dressing material ? A. Dispose of the dressing in a biohazardous waste container . B. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle . C. Double - bag the dressing in clear bags and label it " biohazard D. Discard the dressing in the bedside trash receptacle

A. Dispose of the dressing in a biohazardous waste container .

A nurse is caring for a client who had a stroke and has aphasia . Which of the following interventions should the nurse use to promote communication with this client ? ( Select all that apply . ) A. Make sure only one person speaks at a time . B. Allow plenty of time for the client to respond . C. Avoid discouraging the client by indicating that they cannot be understood . D. Speak at a higher volume to the client . E. Use brief sentences with simple words .

A. Make sure only one person speaks at a time .

A nurse is caring for a client who has an infection . The nurse should use which of the following strategies to prevent the transmission of the client's infection ? A. Performing hand hygiene before , during , and after direct contact with the client B. Placing the client in a room with positive - pressure airflow C. Encouraging the client to consume a high - protein diet D. Changing the client's bed linens each day

A. Performing hand hygiene before , during , and after direct contact with the client

A nurse is caring for a client who has an infection . The nurse should use which of the following strategies to prevent the transmission of the client's infection ? . A. Performing hand hygiene before , during , and after direct contact with the client B. Placing the client in a room with positive - pressure airflow C. Encouraging the client to consume a high - protein diet D. Changing the client's bed linens each day

A. Performing hand hygiene before , during , and after direct contact with the client

The nurse is working with a client with a moderate hearing impairment . To promote communication with this client , the nurse should : A. Use visual aids such as the hands and eyes when speaking B. Approach a client quietly from behind before speaking C. Use a louder tone of voice than normal D. Select a public area to have a conversation

A. Use visual aids such as the hands and eyes when speaking

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses . Which of the following statements by a nurse indicates understanding ? A. " I will get the caller off the phone as soon as possible so I can alert the staff . B. " I will listen for background noises . " C. " I will begin evacuating clients using the elevators . " D. " I will not ask any questions and just let the caller talk . "

B. " I will listen for background noises . "

A nurse is preparing a sterile field . Which of the following actions should the nurse identify as contaminating the field ? A. Opening the sterile tray by first unfolding the flap farthest from his body . B. Opening a sterile package over the middle of the sterile field C. Holding a sterile item at just above waist level D. Placing a sterile dressing 5 cm ( 2 in ) from the border of the sterile field

B. Opening a sterile package over the middle of the sterile field

A nurse is assessing a client who has narcolepsy . Which of the following findings should the nurse expect ? ( Select all that apply ) . A. Sleep apnea B. The urge to move the legs when trying to sleep . C. A lack of rapid eye movement ( REM ) sleep D. Sudden attacks of sleep E. Hallucinations at the onset of sleep

D and E

The client was working in the kitchen and was splashed in the face with a caustic cleaning agent . His eyes were affected , and he was brought to the hospital for treatment . After cleansing and evaluation , his eyes were bandaged . When assisting this client , who has temporary visual loss , to eat the nurse should : A. Allow the client to experiment with foods B. Feed the client the entire meal C. Assign ancillary personnel to feed the client D. Orient the client to the location of the foods on the plate

D. Orient the client to the location of the foods on the plate

A nurse is assessing a client who has insomnia . Which of the following questions is the highest priority for the nurse to ask the client ? A. " Do you have difficulty staying awake when you are driving ? " B. " When did you begin to have trouble sleeping ? " C. " Are there any specific factors that you think are affecting your ability to sleep ? " D. " Can you describe your bedtime routine to me ? "

A. " Do you have difficulty staying awake when you are driving ? "

A nurse is caring for a client who requires droplet precautions . Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray ? A.gown B. mask C.goggles D.gloves

B. MASK

A nurse is preparing a sterile field . Which of the following actions should the nurse perform when opening the sterile pack ? A. Move to the opposite side of the pack to open the fourth flap . B. Reach around the pack and open the top flap away from the body . C. Place the pack on a sterile work surface . D. Open the right flap with the left hand .

B. Reach around the pack and open the top flap away from the body .

A nurse is planning care for a client who has manifestations of a Clostridium difficile ( C. difficile ) infection . Which of the following actions should the nurse plan to take ? A. Use an alcohol - based agent to perform hand hygiene when caring for the client . B. Place a surgical mask on the client during transport . C. Place the client on contact precautions . D. Obtain a blood specimen to test for C. difficile .

C. Place the client on contact precautions .

A nurse is teaching a client who reports insomnia about promoting rest and sleep . Which of the following statements should the nurse identify as an indication that the client understands the instructions ? A. " I will walk briskly for 30 minutes before bedtime . " B. " I will do my muscle relaxation techniques each afternoon . " C. " I will have a cup of hot cocoa immediately before bedtime . " D. " I will no longer have a glass of wine before bedtime . "

D. " I will no longer have a glass of wine before bedtime . "

A nurse is caring for a client who has methicillin resistant Staphylococcus aureus ( MRSA ) in an abdominal wound . The nurse enters the room to check the client's pulse . Which of the following actions should the nurse take ? A. Wear protective eyewear . B. Wear sterile gloves C. Wear an N95 respirator mask . D. Wear clean gloves

D. Wear clean gloves

A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia . Available diphenhydramine 25 mg tablets . How many tablets should the nurse administer per dose ? ( Round the answer to the nearest whole number . Use a leading zero if it applies . not use a trailing zero . )

2 TABLETS

A nurse educator is teaching staff members about facility protocol in the event of a tornado . Which of the following should the nurse include ? ( Select all that apply . ) A. Instruct ambulatory clients in the hallways to return to their rooms B. Open doors to client rooms C. Place blankets over clients who are confined to beds . D. Draw shades and close drapes E. Move beds away from the windows

C D and E