2024 fundamentals first exam

Migration of leukocytes to the area of the wound

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection?

iatrogenic

A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as:

"Limit your intake of water each day to about 4 to 5 glasses."

A client who has had repeated infections asks the nurse what he can do to improve his ability to resist infection. Which suggestion would be least appropriate for the nurse to give?

mechanical debridement

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

Wear gloves whenever entering the client's room.

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Area of active drainage

A nurse is preparing to obtain a specimen for an aerobic wound culture. The nurse would obtain the specimen from which area?

Stop removing staples and inform the surgeon

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

the client has developed a bacterial infection

A nurse is reviewing the white blood cell (WBC) count and differential of a client and notes that there is a significant shift to the left. The nurse interprets this as indicating

temperature of 103.1°F (39.5°C) A WBC count of 15,000 with 12% bands

A nurse is working with a 50-year-old woman status post liver transplant. She is on multiple immunosuppressive drug therapies, is intubated, and is NPO. with parenteral nutrition running through a central line. What would raise the nurse's suspicions that the client is developing septicemia?

Subcutaneous tissue

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy

The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

Exogenous healthcare-associated

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?

Perform surgical hand scrub using detergent

An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?

Prodromal period

During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period?

Record the quantity of drainage once per shift and document on the intake and output record.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan?

Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.

Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process?

Nurses should remove PPE at the doorway or in an anteroom, except for the respirator. To remove a gown, nurses should unfasten ties, if at the neck and back, and allow the gown to fall away from shoulders. During some care activities for an individual client, nurses may need to change gloves more than once.

Nurses wear personal protective equipment (PPE) to protect themselves and clients from infectious materials. Which examples accurately represent the proper use of personal protective equipment in a health care agency?

inserting an arm within each sleeve while touching the outer surface of the gown

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique?

Wear personal protective equipment (PPE) when appropriate. Standard precautions should be used when family members have active infections. Do not share drinking glasses with family members who are ill. Keep the entire living environment as clean as possible.

The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply.

The nurse works outward from the wound in lines parallel to it.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

Apply a skin protectant to the skin around the incision.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

pouring the sterile solution from a height of 5 in. (13 cm)

The nurse is adding a sterile solution onto a prepared sterile field. What is the best technique performed by the nurse?

Use a mask when within 3 ft (1 m) of the client

The nurse is caring for a client who has an infection spread by respiratory droplets and is under droplet precautions. Which precautions should the nurse take?

The LPN is donning personal protective equipment appropriately.

The nurse is caring for a client with a cough and copious secretions. Before providing care, the nurse observes the licensed practical nurse (LPN) standing outside the client's room and donning personal protective equipment as shown above. How should the nurse best interpret the LPN's actions?

infectious disease communicable disease contagious disease

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition?

droplet

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

Has any one in the family recently been sick?" "Have you been frequently out in the community?" "Are you taking steroids?"

The nurse is conducting assessment on a client with cancer who is undergoing treatments. The client reports having the flu. Which question(s) should be asked?

parasite

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as:

Pain with redness and swelling Localized heat Purulent or malodorous drainage

The nurse is providing discharge education for a client with diabetes. Which symptom(s) of foot ulcer infection should the client report to the health care provider? Select all that apply.

perform meticulous hand hygiene and don a new mask with each client encounter

The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection?

A= Assessment

The nurse is speaking to the health care provider regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?

Drop the item from 6 in (15 cm) above the sterile field

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take?

Touch the inside of the gown and pull it away from the torso.

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct?

Neonates may have an infection without fever.

Which statement about neonatal development is accurate?