Unit 2 Ati hygiene, infection, safety, health promotion and disease prevention, therapeutic communication, Teaching

a nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. which of the following interventions should the nurse include? (select all that apply) A. help the client see the benefits of their actions B. identify the clients support systems C. suggest and recommend community resources D. devise and set goals for the client E. teach stress management strategies

A, B, C, E

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that healthcare professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply) A. Planning and evaluating control and prevention strategies B. determining public health priorities. C. Ensuring proper medical treatment. D. Identifying endemic disease E. monitoring for common-source outbreaks.

Ans: A. Planning and evaluating control and prevention strategies B. determining public health priorities. C. Ensuring proper medical treatment. E. monitoring for common-source outbreaks. Rationale: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies Reporting of communicable and infectious diseases assists with determining public health policies. Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available. Reporting of communicable and infectious diseases assists with monitoring for common-source outbreaks

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating a sterile field? (Select all that apply) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed one hour because the provider receives an emergency call. D. the nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

Ans: B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed one hour because the provider receives an emergency call. D. the nurse turns to speak to someone who enters through the door behind the nurse. Rationale: Fluid permeation of the sterile drape or barrier contaminates the field. Prolonged exposure to air contaminates a sterile field. Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP).. Which of the following instructions should the nurse include when discussing hand washing? (select all that apply) A. apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for atleast 15 seconds. C. Rinse the hands with hot water D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

Ans: B. Wash the hands with soap and water for atleast 15 seconds. D. Use a clean paper towel to turn off hand faucets. Rationale: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 min. If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.

a nurse at a health department is planning strategies related to heart disease. which of the following activities should the nurse include as part of primary prevention? A. providing cholesterol screening B. teaching about a healthy diet C. providing information about antihypertensive medications D. developing a list of cardiac rehabilitation programs

B

a nurse at a provider's office is talking about routine screenings with a 45- year old female client who has no specific family history of cancer or diabetes mellitus. which of the following client statements indicates that the client understands how to proceed? A. "So i don't need the colon cancer procedure for another 2 to 3 years". B. "for now, i should continue to have a mammogram each year." C. "because the doctor just did a Pap smear, I'll come back next year for another one." D. " I had my blood glucose test last year, so I won't need it again for 4 years."

B

a nurse is caring for a school-age child who is sitting in a chair. to facilitate effective communication, which of the following actions should the nurse take A. touch childs arm B. sit at eye level C. stand facing child D. stand with relaxed posture

B

which of the following strategies should a nurse use to establish a helping relationship with a client A. make sure the communication is equally reciprocal between the nurse and client B. encourage client to communicate his thoughts and feelings C. give nurse-client communication no time limits D. allow communication to occur spontaneously throughout nurse-client relationship

B A. make sure the communication is equally reciprocal between the nurse and client B. encourage client to communicate his thoughts and feelings C. give nurse-client communication no time limits D. allow communication to occur spontaneously throughout nurse-client relationship

A nurse in a provider's office is collecting data from the motor of a 12-month-old infant. The client states that her son is older enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which the following domains? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic

B. Affective

A nurse is evaluating how well a client learned the information the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select or prepare meals. C. Encourage the client to fill out an evaluation form. D. Ask the client if she has resources for further instruction on this topic.

B. Ask the client to explain how to select or prepare meals.

A nurse is caring for a client who states, " I have to check with my wife and see if she thinks I am ready to be discharged." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse displaying to enhance communication between the nurse and the client? A. Pacing B. Reflecting C. Paraphrasing D Restatin

B. Reflecting Reflecting directs the focus of the conversation back to the client so that the client can further explore his own feelings

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique. C. The client states that he understands. D. The client is able to write the steps on a piece of paper.

B. The client is able to demonstrate the appropiate technique.

a nurse if caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. which of the following statements should the nurse use (select all that apply) A. you will do great. you just have to get used to it. B. what are you worried about going home C. your daily routines will be different when you go home D. tell me about your support system youll have after you leave the hospital E. let me tell you about a friend of mine with a colostomy who also enjoys swimming

C D E A. you will do great. you just have to get used to it. B. what are you worried about going home C. your daily routines will be different when you go home D. tell me about your support system youll have after you leave the hospital E. let me tell you about a friend of mine with a colostomy who also enjoys swimming

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you give me pain medication after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say."

C. "Can you tell me about how long the surgery will take."

A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and the client agree are reasonable. D. Determine what the client knows about stress incontinence.

D. Determine what the client knows about stress incontinence.

a nurse is caring for a young adult at a college health clinic. which of the following actions should the nurse take first? A. give the client information about immunization against meningitis B. tell the client to have a TB skin test every 2 years C. determine the clients health risks D. teach the client about exercise recommendations

C the first action that should be taken using the nursing process is assessment. talk with the client first to determine what risk factors the client might have before initiating the health promotion and disease prevention measures.

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurses priority? a. complete a fall risk assessment b. educate the client and family on fall risk c. eliminate safety hazards from the clients environment d. make sure the client uses assistive aids in their possession

a. complete a fall risk assessment

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (select all that apply) a. place a belt restraint on the client when they are sitting on the bedside commode b. keep the bed at the lowest position with all side rails up c. make sure the client's call light is within reach d. provide the client with nonskid footwear e. complete a fall risk assessment

c, d, e

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurses priority? a. extinguish the fire b. activate the fire alarm c. move clients away who are nearby d. close all open doors on the unit

c. move clients away who are nearby

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? a. open the windows in the client's room to allow smoke to escape b. obtain a class C fire extinguisher to extinguish the fire c. remove all electrical equipment from the client's room d. place wet towels along the base of the door to the client's room

d. place wet towels along the base of the door to the client's room

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements a nurse requires further instruction? a. "I will place the client on their side" b. "I will go to the nurses station for assistance" c. "I will note the time the seizure began" d. "I will prepare to insert an airway"

b. "I will go to the nurses station for assistance"

A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical examination was in high school. which of the following health screenings should the nurse expect the provider to perform for this client? A. testicular examination B. blood glucose C. fecal occult blood D. prostate-specific antigen

A

which of the following actions should the nurse take when using the communication technique of active listening (select all that apply) A. open posture B. write down what client says to avoid forgetting details C. establish and maintain eye contact D. nod in agreement with the client throughout conversation E. respond positively when giving feedback

A C E A. open posture B. write down what client says to avoid forgetting details C. establish and maintain eye contact D. nod in agreement with the client throughout conversation E. respond positively when giving feedback

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply) A. A bottle containing a sterile solution B.The edge of the sterile drape at the base of the field. C. The inner wrapping of an item on a sterile field. D. An irrigation syringe on the sterile field. E. One gloved hand with the other gloved hand.

Ans: C. The inner wrapping of an item on a sterile field. D. An irrigation syringe on the sterile field. E. One gloved hand with the other gloved hand. Rationale: The inner wrappings of any objects the nurse dropped onto the sterile field are sterile. The nurse may touvh them with sterile gloves. Any objects the nurse dropped onto the sterile field during the setup are sterile. The nurse may touch the syringe with sterile gloves. One sterile gloved hand may touch the other sterile gloved hand because both are sterile.

When entering a clients room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A. keep the sterile field at least 6 feet away from the clients bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. C. place a mask on the client to limit the spread of microorganisms into the surgical wound D. keep a box of facial tissues nearby for the client to use during the dressing change.

Ans: C. place a mask on the client to limit the spread of microorganisms into the surgical wound Rationale: Placing a mask on the client prevents contamination of the surgical wound during the dressing change.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. the flap closest to the body B.The right side flap C. The left side flap D. The flap farthest from the body

Ans: D. The flap farthest from the body Rationale: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one furthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

Ans: A. Fever B. Malaise E. Increase in pulse and respiratory rate Rationale: A fever indicates that the infection is affecting the whole body, and therefore systemic Malaise indicates that the infection is affecting the whole body, and therefore systemic. An increase in pulse and respiratory rate indicates that the infection is affecting the whole body, and therefore systemic.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply) A. Place the client in a room that has negative air pressure of at least six exchanged per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled lines. E. Wear a gown when performing care that may result in contamination from secretions.

Ans: B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that may result in contamination from secretions. Rationale: The nurse should wear a mask when within 3 ft of the client. The nurse should place a surgical mask on the client during transport to another area of the facility. A gown should be worn if the nurse's clothing or skin may be contaminated with body secretions or excretions

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following shoulf the nurse suspect? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes Zoster

Ans: D. Herpes Zoster Rationale: Vesicles that follow along a unilateral dermatome can indicate herpes zoster.

A nurse is caring for a client who reports a severe soar throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

Ans: D. Illness Rationale: The illness stage is when the client experiences signs and symptoms specific to the infection