Unit 1 Foundations EAQ

The registered nurse is teaching a nursing student about teaching strategies for health promotion in patients. Which statement by the nursing student indicates a need for further learning?

"I should demonstrate assessment of carotid pulse to a young child."

The nurse educator is delivering a lecture on nursing as a profession to a group of nursing students who have recently joined the baccalaureate nursing degree course. Which statements are true? Select all that apply.

1 2 3

For which patient would a follow-up visit within 1 week be recommended

185/100

at which age does the respiratory system begin to decline in healthy people?

25

which value indicates normal pulse pressure?

36 30-50 mm is normal

pulse pressure of 150/90

60

Which temperature indicates moderate hypothermia?

86

What is the average rectal temperature for adults?

99.5

Which statement is true regarding the donning and removing of caps, masks, and eyewear?

Eyewear should be worn only when the procedure has a risk of splashing.

Which disease can be transmitted when a nurse is drawing blood from a patient with an infection?

Hep. B

What is a reason for oversensitivity of older adults to the environmental temperature?

Inefficient thermoregulatory sy

An elderly patient has been put on a potentially toxic drug for treatment of arthritis. The patient and family have expressed concern about the drug. What is the role of the nurse in this particular situation?

Provide information so the patient can decide whether to accept the treatment or refuse

Which task can be delegated to nursing assistive personnel (NAP)? Select all that apply.

The NAP can determine the frequency of respiration, measure oxygen saturation, and obtain pulse measurement frequency at appropriate times if the condition of the patient is stable

For which patients should the nurse pull the ear pinna backward, up and out during temperature assessment at the tympanic membrane site?

adults

An 18-year-old patient is in the emergency department with fever and cough. The nurse obtains vital signs, auscultates lung sounds, listens to heart sounds, determines patient's level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed?

assessment

Which action should the nurse avoid while assessing the blood pressure (BP) of a 10-month-old patient?

choosing cuff based on name of cuff

Which factor can alter the defense mechanism of sebum?

excessive bathing

What would a nurse use for a high-level disinfection?

hydrogen peroxide

How should the nurse determine the ventilatory rhythm in a patient?

observing the chest or the abdomen

Which manifestation is often called the fifth vital sign?

pain

Which site is preferred for assessing the heart rate in a patient?

radial

The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort?

sims position

Which type of specimen is collected by using a sterile tongue blade?

stool specimen

A patient is suspected of having malaria. Which mode of transmission spreads malaria?

vector

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection?

obstructs normal flushing action of urine flow The presence of a catheter in the urethra breaches the natural defenses of the body . The reflux of microorganisms up the catheter lumen from the drainage bag or backflow of urine in the tubing increases the risk of infection. A catheter can help in keeping an incontinent patient's skin dry, but that normally does not lead to a urinary tract infection. The catheter can become caught up in the linens or with other equipment, but that does not cause a urinary tract infection. A patient with a catheter is producing urine and urinating; thus the patient is staying hydrated and still urinating.

The registered nurse delegates an nursing assistive person (NAP) to measure the temperature of an intubated patient. Which route selected by the NAP would be correct in this condition?

oral

Which requirement is necessary for measuring oxygen saturation in a patient with emphysema?

oximeter

A patient who had undergone a hysterectomy 10 days ago came for a follow-up visit. The patient notices purulent drainage at the incision site. The nurse suspects wound infection and performs assessment for confirmation. Which clinical findings would the nurse evaluate? Select all that apply.

pain redness tenderness

The nurse is caring for a patient who has been admitted to the hospital with terminal leukemia. The patient has expressed a preference for nonpharmacological pain control. The nurse refers to articles and systematic reviews to learn the best possible nonpharmacological methods to treat cancer pain. How would the nurse's actions be categorized, according to the QSEN competencies? Select all that apply.

patient centered care evidence based practice

The community health nurse is conducting a program on health and fitness awareness for medically underserved people. Who would be categorized as medically underserved?

people of poor socioeconomic status

A patient who had a hysterectomy 10 days ago has come for a follow-up visit. The patient is experiencing pain and itching at the incision site. The nurse suspects a wound infection and performs an assessment for confirmation. When assessing this patient, what actions should the nurse perform to reduce the spread of infection? Select all that apply.

perform hand hygiene, put on gloves, use personal protective equipment

The nurse is explaining the procedure of measuring oxygen saturation to a patient. This explanation occurs during which step in the nursing process?

planning

The nurse is assessing a patient for blood pressure (BP) and identifies that the patient's BP is inadequate for perfusion and oxygenation of tissues. Which interventions should be provided immediately in this situation?

position patient in supine

After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. What is the rationale behind the nurse's action?

preventing transmission of microorganisms

A patient reporting itching and tingling arrives at the hospital. The nurse suspects a herpes simplex infection and keeps the patient in an isolation room. What would be the patient's stage of infection?

prodromal stage

The nurse usually is assigned multiple patients at one time. What should the nurse do to ensure individual patient satisfaction? Select all that apply.

provide quality care ensure all leave with positive image manage time

The nurse is being appointed as nurse educator in a nursing school. What are the responsibilities of the nurse educator? Select all that apply.

provide students with knowledge

The nurse is teaching a group of nursing students about the normal defense mechanisms of the body against infections. Which statements are true about the skin as a primary defense against infections? Select all that apply.

provides barrier removing adhered organisms fatty acids

The nurse is participating in a clinical care coordination conference for a patient with terminal cancer. The nurse talks with colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A nonnursing colleague asks about this code. What does this code do?

provides principles of right and wrong when providing patient care.

Which priority nursing intervention should be implemented for a patient with hypothermia?

removing wet clothes

While caring for a patient with testicular cancer in a health care setting, the nurse observes that the patient develops a urinary tract infection. Which actions of the nurse could be responsible for the development of this health care-associated infection? Select all that apply.

repeated irrigation improper collection of specimen

A patient is diagnosed with pulmonary tuberculosis. Which personal protection equipment (PPE) is most important to be worn whenever entering the patient's room?

respirator Patients with pulmonary tuberculosis require airborne precautions because the droplets are smaller than 5 microns and remain for longer periods in the air. Therefore, a respirator is the most appropriate personal protection equipment (PPE) that the nurse should use. Gowns and gloves are most important when a nurse performs a physical examination to avoid a contact infection. A head cap is applied when the nurse is in a surgical room.

The nurse is learning about the effects of health care reform. Which type of actions should the nurse perform in response to health care reform? Select all that apply.

revise change explore

A licensed practical nurse is preparing to assist in a sterile procedure. Which nursing action is appropriate in surgical hand asepsis?

scrubbing hands for 5 mins

The nurse is delegating a task of measuring a patient's oxygen saturation (SpO2). Which instruction should be provided to the nursing assistive person (NAP)?

select appropriate sensor site

The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching?

should use a large cuff

The registered nurse is teaching a student nurse about the interventions to be followed when the blood pressure is above the acceptable range. Which statement by the nursing student indicates effective learning?

should verify the correct cuff size

A nurse is assessing the body temperature of an older adult. Which body temperature indicates fever in this patient?

single oral temp of 100.4

Which statements are true regarding blood pressure in older adults? Select all that apply.

skin assess increase systolic pressure slowly change position

The nurse assists a surgical technician in preparing a sterile field. Which action made by the nurse indicates a need for correction?

standing close to the sterile field while opening the last flap While preparing a sterile field, the nurse should open the last flap while standing away to field as to avoid contamination. The flap should be allowed to lie flat on the table surface. The outer edge of the tip of the outermost flap should be grasped because the outer surface of the package is considered unsterile. The outermost flap of the sterile kit should be kept away from the body to prevent contamination.

What equipment is required for the preparation of a sterile field? Select all that apply.

sterile drape counter top surface

A 47-year-old patient has arrived at the clinic after accidentally cutting his forearm with a pair of scissors. Which clinical manifestations would the nurse expect to indicate a local inflammation? Select all that apply.

swelling redness pain

Which vital sign can be altered due to a decrease in sweat glands in older adults?

temp

While preparing a sterile field, a nurse opens the outermost flap by stretching his or her arm away from the sterile field. What is the reason for this action?

to avoid contamination of sterile field

Which site is preferred by the nurse to perform Allen's test?

ulnar

Which statement regarding vascular and cellular responses is true?

vasodilation at the site of injury

The nurse is dressing the surgical wound of a patient in the intensive care unit of a hospital. Which skill should the nurse develop to ensure full dexterity while using gloved hands after applying a sterile gown?

wear gloves with fingers fully extended into them

A nurse performs hand hygiene before providing direct patient care. Which action made by the nurse may cause an infection

wearing rings on both hands

The nurse is assessing the vital signs for a patient who underwent lung surgery. The nurse observes differences in the vital signs as compared to the values recorded before the surgery. What should be the immediate action of the nurse in this situation?

writing a variance note

Which statements are true regarding the factors affecting vital signs of older adults? Select all that apply.

123

As a registered nurse (RN) caring for a 60-year-old patient with complaints of dyspnea, cough, and sweating, it is important to monitor the patient's vital signs. In which situations must the nurse measure the vital signs? Select all that apply.

1245

when does the respiratory system mature in healthy people?

20

What is the acceptable axillary temperature for adults?

97.7

What is the acceptable tympanic body temperature for adults?

98.6 F

The nurse is attending to a patient who has a pressure ulcer that needs a dressing change. What actions should the nurse perform to ensure preparation of a sterile field? Select all that apply.

A clean, dry, work surface above waist level should be used because a sterile object that is held below the waist is considered contaminated. Bracelets and rings can harbor microorganisms and hence need to be removed. Performing hand hygiene before handling equipment helps to reduce the spread of microorganisms. Checking labels and the condition of the supply gives an idea of any previous opening as an open supply may cause soiling or contamination; also, labels provide information about the date of packaging and other important information about the sterility of the product. The outer edge of the outermost flap should be held when opening the commercial kit as the outer surface is considered unsterile but helps to keep the inner kit sterile.

Which nursing interventions should be provided for patients with fever? Select all that apply.

A patient with fever should be helped in such a way that there is maximum heat loss by reducing external covering on the body without causing shivering. Supplemental oxygen can be provided to the patient to improve oxygen delivery to body cells. Onset and duration of febrile episode phases should be identified. Physical activity should be limited in the patient to minimize heat production in the body. The frequency of ambulation should be minimized to allow the patient to rest.

A nurse reviews the data of patients with different infections. Which patient is capable of transmitting an infection?

A. mumps

The nurse is caring for a 37-year-old male who had abdominal surgery 1 day ago. Upon examining the incision, the nurse notices a purulent exudate has formed around the incision site. Of what does a purulent exudate consist? Select all that apply.

Accumulation of fluid, dead tissue cells, and WBCs form a purulent exudate at the site of inflammation.

A nursing student uses a surgical mask to assist in a sterile surgical procedure. Which action made by the nursing student indicates a need for correction?

After using a surgical mask, the mask should be removed by untying the bottom mask strings, followed by the top strings. The outer surface of the mask should never be touched while removing it. Used masks should be dropped in a trash receptacle. Surgical masks should be removed before leaving the surgical room to prevent infection. While using a surgical mask, the two lower ties of the mask should be tied around the neck.

The senior nurse is explaining to the nurse who holds an associate degree about immediate future options in advanced nursing education. Which educational options should be included? Select all that apply.

BScN BN

Which microorganism causes gas gangrene?

Clostridium perfringens causes gas gangrene

Arrange the steps of the preparation of a sterile field chronologically

First, the sterile kit containing the sterile items should be placed on a work surface above waist level and the outside cover should be opened and placed on the work surface. The outer edge of the tip of the outermost flap should be grasped and the outermost flap should be opened away from the body while keeping the arm stretched away from the sterile field. The outer edge of the first side of the flap should be grasped and the side flap should be opened by pulling the side. The nurse should allow the kit to lie flat on the table surface. The arm should not be extended over the sterile surface. The outer edge of the second side of the flap should be grasped and the opening of the second side of the package should be pulled. The outer edge of the last and innermost flap should be grasped. Finally, the nurse should stand away from the sterile package and the flap should be pulled back, allowing the items to fall on the work surface.

The nurse works in a medical-surgical unit. Which patient should the nurse evaluate as the highest risk for health care-associated infections (HAIs)?

Health care-associated infections (HAIs) are those that are acquired by patients in the hospital during their stays. People whose immunity is compromised are at risk of these infections. Those who are at greater risk include the elderly, the malnourished, or those who have some underlying conditions that compromise their immunity, such as diabetes or malignancies. Therefore, the 53-year-old diabetic patient is at increased risk of an HAI. Gastroenteritis, fracture, and appendectomy do not increase the risk of HAIs.

Which statement about vital signs in older adults is correct?

Identification of an acceptable pulse oximeter probe site is difficult with older adults

In which order does the chain of infection cycle occur chronologically?

Infection occurs in a cycle that depends on the presence infectious agents, reservoirs, portal to exit, mode of transmission, portal to entry, and host. First, infectious agents choose a reservoir to multiply. After multiplying, they exit through sites such as the skin, urinary tract, and reproductive tract. These agents find different modes of transmission to enter the host.

Which statement is true regarding the pulse rate of an older adult?

It takes longer for the heart rate to rise in older adults during illness.

Which microorganism exits through a man's urethral meatus during sexual contact?

Neisseria gonorrhea exits through a man's urethral meatus or a woman's vaginal canal during sexual contact. Ebolavirus is transmitted through blood or body fluids. Clostridium difficile causes antibiotic-induced diarrhea. Legionella pneumophila grows only at certain temperatures.

What is evidence-based practice?

Optimal patient care based on current research

The health care provider asks the certified registered nurse anesthetist (CRNA) to provide spinal anesthesia to a patient who is scheduled for a hernia operation. What is the CRNA's next step?

Provide the anesthesia under the supervision of a primary health care provider with knowledge of surgical anesthesia

The examination for registered nurse licensure is exactly the same in every state in the United States. What should the public understand about this exam?

Provides a minimum standard of knowledge for a registered nurse in practice

Which disease requires contact precautions?

Scabies spreads through skin contact and the nurse should take contact precautions. Measles require airborne precautions. Diphtheria and pharyngitis require droplet precautions.

The registered nurse teaches a nursing student about the assessment of vital signs in a patient with orthostatic hypotension. Which statement made by the nursing student indicates a need for further learning?

"I should measure blood pressure within 30 minutes after the patient changes position.

A nurse reviews the laboratory reports of a patient with infection. Which laboratory parameter would be normal during infection?

The basophil count would be normal during infection. The monocyte count may increase if the patient has a protozoan infection. The neutrophil count may increase if the patient has an acute suppurative infection. The lymphocyte count may increase if the patient has a chronic bacterial or viral infection.

Which instrument used by the nurse requires surface disinfection?

There are two types of disinfection: disinfection of surfaces and high-level disinfection. Noncritical items such as blood pressure cuffs require a surface disinfection. Semi-critical items such as endoscopes require high-level disinfection. Critical items such as cardiac and urinary catheters require sterilization.

The nurse is teaching student nurses about the inflammatory response to an injury. Arrange the events in the order of their occurrence in a response to injury.

When a tissue is injured, a series of well-coordinated events occurs including vascular and cellular responses, formation of inflammatory exudates, and tissue repair. Acute inflammation is an immediate response to an injury. Rapid vasodilatation occurs, allowing more blood near the location of the injury. An injury causes tissue damage and possibly necrosis. As a result, the body releases chemical mediators that increase the permeability of small blood vessels; thus fluid, protein, and cells enter interstitial spaces. The accumulation of fluid appears as localized swelling. The accumulation of fluid, dead tissue cells, and white blood cells (WBCs) form an exudate at the site of inflammation. In the last step of tissue repair, granulation tissue formation occurs.

A registered nurse teaches a nursing student about the nursing skills required to care for patients with infections. Which statements made by the nursing student indicate the need for further learning? Select all that apply.

When there is a risk of a splash, a nurse should use a gown, mask, and eye protection. The nurses should use clean glove when caring for a patient's mucous membranes. The nurses should use only cleaned equipment. The nurses should instruct and ensure that patients cover their mouths and noses when they cough and sneeze. The nurses should keep bedside table surfaces clutter-free, clean, and dry while performing aseptic techniques.

The nurse pours a sterile liquid into a container. Which action made by the nurse is appropriate?

While pouring a sterile liquid into a container, a small amount of liquid should be poured in a disposable cap before it is poured into the container because the discarded solution cleans the lip of the bottle.

While assessing the condition of a 70-year-old patient, the nurse observes decreased tidal volume. What is the likely reason for this observation?

abnormal curvature of lungs

The nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with the family. Which role is the nurse playing for the patient?

advocate

apical pulse

angle of louis

Which part of a sterile gown is actually considered sterile?

anterior of the sleeves

While assessing a patient, the nurse finds that the radial pulse is abnormal. Which pulse should the nurse assess next in this situation?

apical

Which statement regarding health care-associated infections requires correction?

are reimbursed The costs of health care-associated infections (HAIs) are not reimbursed; therefore, the prevention of HAIs plays an important role in the managed care of health care systems. HAIs can increase the cost of health care because they increase infections in patients. The invasive procedure involved, the therapies received, and the length of hospitalization can influence the risk of HAIs in patients. HAIs can be caused by invasive procedures performed during the delivery of health services in a health care facility.

Which action should the nurse perform immediately after finding abnormal vital sign values in a patient who underwent abdominal surgery?

asking another nurse to repeat assessment

The nurse assesses the popliteal region to determine a patient's pulse. What would be the assessment criteria of this action?

assess lower leg

A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/minute, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?

base line vital signs

The nurse checks for the presence of earwax in a patient's ear canal before measuring tympanic membrane temperature with an electronic thermometer. What is the rationale behind this action?

block optical pathway

which vital sign finding should the nurse report to the primary health care provider immediately?

capnography of 32

What is an infective disease that can be transmitted directly from one person to another considered?

communicable disease When an infectious disease can be transmitted directly from one person to another, it is termed a communicable disease. No vector is necessary for transmission. A susceptible host is someone who is more prone to develop an infectious disease process. The port of entry is where microorganisms enter the body and the portal of exit is where microorganisms exit a host such as blood or the skin.

While assessing the respiration of an older adult, the nurse finds it difficult to identify an acceptable site for placement of pulse oximeter probe. What would be the reason for this difficulty?

decreased CO

For which patients does the nurse measure blood pressure (BP) by palpation? Select all that apply.

decreased heart contractility blood loss

The registered nurse is teaching a nursing student about precautions to be followed while measuring blood pressure (BP). Which statements made by the nursing student indicate a need for further learning? Select all that apply.

deep breaths talk IV

A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply

determine patient med history use equ appropriate for age use vital signs to determine med admin

Which symptom is associated with an elevated temperature

diaphoresis

Which type of medical equipment is cleaned outside the health care facilities?

drainage collection device

In a hospital there is an acute shortage of nurses due to retirement. What should the remaining nurses do? Select all that apply.

efficient time professionally

What major infections are caused by Escherichia coli? Select all that apply.

gastroenteritis UTI

Which action should the nurse avoid while opening a sterile item on a flat surface?

graspring 3.5 cm of border The nurse should grasp only 2.5 cm (1 inch) of the border to maneuver the field on a table surface while opening a sterile item on a flat surface.

The nurse is assessing oxygen saturation in a patient with chronic bronchitis. What is the correct order of steps to be implemented by the nurse?

hand hyg position patient instruct attach probe leave probe

A registered nurse evaluates the nursing assistive personnel who is wearing a mask. Which action made by the nursing assistive personnel indicates a need for correction?

having a casual conversation while wearing the mask While wearing a mask, talking should be kept to a minimum to reduce respiratory airflow. A mask that has become moist does not provide a barrier to microorganisms and should be discarded. While wearing a mask, the two top ties should be tied at the back of the head and above the ears. The top of the mask should fit below the glasses.

Which conditions may result from decreased sweat gland reactivity in an older patient? Select all that apply.

heat stroke hyperthermia

The nurse has many roles to perform. Which statements illustrate the nurse's role as a patient caregiver? Select all that apply

implement provides assists

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed?

implementation

A patient sprained her ankle. The nurse instructs the patient to keep the leg elevated and applies cold compresses on the affected ankle. Which standard of practice is the nurse performing?

implementation

Which intervention does the primary health care provider order the nurse to perform when blood pressure is insufficient for adequate perfusion and oxygenation of tissues?

increase rate of intravenous infusion

While assessing the heart sounds of a patient, the nurse notices muffled sounds. What could be the possible reason?

increased airspace in the lungs

The nurse is caring for a patient who is suffering from a gastrointestinal infection. The nurse understands that any infection occurs in four stages. Arrange the stages of infection in the correct order.

incubation prodromal illness convalesence

A registered nurse is teaching a student nurse about the various stages of infections. Which statement made by the student nurse indicates a need for additional teaching?

incubation stage for mumps at 5 days

The nurse is caring for a patient who has a respiratory infection. The nurse understands that an infection occurs in a cycle and involves several elements. What are the elements in the chain of infection? Select all that apply.

infectious agent, susceptible host, source of pathogen growth

Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for patients at risk for bed sores. This is an example of which type of education?

inservice ed

While assessing the axillary temperature, the nurse raises the patient's arm away from the torso. What is the rationale behind this action?

inspecting presence of lesions

While using an antiseptic hand rub to perform hand hygiene, the nurse feels dryness in his or her hands after rubbing them together for 10 to 15 seconds. What is the reason for this dryness?

insufficient antiseptic solution applied

Which action increases the risk of contamination while applying a sterile gown?

lifting the gown upward and stepping toward the table

What is the correct order of steps for measuring blood pressure using the one-step method?

locate close inflate release note deflate

The nurse decides not to measure the temperature of an older adult using the oral site. What is the likely reason for this decision? Select all that apply.

loss of teeth poor muscle control

While assessing the oral temperatur

maintains proper position

The nurse cares for a patient who has chickenpox. Which protection barriers should the nurse use? Select all that apply.

mask n95 respirator

A 40-year-old patient is diagnosed with colon cancer. While interacting with the patient, the nurse learns that he has a twin brother. Which nursing actions are appropriate for the patient's brother? Select all that apply

motivate to get colonoscopy encourage a stool sample

After performing a prescrub wash, a nurse dries his or her hands and forearms with a paper towel. What is the rationale behind this action?

Drying the hands and forearms with a paper towel can promote a reduction in microorganisms on the hands and arms

A 65-year-old patient is undergoing treatment for chronic bronchitis and develops a health care-associated exogenous infection. What could be the reason for this condition?

Exogenous infections are caused by microorganisms found outside the individual such as Aspergillus, Salmonella and Clostridium tetani.