260 exam 1 review questions

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? "You will receive medication through this device." "Drainage will occur by gravity and capillary action." "It provides a way to remove drainage and blood from the surgical wound." "The bulb-like system will stay in place permanently after your mastectomy."

"It provides a way to remove drainage and blood from the surgical wound."

In order to maintain effective hand hygiene, what is the minimal amount of time that a nurse should scrub hands that are not visibly soiled? 20 seconds 30 seconds 1 minute 5 minutes

20 seconds

Which nurse would be at the highest risk of causing a hazardous situation? A nurse who has worked 32 hours of overtime this week A nurse who has placed a client in the bed with three side rails up A nurse who is transferred to another unit to assist with care A nurse who is administering medications to four clients

A nurse who has worked 32 hours of overtime this week

A nurse is caring for a client who has been transported for a diagnostic test. The nurse is changing the client's bed linens and moves them to the location in the image. Which anticipated outcome is most plausible based on the nurse's actions? (the nurse is putting dirty linen on a chair in the image) Contaminants can be transferred onto the furniture and spread microorganisms. Some hospital policies allow for temporary placement of soiled lines on furniture. An incident report will be created and sent to risk management. The furniture will be tagged for removal from the hospital premise due to contamination.

Contaminants can be transferred onto the furniture and spread microorganisms.

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? Discard the swab and inform the health care provider that the wound is too infected to culture Obtain the swab as prescribed and send it to the lab for culture Obtain the swab and then clean the wound Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? Healthcare-associated infection Respiratory infection Droplet infection Sexually transmitted infection

HAI

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? Yes, this helps prevent vaginal odor. Yes, this decreases vaginal secretions. No, douching removes normal bacteria. No, douching may increase secretions.

No, douching removes normal bacteria.

A nurse is developing a foreground question for nursing research using the PICO model. Which component would be represented by the statement, "a 45-year-old male with coronary heart disease and atrial fibrillation"? A. P B. I C. C D. O

P

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate? Place a surgical mask on the client and transport to the CT department at the specified time. Notify the CT department in advance so other clients and staff can be removed from the area. Question the need for the examination, because the client must remain under airborne precautions. Request that the examination be done at the bedside.

Place a surgical mask on the client and transport to the CT department at the specified time.

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be? Assign a care provider who shares the same culture as the client. Assess the skin every day using the Braden scale. Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). Assess the client's cultural views regarding hygiene and self-care.

Assess the client's cultural views regarding hygiene and self-care.

What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? Avoid stuffed animals and blankets in the crib. Educate about, and be aware of, signs of risky behaviors. Include safeguards to prevent falls in the home. Teach seat belt safety.

Avoid stuffed animals and blankets in the crib.

A nurse is caring for a female client with diarrhea. What information does the nurse teach the client about perineal care and self-care? Bathe the perineal area with a mild soap and water. Clean the perineal area from the front to back. Insert any suppository medication prior to cleaning the perineal area. Wear gloves while performing perineal self-care.

Clean the perineal area from the front to back.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. The nurse's back is facing the sterile field. The nurse keeps hands above waist level while donning sterile gloves. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field. The nurse disposes of an opened container of sterile saline after 24 hours.

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field.

The nurse is providing an in-service educational program for the interprofessional health care team about infection control precautions. What teaching will the nurse include? Select all that apply. Wear personal protective equipment (PPE). Practice hand hygiene. Use standard precautions only for clients with infection. Use equipment repeatedly on clients with similar conditions. Keep client's environment clean.

Wear personal protective equipment (PPE). Practice hand hygiene. Keep client's environment clean.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.

a surgical incision with sutured approximated edges

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? Activate the fire alarm and notify the appropriate person. Attempt to extinguish the fire. Alert the local fire department. Answer all telephone calls and call bells

activate the fire alarm

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client? standard airborne droplet contact

airborne

For which client would the use of standard precautions alone be appropriate? a client with diphtheria who needs p.m. care a client with TB who needs medications administered an incontinent client in a nursing home who has diarrhea a child with chickenpox who is treated in the emergency room

an incontinent client in a nursing home who has diarrhea

Which is a tenet of Maslow's basic human needs hierarchy? A need that is unmet prompts a person to seek a higher level of wellness. A person feels ambivalence when a need is successfully met. Certain needs are more basic than others and must be met first. People have many needs and should strive to meet them simultaneously.

certain needs are more basic than others and must be met first

A nurse develops the following foreground question using the PICOT format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention? Overweight clients Chromium supplements No supplements Weight loss

chromium supplements

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? Clear clutter in the walkways of the new home. Change the older adult's routine. Take walks outside. Use the stairs in the new home.

clear clutter out of hallways

Which statement is most applicable to evidence-based practice? It emphasizes personal experience over science. Clinical expertise is integrated with external evidence. It involves gaining solutions to problems. The purpose is to learn about a specific problem.

clinical expertise is integrated with external evidence

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? Cutting up food and opening drink containers for the client Seeking input from the client regarding preferences for a snack Providing the mother the phone number for the Poison Control Center Assisting the client to validate feelings regarding treatment options

cutting up food and opening drink containers for the client

The nurse is preparing a client who is in droplet isolation for transport to radiology. What is the appropriate nursing intervention(s)? Select all that apply. facilitating interdepartmental coordination about the transport removing the client's mask for transport placing a clean sheet on the stretcher that the client will be transported upon ensuring that the client has a mask on reminding transporter to utilize droplet precautions

facilitating interdepartmental coordination about the transport placing a clean sheet on the stretcher that the client will be transported upon ensuring that the client has a mask on reminding transporter to utilize droplet precautions

What is the leading cause of injury-related deaths in adults 65 and older? falls alcoholism violence motor vehicle accidents

falls

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? full-thickness skin loss skin pallor blister formation eschar formation

full thickness skin loss

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? taking medications as prescribed proper intake of food and fluids thorough hand hygiene adequate sleep and rest

hand hygiene

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? Lying with the head slightly lowered High Fowler's position Supine with one pillow Side-lying with head slightly elevated

high fowlers position

Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls? Keep bed in the high position. Keep side rails up at all times. Apply restraints to all confused clients. Lock wheels on beds and wheelchairs.

lock wheels on bed and wheelchairs

The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs? Love and belonging Physiologic Self-esteem Self-actualization

love and belonging

Which provides the best framework for prioritizing client problems? Availability of hospital resources Family member statements Maslow's hierarchy of needs Nursing skill

mallows

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action? Restrain the client's hands Open a new sterile dressing kit Continue changing the dressing Wash the client's hands

open a new sterile dressing

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? Physiological Safety Love and belonging Self-actualization

physiological

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply. place a mask on the client refuse to transport the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

Which interventions will be most effective in preventing the spread of infection in the health care setting? Sterilizing all client supplies Frequent room air exchanges Proper handwashing Donning gloves for all client care

proper hand washing

An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching? Combine medications into a few pill bottles for ease of use. Put a small nightlight in the hall and stairway. Decorate the parent's room with small rugs and wall hangings. Locate the parent in a room near the kitchen.

put a small nightlight in the hall and stairway

Which action is the best example of a nurse donning/removing protective equipment properly? Removing respirator after leaving client's room Removing gown after leaving client's room Donning gown after entering client's room Donning respirator inside of client's room

removing respirator after leaving the clients room

A client who was receiving care on a psychiatric unit died by suicide at a time when nurses are known to have been handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event? Inform local health care institutions about the event to promote safety. Change the institution's policies regarding supervision of clients. Appropriately discipline the nurses who were participating in the shift change. Report the event to the Joint Commission.

report even to the JC

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority? Extinguish the fire. Rescue the client. Raise an alarm. Confine the fire.

rescue

A nurse is providing oral care to an unconscious client. When planning this intervention, the nurse should prioritize which nursing diagnosis? Risk for Aspiration Adult Failure to Thrive Nausea Risk for Trauma

risk for aspiration

The nurse provides the mother of a toddler with the phone number for the poison control center. Which level of Maslow's hierarchy of needs is the nurse addressing? Physiologic needs Self-actualization needs Loving and belonging needs Safety and security needs

safety and security needs

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as: serous. sanguineous. serosanguineous. purulent.

serosanguineous.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? As a stage I pressure injury As a stage II pressure injury As a stage III pressure injury As a stage IV pressure injury

stage 1

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV

stage III

A nurse is changing the bed linen of a client admitted to the health care facility. Which isolation precaution should the nurse follow? Standard precautions Droplet precautions Contact precautions Airborne precautions

standard precaution

is this the correct order for evidence based practice? Design a question related to a clinical area of interest. Collect the most relevant and best evidence available. Critically evaluate the collected evidence. Integrate the evidence with clinical expertise, client preferences, and values as the decision is made to make a change Evaluate the decision or change.

yes