317-Midterm Practice Questions
Which of the following is the best indicator that a patient needs TPN? a. Serum albumin level of 2.5 g/dL or less b. Residual of more than 100 mL c. Absence of bowel sounds d. Presence of dumping syndrome
a
Mrs. Babb has had four urinary tract infections in the past year. Which physiologic change of aging is likely causing Mrs. Babb's problem? a. Decreased bladder contractility b. Diminished ability to concentrate urine c. Decreased bladder muscle tone d. Neurologic weakness
A
. 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? RACE a) Evacuate the client. b) Confine the fire. c) Raise an alarm. d) Extinguish the fire.
A
. Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy? a) raising all side rails while the client is in bed b) raising one bed rail to offer stabilization when standing c) placing the client in a bed with a bed alarm d) providing a bed that is low to the floor
A
1 An 80-year-old woman tells the nurse that she just itches all the time and her skin seems very dry. How do these symptoms relate to aging skin? a) activity of the glands in the skin lessens b) the symptoms are indicators of a disease c) skin gland activity increases, leading to acne d) the symptoms are unrelated to aging skin
A
1) Which is one of the most important benefits of a nurse helping with bathing? a) Nurse-client relationships are facilitated. b) The nurse improves technical skills. c) Staff-nurse relationships are more collegial. d) The client sees professional staff.
A
10. A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. What would be most appropriate to include? a) "Clear the clutter from the stairways and walkways." b) "Keep all medications within the client's reach." c) "Get the client immunized against whooping cough." d) "Avoid the use of nightlights in the client's bedroom."
A
12. Dehiscence is the softening of tissue due to excessive moisture. a) False b) True
A
13) The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response? a) "You are free to move onto the stretcher without assistance, but I will supervise for your safety." b) "You cannot transfer without my help because you need a friction-reducing device to prevent harm to your skin." c) "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." d) "I can only allow you to transfer without assistance based upon a physician's order, so I will now help you."
A
14. When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Off-load pressure from the heel. b) Contact the surgeon for deibridement. c) Place a TED hose on the client's leg. d) Using sterile technique, debride the wound.
A
2A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: a) primary intention. b) secondary intention. c) tertiary intention. d) dehiscence.
A
3) While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? a) Periodontitis b) Halitosis c) Caries d) Plaque
A
3. A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? a) white blood cells, debris, bacteria b) clear, watery blood c) mixture of serum and red blood cells d) large numbers of red blood cells
A
8. A full-thickness burn develops a leathery covering called a(an): a) eschar. b) static. c) abrasion. d) erythema.
A
8. Of all factors, what is the most important risk factor in pulmonary disease? a) active and passive cigarette smoke b) loss of the ozone layer of the atmosphere c) dangerous chemicals in the workplace d) air pollution from vehicles
A
9) A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which condition is likely affecting the client? a) Orthostatic hypotension b) Thrombophlebitis c) Anemia d) Bradycardia
A
9. A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate? a) "Performing Kegel exercises can help with muscle strengthening." b) "You need to decrease your daily fluid intake to help with this." c) "Coffee and diet sodas are not factors with being incontinent of urine." d) "It is best to have a Foley catheter inserted to prevent incontinence."
A
Checking the placement of a gastrostomy or jejunostomy tube requires regular comparisons of which of the following? a. Tube length b. Gastric fluid c. pH d. Air pressure
A
Nurses provide many interventions to prevent falls in health care settings. What would be an appropriate intervention to prevent falls? a) Lock wheels on beds and wheelchairs. b) Keep bed in the high position. c) Keep side rails up at all times. d) Apply restraints to all confused clients.
A
Which of the following is the most abundant and least expensive source of calories in the world? a. Carbohydrates b. Fats c. Proteins d. Milk
A
Which of the following is the primary function of carbohydrates? a. To supply energy b. To form antibodies c. To maintain body tissues d. To provide the blood-clotting factor
A
Who or what is the primary source of information for a nursing history? a) The client b) Other health care personnel c) Previous medical records d) Family members
A
Which of the following actions would a nurse perform when measuring a patient's urinary output? (Select all that apply.) a. The nurse asks the patient to void into a bedpan, urinal, or specimen hat, either in bed or in the bathroom. b. The nurse pours the urine from the collection device into the appropriate measuring device. c. The nurse places the calibrated container on a flat surface for an accurate reading and reads the amount by looking down into the specimen. d. The nurse records the total amount voided during each shift and the 24-hour period on the patient's permanent record. e. The nurse discards the urine into the toilet unless a specimen is required. f. The nurse informs a patient that due to legal considerations he cannot measure and record his own output.
ABDE
Which of the following are accurate guidelines for preventing complications with enteral feedings? (Select all that apply.) a. Elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward. b. Give large, infrequent feedings. c. Flush the tube before and after feeding. d. Clean and moisten the nares every 4 to 8 hours. e. Change the delivery set every other day according to agency policy. f. Check the residual before intermittent feedings and every 8 hours during continuous feedings.
ACD
Which of the following is a normal characteristic of urine? (Select all that apply.) a. A freshly voided specimen is pale yellow, straw-colored, or amber, depending on its concentration. b. Freshly voided urine smells like ammonia. c. Fresh urine should be clear or translucent. d. The normal pH of urine is about 3.2, with a range of 2.6 to 5. e. The normal range of the specific gravity of urine is 1.010 to 1.025. f. Organic constituents of urine include ammonia, sodium, chloride, and potassium.
ACE
13. A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. a) Nasal cannula b) Venturi mask c) Humidified venturi mask d) Partial rebreather mask e) Simple oxygen mask
ADE
Which of the following factors increase BMR? (Select all that apply.) a. Growth b. Aging c. Prolonged fasting d. Infections e. Emotional tension f. Sleep
ADE
7. A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? a) "I will tell the doctor you are having problems; maybe he can help." b) "When you increase fiber in your diet, you also need to increase liquids." c) "Just give it a few more days and you should be fine." d) "Well, that shouldn't happen. Let me recommend a good laxative for you."
B
. The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? a) "What are your plans after discharge?" b) "Please tell me your thoughts about treating this diagnosis." c) "You need to stop smoking for us to effectively combat this disease." d) "Do you want to be discharged without treatment?"
B
10) The proper use of the principles of body mechanics: a) acts as a safeguard against legal action by the client. b) acts to prevent injury to the client and/or nurse. c) primarily protects the client from injury. d) Primarily protects the nurse from injury.
B
10. Montgomery straps allow the nurse to change a dressing without the use of tape. a) False b) True
B
12. A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to: a) take a cough suppressant to decrease coughing. b) increase her fluid intake to thin secretions. c) decrease exercise and increase rest periods. d) eat small, frequent meals to conserve energy.
B
13. A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer? a) 35-year-old client who was admitted after a motor vehicle accident and has bilateral casts b) 65-year-old incontinent client with a hip fracture on bed rest c) 45-year-old client who has cancer, is receiving chemotherapy, and being admitted with leukopenia d) 70-year-old client with Alzheimer's who wanders the nursing unit and refuses to sit and eat meals
B
14) After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed? a) To the dominant side of the client, with legs together and one foot near the head of the bed b) Near the client's hip, with legs together c) To the nondominant side of the client, with legs together and one foot near the head of the bed. d) Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed
B
3. The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis? a) Client's report of researching treatment options for melanoma b) Client's report of increased consumption of alcohol c) Client's report of eating more fruits and vegetables d) Client's report of reading the Bible and praying daily
B
3. The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? a) Reduce the frequency of meals in order to allow the client to develop an appetite. b) Try to ensure that the client's food is attractive and sufficiently warm. c) Offer larger meals and encourage the client to eat as much as is comfortable. d) Offer nutritional supplements and explain the potential benefits of each.
B
4. The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? a) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." b) "Your wound will heal slowly as granulation tissue forms and fills the wound." c) "As soon as the infection clears, your surgeon will staple the wound closed." d) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."
B
5. A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? a) Use clean technique to clean the wound. b) Clean the wound from the top to the bottom, and center to outside. c) Once the wound is cleaned, dry the area with an absorbent cloth. d) Clean the wound from the bottom to the top, and outside to center.
B
5. In what situation would the use of side rails not be considered a restraint? a) The institution's policies mandate using side rails. b) A client requests they be up at night. c) The nurse keeps them raised at all times. d) A visitor requests their use.
B
8) A staff development nurse is discussing techniques to prevent back injury with a group of unlicensed assistive personnel (UAP). The nurse informs the group that back stress and injury can be prevented by: a) holding the object that you are lifting/moving away from the body. b) spreading the feet shoulder-width apart to broaden the base of support. c) using the strength of the back muscles during strenuous activities. d) pulling equipment, rather than pushing it, when possible.
B
8. Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called which of the following? a) Evidence-based practice b) Evaluative statement c) Standard d) Criteria
B
9. The nurse would recognize which client as being particularly susceptible to impaired wound healing? a) a client whose breast reconstruction surgery required numerous incisions b) an obese woman with a history of type 1 diabetes c) A client who is n.p.o. (nothing by mouth) following bowel surgery d) a man with a sedentary lifestyle and a long history of cigarette smoking
B
The care plan for a client who has been frequently admitted to the hospital for exacerbation of COPD (chronic obstructive pulmonary disease) has a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis? a) Assess the severity of the client's illness. b) Assess the client's knowledge of COPD. c) Assess the client's financial resources. d) Assess the client's access to health care.
B
The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? a) low blood pressure b) high respiratory rate c) low pulse rate d) high temperature
B
Which of the following foods provides a complete protein? a. Vegetables b. Meats c. Grains d. Legumes
B
4. A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? a) Anuria b) Oliguria c) Polyuria d) Dysuria
D
Which of the following statements accurately describe the action of carbohydrates in the body? (Select all that apply.) a. Carbohydrates are more difficult to digest than protein or fat. b. Ninety percent of carbohydrate is digested. c. The percentage of carbohydrates decreases as fiber intake increases. d. All carbohydrates are converted to glucose for transport through the blood or for use as energy. e. The period between when carbohydrates are consumed and when they are used for energy varies from 10 to 24 hours.
BCD
Which of the following actions are appropriate when conducting a physical assessment of a patient's urinary function? (Select all that apply.) a. The nurse palpates the right kidney by pushing down on it when the patient exhales. b. The nurse should palpate the kidney only under supervision. c. The nurse checks for costovertebral tenderness by placing one palm flat over the costovertebral angle and striking the back of the hand with the other fist. d. When percussing the bladder, a dull sound indicates an empty bladder e. To examine the meatus, the female patient should be placed in a dorsal recumbent position. f. The nurse may use a bedside scanner to assess the bladder
BCEF
Who or what is the primary source of information for a nursing history? a) The client b) Other health care personnel c) Previous medical records d) Family members
a
1. The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action? a) Tell the client that the physician has ordered sleep medication if necessary. b) Determine if the nurses have time to give the client's bath at night. c) Reschedule the client's bath to the evening shift. d) Ask the client for permission to give the bath in the morning.
C
1.After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat? a) Cream of wheat, cranberry juice, and milk b) Fat-free broth, ginger ale, and custard c) Bouillon, apple juice, and gelatin d) Clear broth, hot tea, and yogurt
C
11. The nurse instructs the family of an older adult client with a visual impairment and decreased mobility that the most common problem for these clients is related to: a) electrical cords b) medication errors c) falls d) aspiration
C
12) A nurse is promoting exercise and activities for an elderly patient. Which teaching point would be appropriate for this patient? a) Encourage the patient to quickly increase the repetitions for arm and leg exercises. b) Teach the patient to force joints to meet their natural limit and beyond prior to modifying exercises. c) Encourage the patient to warm up before beginning exercises and to cool down after exercising. d) Instruct the patient to continue exercise even if feeling weakness, to build up stamina.
C
2) Which client would be most at risk for alterations in oral health? a) Healthy young adult b) Woman who is pregnant c) Man with a nasogastric tube d) Infant who is breast-fed
C
2. When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? a) Surveillance b) Maintenance c) Psychomotor d) Psychosocial
C
4) A nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is: a) "You will need to sit up for your bath, and then I will change your bed." b) "I really have limited time. Let me give you your bath right now." c) "I will set up your bath for you. I will come back and help you with your bath." d) "You will be able to take your bath by yourself tomorrow when you can get up."
C
6) A nurse is providing oral care to a client with dentures. What action would the nurse perform first? a) Wash the client's face. b) Apply lubricant. c) Don gloves. d) Assess the mouth and gums.
C
6. While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound? a) Stage IV pressure ulcer b) Stage III pressure ulcer c) Stage II pressure ulcer d) Stage I pressure ulcer
C
7. A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a) keeping an accurate medication record b) notifying the nursing team of the client's condition c) accurately documenting client care on the client record d) documenting client data on the flow sheet
C
8. A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition? a) Fecal incontinence b) Secondary constipation c) Fecal impaction d) Iatrogenic constipation
C
A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a) keeping an accurate medication record b) notifying the nursing team of the client's condition c) accurately documenting client care on the client record d) documenting client data on the flow sheet
C
Men have a higher need than women for which of the following nutrients due to their larger muscle mass? a. Carbohydrates b. Minerals c. Proteins d. Vitamins
C
Mrs. Blase is an obese patient who visits a weight control clinic. When considering a weight-reduction plan for this patient, the nurse should consider which of the following guidelines? a. To lose 1 pound/week, the daily intake should be decreased by 200 calories. b. One pound of body fat equals approximately 5,000 calories. c. Psychological reasons for overeating should be explored, such as eating as a release for boredom. d. Obesity is very treatable, and 50% of obese people who lose weight maintain the weight loss for 7 years.
C
Which of the following events occurs when micturition is initiated? a. The detrusor muscle expands. b. The internal sphincter contracts. c. Urine enters the posterior urethra. d. The muscles of the perineum and external sphincter contract
C
Which of the following nutrients supply energy to the body? (Select all that apply.) a. Vitamins b. Minerals c. Carbohydrates d. Protein e. Water f. Lipids
CDF
4. Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a) Consult with the physical therapist to determine the client's ability. b) Instruct the client's family to assist the client to ambulate to the bathroom. c) Continue assisting the client to the bathroom to ensure the client's safety. d) Revise the care plan to allow the client to ambulate to the bathroom independently.
D
5) When providing oral care, what does the nurse recognize as the most important component of the oral care process? a) application of moisturizing ointment to the lips b) selection of toothpaste c) use of a mouthwash or breath freshener d) a thorough, mechanical cleaning
D
0. A nursing student is conducting an interview with a client. Which of the following best demonstrates use of open-ended questions in an interview? a) Do you participate in any illicit drugs? b) Are you feeling well? c) Do you smoke? d) How are you feeling?
D
1. What does pulse oximetry measure? a) Peripheral blood flow b) Venous oxygen saturation c) Cardiac output d) Arterial oxygen saturation
D
11)While performing passive range-of-motion exercises on the lower extremities of a client with a spinal cord injury, the nurse assesses permanent flexion of the muscles. What term will the nurse use to document this finding related to the muscles? a) Atrophy b) Tonus c) Ankylosis d) Contractures
D
11. A home care nurse is visiting a client as a part of a regular visit. The client's daughter age 4 years falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect? a) Resolution of inflammation b) Increased blood flow c) Relief of muscle stiffness d) Help in controlling swelling
D
2. What is the route of administration for TPN? a) Intramuscular b) Subcutaneous c) Oral d) Intravenous
D
5. Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education? a) "I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper." b) "At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night." c) "I've made a point of scheduling when I drink water instead of waiting until I'm thirsty." d) "I make sure to limit how much I drink so that I don't have accidents."
D
6. A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? a) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. b) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence. c) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. d) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.
D
7) The mother of a 2-year-old child tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother? a) "You really like to keep your child clean. Good for you!" b) "Show me exactly how you use the hairpin." c) "That's not good. Use a Q-tip or your finger instead." d) "That is dangerous; you might puncture the eardrum."
D
7. A 77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the client's chance of skin breakdown? a) Keep the client in a semi-Fowler's or high-Fowler's position. b) Ensure the client is adequately hydrated. c) Massage or stimulate the client's skin surfaces daily. d) Reposition the client on a regular basis.
D
7. During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Humidifier b) Nasal cannula c) Oxygen analyzer d) Flow meter
D
9. Oxygen and carbon dioxide move between the alveoli and the blood by: a) hyperosmolar pressure. b) negative pressure. c) osmosis. d) diffusion.
D
A 68-year-old client in the hospital with a chronic illness is 25% overweight. This client refuses to eat vegetables and continues to ask for food to be delivered from the local pizza restaurant. Which of the following might this client be experiencing? a. Protein-calorie malnutrition b. Undernutrition c. Overnutrition d. Both over and undernutrition
D
A nursing student is conducting an interview with a client. Which of the following best demonstrates use of open-ended questions in an interview? a) Do you participate in any illicit drugs? b) Are you feeling well? c) Do you smoke? d) How are you feeling?
D
A patient is taking delayed-release omeprazole (Prilosec) capsules for the treatment of gastroesophageal reflux disease (GERD). Which statement will the nurse include in the teaching plan about this medication? A. "Take this medication once a day after breakfast." B. "You will only have to be on this medication for 2 weeks for a life long treatment of the reflux disease." C. "The medication may be dissolved in a liquid for better absorption." D. The entire capsule should be taken whole, not crushed, chewed or opened
D
Which of the following catheters should be used to drain a patient's bladder for short periods (5 to 10 minutes)? a. Foley catheter b. Suprapubic catheter c. Indwelling urethral catheter d. Straight catheter
D
Which of the following collection devices is a nurse's best option when collecting urine from a nonambulatory male patient? a. Specimen hat b. Large urine collection bag c. Bedpan d. Urinal
D
Which of the following sugars must be broken down by enzymes in the intestinal tract before they can be absorbed? a. Glucose b. Fructose c. Galactose d. Lactose
D
Which of the following vitamins is water soluble? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin C
D
1 A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? a) The nurse performs routine care and is moving to another patient. b) The nurse is caring for a client with a C. difficile infection. c) The nurse finishes patient care and hands are not visibly soiled. d) The nurse finishes cleaning a patient's table.
b
10 The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective? a) Revising the facility's infection control protocols b) Incentivizing health care workers to utilize hand hygiene c) Limiting visitors to family members over the age of 18 d) Encouraging visitors to adhere to isolation precautions
b
3 A nurse who is taking the vital signs of a client with acute diarrhea is ordered to attend to another client. What is the highest priority nursing action the nurse must perform before leaving the client's room? a) removing personal protective equipment that is most contaminated first b) thorough handwashing c) spraying of disinfectant d) placing one bag of contaminated items within another
b
5 The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents the appropriate use of hand hygiene? a) The nurse uses hand hygiene instead of gloves when in contact with blood. b) The nurse keeps fingernails less than ¼ inch long. c) The nurse refrains from using hand moisturizer following hand hygiene. d) The nurse uses gloves in place of hand hygiene.
b
8 When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission? a) Airborne b) Contact c) Vehicle d) Vector
b
9 A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on the QSEN competency of safety? a) The nurse keeps visitors 3 feet away from the infected person. b) The nurse places the client in a private room with monitored negative air pressure. c) The nurse uses droplet precautions when providing care for the client. d) The nurse places the client in a private room with the door open.
b
Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called which of the following? a) Evidence-based practice b) Evaluative statement c) Standard d) Criteria
b
The nurse is caring for a client who has active tuberculosis (TB) and is in Airborne Precautions. The primary care provider orders a computed tomography (CT) examination of the chest. Which of the following actions by the nurse is appropriate? a) Question the need for the examination because the client must remain in Airborne Precautions. b) Place a surgical mask on the client and transport to the CT department at the specified time. c) Notify the CT department in advance so other clients and staff can be removed from the area. d) Request that the examination be done at the bedside.
b
Which of the following nursing interventions would be least effective when trying to maintain safety for the patient with an indwelling catheter? a. Maintain a closed drainage system. b. Restrict fluid intake. c. Apply a topical antibiotic ointment to urinary meatus. d. Report signs of infection immediately.
b
Which of the following procedures is appropriate when aspirating fluid from small-bore feeding tubes? a. Use a small syringe and insert 10 mL of air. b. If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. c. Continue to instill air until fluid is aspirated. d. Place the patient in the Trendelenburg position to facilitate the fluid aspiration process.
b
4 The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown? a) Before taking the client's pulse b) After entering the client's room c) Before entering the client's room d) After taking the client's pulse
c
7 The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by the Centers for Disease Control (CDC) for hand hygiene? a) Do not wash hands; apply clean gloves. b) Wash hands with soap and hot water. c) Decontaminate hands using an alcohol-based hand rub. d) Wash hands with soap and water, followed by an alcohol-based hand rub.
c
6 A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? a) An infectious agent b) A portal of exit c) A portal of entry d) A reservoir
d
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action"? a) Consult with the physical therapist to determine the client's ability. b) Instruct the client's family to assist the client to ambulate to the bathroom c) Continue assisting the client to the bathroom to ensure the client's safety d) Revise the care plan to allow the client to ambulate to the bathroom independently.
d
The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard? a. The sample collected immediately after lunch b. The bedtime voiding c. The voiding collected at 4 p.m. d. The first voiding of the day
d