EAQ 1
c
5 days after a client has abdominal surgery the nurse assesses the clients incision site for signs of dehiscence. which clinical finding supports that the client is experiencing wound dehiscence? a. increased bowel sounds b. loosening of the sutures c. serosanguineous drainage d. purplish color of the incision
b
a client arrives at the emergency department after being bitten by a dog. the bite involved tearing of skin and deep soft tissue injury. which action would the nurse take first? a. inform the owner of the dog about the clients injury? b. assess the clients injury, vital signs, and east history c. obtain a prescription for human rabies immune globulin d. notify the appropriate community agency to capture the dog.
a
to ensure client and visitor safety during transport of a client with Influenza A (H1N1) for a computed tomography, the. nurse would take which precaution? a. place a surgical mask on the client b. other than standard precautions, no additional precautions are needed c. minimize close contact d. cover the patients legs with a blanket
a
what color would the nurse anticipate when assessing a clients skin tears? a. red b. gray c. black d. yellow
a
which type of debridement would the healthcare provider schedule for a client who requires removal of large amounts of nonviable tissue quickly a. surgical debridement b. autolytic debridement c. enzymatic debridement d. mechanical debridement
a
under which type of health care services would the nursing student include subacute care? a. tertiary care b. continuing care c. restorative care d. secondary acute care
c
which action would the nurse take to decrease the risk of transmission of VRE? a. insert a urinary catheter b. initiate droplet precautions c. move the client to a private room d. use high-efficiency particulate air (HEPA) respirator during care
a
which will the nurse document to prevent injury when an adolescent is admitted to the hospital for a surgical procedure? a. allergies b. pain level c. grade in school d. emergency contact
495
I/O of a client over an 8hr period is 15o Ml urine voided at 800. 220 mL of urine at 1200; 235mL at 1600; 200mL gastric tube formula and 50mL water administered initially and then repeated 2 times. IV administered 900mL in the bag at 800 and 550 remains in the bag at 1600. what is the difference between the clients input and output? _____mL
c, e
a client underwent surgery and developed a wound without tissue loss. while caring for the client, the nurse detects abscesses formation. which assessments made by the nurse supports the observation? (select all that apply) a. necrosis of skin edges b. swelling of the incision line c. purulent drainage from the incision site d. erythema off the incision line of more than 1cm e. localized fluctuant beneath the wound when palpated
d
how would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? a. red b. black c. green d. yellow
a, b, c
the nurses teaching self management care in preventing and spreading methicillin-resistant staphylococcus aureus (MRSA). which statements made by the client indicate the need for further learning? (select all that apply) a. "I can share athletic equipment" b. "I can participate in contact sports" c. "I should sit on upholstered furniture" d. "I should use antibacterial soaps for bating" e. "I should wash all infected skin areas before covering those areas"
Gown, mask, goggles, gloves
order of DONNING
c
the nurse places a client in restraints due to violent combative behavior. which intervention would the nurse perform next? a. offer food and drink b. document the behavior c. obtain a written or verbal prescription d. provide a q:1 attendant in the room
b, c, e
which dressings would the nurse view as beneficial for the recovery of a clients red-colored wound that was caused by pressure? (select all that apply) a. absorptive dressings b. hydrocolloid dressings c. transparent film dressings d. moist gauze dressings with antibiotics e. non-adhering dressings with antibiotic ointment
a, b
which findings indicate that the nurses are providing safe healthcare? (select all that apply) a. exhibits good decision making skills b. acts within the scope of practice of their license c. provides cost effective interventions to the clients d. offers both curative and preventative interventions for the clients e. executes interventions that have reduced the duration of hospital stays of the client
a, c, e
which information would the nurse document in the medical record regarding a clients reported allergies? (select all that apply) a. medication names b. date of allergic reaction c. type of allergic reaction d. family history of allergies e. epinephrine (EpiPen) use for allergic reaction
b, c, d
which services do nurse-managed clinics provide in preventative and primary care services? (select all that apply) a. crisis intervention b. wellness counseling c. health risk appraisal c. employment readiness e. communicable disease control
a
within the first 2 hours of a radical neck dissection, a large amount of bloody fluid is collected in the portable wound drainage system. which action would the nurse take first? a. obtain the clients vital signs b. notify the primary healthcare provider c. document the amount in the medical record d. continues to monitor the amount for another hours.
gloves, gown, goggles, mask
order of DOFFING
physiological, safety and security, love and belonging, self esteem, self actualization
place the terms in order of Maslow's hierarchy of needs (bottom to top): Love and belonging self esteem safety and security physiological self actualization
a
the nurse stops at the scene an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. then nurse wraps the mans hand in a soiled cloth and derives him to the nearest hospital. how would the nurses behavior be interpreted? a. nurse is negligent and can be sued for malpractice. b. the nurse is practicing under guidelines of the nurse practice act c. the nurse is protected for these actions in most states by the Good Samaritan legislation d. the nurse is treating a health problem m that can and should be addressed by a primary healthcare provider
c
the unit nurse manager comes to work obviously intoxicated. which action is the staff nurse ethically obligated to take? a. call the security guard b. tell the nurse manager to go home c. have the supervisor validate the observation d. offer the nurse manager to a large cup of coffee.
a, c, d
which are the major attributes of quality health care? (select all that apply) a. safe b. timely c. effective d. efficient e. equitable
a, b, d
which are the minor attributes that affect the quality of care provided for the client by the nurse? (select all that apply) a. timely care b. equitable care c. cost-effective d. patient-centered care e. sound decision making
a
a client who has a history of emphysema is transported back to the nursing unit after radical neck dissection for cancer of the tongue. the client is receiving O2 and IV infusion. within the first hour, the client has 50 mL of drainage system. which initial action would the nurse take? a. inspection thaw dressing b. increase O2 Flow rate c. notify the healthcare provider d. place the client in the supine position
b
a client with tuberculosis is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions. which nursing intervention would the nurse implement this time? a. ensure regular visits by staff members to meet the client needs b. explore what the airborne precautions mean to the patient c. report the situation to the infection control nurse immediately d. reteach the concepts of airborne precautions to the nurse
a, b, e
a person who underwent surgery reports pain at bony prominences and has skin breakdown and tears. which interventions performed by the nurse would be included in the plan of care? (select all hat apply) a. cleansing the ulcer with saline b. removing the loose bits of tissue c. measuring wound size every alternate week d. repositioning the client at least every 5 hours e. changing the old dressings daily if the ulcer is uncovered
a
an emaciated older adult with dementia develops a pressure ulcer after refusing to change position for extended periods. the family blames the nurses and threatens to sue. which is considered when determining the source of blame for the pressure ulcer? a. the client should have been turned regularly b. older clients frequently develop pressure ulcers c. the nurse is not responsible to the clients family d. nurses should respect the clients right not to be moved
d
an older adult client is brought to the hospital by a family member because of deep partial-thickness burns in the arm and hands. the client protests being hospitalized and asks, "why cant I just o home and have my spouse care for me?" which is the best response for the nurse? a. "you sound upset, but your primary healthcare provider knows what's best. you should do what is prescribed" b. "your spouse Is very capable but if you burns get infected, a family member cant give you the injections you will need" c. "your burns are more serious Han you thin, and we have specially trained people here just to take care of you" d. "you may heal more slowly because of your age, and you may need the special care and equipment available in the hospital"
b
client has a stage 3 pressure injury. which nursing intervention can prevent further injury by eliminating shearing force? a. maintain the head of the bed at 30 degrees or less b. use a draw sheet to pull up, transform and position the client c. reposition the client every 2 hours, propping with pillows d. perform passive ROM exercises every 8 hours
d
hospitalized patient develops an infection at the catheter insertion site. the nurse uses the term iatrogenic when describing the infection. which rationale explains the nurses comment? a. poor personal hygiene is the cause b. inadequate dietary intake is the cause c. the clients developmental level is the cause d. a procedure performed at the hospital is the cause
a
how would a nurse explain the purpose of standard precautions to the nursing assistant on a surgical unit? a. decrease the risk of transmitting unidentified pathogens b. used by staff when clients are suspected of having a communicable disease c. censure clients perform hygiene practices in a universal way d. create categories requiring the client to follow additional precautions
970
nurse who is working the 8am to 4pm shift must document a clients fluid intake and output. IV drip is infusing 50mL per hour. client drinks 4oz of orange juice and 6 oz of tea at 8:30 am and vomits 200mL at 9am. at 10 am client drinks 60 mL of water with medications. Client voids 550mL of urine at 11. at 12:30 eats 3oz of soup and 4oz of ice cream. client voids 450mL at 2pm. calculate the total intake for the 8am-4pm shift. _____mL
d
the client has a large, open, abdominal wound. the healthcare providers prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. which top would the nurse take to maintain sterility when changing the dressing? a. use 2 square gauze pads to cleanse the would, 1 for each half of the wound b. apply new Montgomery straps each time the dressing is changed c. hold the wet cause with the tips fo forceps higher than the wrist d. cleanse the wound with wet, sterile gauze front eh center of the wound outward.
b, c, e
the community nurse is assessing an older adult client who lives alone at home. thew nurse finds the client refrains from physical activity for fear of falling when walking. which intervention (s) by the nurse are beneficial to promote a healthy lifestyle? (select all that apply) a. instruct the client to apply bedside rails b. encourage the client to wear nonskid shoes c. suggest that'll client use an assistive device d. ask the client to install handrails in the bathroom e. help the client rearrange the furniture in the house
b
the nurse change a dressing on a clients wound with vancomycin resistant enterococci (VRE)> which step would the nurser take to ensure proper disposal of the soiled dressing? a. place the dressing in the bedside trash can b. place the dressing in a red bag/biohazard material bag c. contact environmental services personable to pock up the dressing d. transport the dressing to the laboratory rot be placed in the incinerator.
c
the nurse documents the data gathered during the assessment in a clients medical record. which would the nurse do to ensure that the data is meaningful to other healthcare providers? a. record subjective information in own words b. form judgements through written communication c. record objective information using accurate terminology d. compare data from the physical examination with client behavior
c
the nurse is advising an older adult to apply moisturizer when the skin is moist. which physical change in the client is associated with this advice? a. thinning subcutaneous layer b. degeneration of elastic fibers c. decreased dermal blood flow d. benign proliferation of capillaries
b
the nurse is caring for a patient who had major abdominal surgery 1 day ago. which factor increases the risk of this client developing wound dehiscence? a. placement of a t-tube b. a BMI of 35 c. presence of excessive flatus d. reciting beta blockers
d
the nurse is caring for a patient who returns from surgery with a drain that is attached to a portable wound drainage system exiting from the surgical site. which principle underlying the function of a portable drainage system will the nurse consider when planning care for this client? a, gravity b. osmosis c. active transport d. negative pressure
a
the nurse is reviewing discharge plans with a client who is hospitalized with Hep. A. the nurse concludes that the client understands preventative measures to reduce the risk of spreading the disease when the client makes which statement? a. "I should wash my hands frequently" b. "I should launder may own closes separately" c. "I should put used tissues in the garbage" d. "I should wear a mask when leaving the house"
a
the nurse is teaching a student nurse about precautions to take when treating a client with open burn wounds. which statement made by the student nurse indicates the need for further teaching? a. "I should use non sterile gloves when applying ointments" b. "I should use non sterile disposable gloves when removing old dressings" c. "I should wear PPE before caring for the client" d. "I should remove PPE before leaving 1 client to treat another"
a
the nurse is teaching unlicensed assistant personable about ways to prevent the spread of infection. the nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? a. hand washing before and after providing client care b. cleaning all equipment with an approved disinfectant after use c. Using PPE when providing client care d. using medical and surgical aseptic technique
c
the nurse provides postoperative care to a client who has undergone hypophysectomy. which action would the nurse take if there is a yellowish discharge at the dressing site? a. change the dressing b. remove the discharge with alcohol swabs c. inform the primary healthcare provider d. reinforce the dressing to prevent leakage
c
the nursing staff used seclusion for a client due to behavior that placed other clients and staff at risk for harm. which intervention would the nurse perform first when reintegrating the client into the unit? a. document behaviors that occurred b. administer antipsychotic medication c. discuss behavior that necessitated seclusion d. plan alternative metnods to respond to stress
d
the school nurse presented a program for teachers about infection control and hand washing techniques. which evaluation method is the most effective way for the nurse to evaluate the teachers knowledge of hand washing techniques? a. observe the teachers lecture the children about hand hygiene b. administer an objectively written final examination to the teachers c. have the teachers share their knowledge of hand washing d. watch the teachers demonstrate infection control techniques
a
to meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take? a. initiate an agency incident report b. repot the fall to the state (provincial) health department c. write a brief description of the incident to be kept by the nurse manager d. determine that no documentation is needed because the visitor is not a client in the hospital
d
when a client with health care-acquired respiratory tract infection asks the nerves what this means, which response will the nurse give? a. "you developed an infection that requires antibiotics" b. "this is a highly contagious infection requiring isolation" c. "an infection you had before beginning treatment has flared up" d. "your infection occurred because of exposure to a healthcare facility"
c
when admitting an older patient, the stool specimen confirmed a diagnosis of a MRSA infection. the nurse inquires about potentially assigning room 2010, bed B, the same isolation rooms another client who has MRSA. which response would the nurse give? a. "the other clients infection is not contagious" b. "this is the usual practice when antibiotic therapy is started" c. "placing patients with the same infection in 1 room is safe" d. "as soon as a private room becomes available;e we will move the client"
c
when assessing the oral cavity of a newly admitted client with acquired immunodeficiency syndrome (AIDS), the nurse identifies ares of white plaque on the clients tongue and palate. which action is the nurse's initial response? a. instruct the client to perform meticulous oral hygiene at least once daily b. identify one of the lesions, scrape the area, and send for a biopsy c. document the presence of lesions, describing their size, location, numbers., and color d. consider findings as universally identified lesions in clients with AIDS that require no treatment
b, c
when preforming a physical assessment of a female client, the nurse positions the client in left lateral recumbent position. which body system would be assessed in this position? (select all that apply) a. heart b. vagina c. rectum d. female genitalia e. musculoskeletal system
d
when teaching a older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding? a. "I should gently pat my skin" b. "I should use mild, heavily fattened soap" c. "I should wash my skin with tepid, rather than hot water" d. "I should apply powders or talc on a perineum wound"
c
which action would the home health nurse take when caring for a client with a pink and moist left leg venous stasis ulcer? a. teach the client to keep the left leg in a dependent position to improve blood flow b. monitor for increases in bruising or bleeding caused by use of anticoagulant medications c. clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly d. educate the client about the need for vascular surgery to improve blood flow to the wound
a
which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis? a. place the client on airborne precautions b. notify the clients healthcare provider c. auscultate the clients breath sounds d. notify the public health department
c
which action would the nurse take when observing that a post surgical client has urine output of 800mL total in the first 24 hours after surgery? a. notify the provider b. increase fluid intake c. document the normal finding d. begin IV infusion of normal saline
b, c, d
which activities would the nurse perform to meet the clients safety and security needs based on Mallow's hierarchy of needs? (select all that apply) a. providing a cold bath to reduce the clients body temperature b. positioning the bed in a low position keeping the side rails up c. monitoring vital signs, such as BP to decrease the risk of falls d. observing a client who has suicidal tendencies to prevent adverse incidents w. collaborating with family members to provide emotional support for the client post-surgery.
b, c, e
which are characteristics of the secondary level of prevention? (select all that apply) a. activities are aimed at health promotion b. focuses on individuals with health problems and illnesses c. activities are directed at diagnosis and promotion interventions d. helps in minimizing the effects of long term disease and disability e. includes screening techniques and treating disease at early stages
c
which category of isolation would the nurse implement for a client who is positive for clostridium difficile? a. airborne precautions b. droplet precautions c. contact precautions d. protective equipment
c
which criteria would the nurse consider when determining if an infection is a healthcare associated infection? a. originated primarily from an exogenous source b. Is associated with a medication-resistant microorganism c. occurred in conjunction with treatment for an illness d. still has the infection despite completing the prescribed therapy
b, c, d, e
which data would the nurse use to determine a clients score not he Braden scale to predict the clients risk for developing pressure ulcers? (select all that apply) a. age b. anorexia c. hemiplegia d. history of diabetes e. urinary incontinence
a, b, c
which factor (s) increase(s) the risk for nurses making medicine errors in the healthcare setting? (select all that apply) a. stress b. fatigue c. overwork d. equipment malfunction e. increased documentation
a, c, e
which factors may help in providing excellent health care services to the client? (select all that apply) a. cultural sensitivity b. high client literacy c. competency in healthcare d. 1 way communication d. interprofessional teamwork
a, d, e
which important points regarding orders from a primary healthcare provider would the nurse keep in mind to prevent any legal complications? (select all that apply) a. follow the primary healthcare providers order unless the order seems to be harmful or is incorrect b. ensure that nursing students verify verbal orders by reading them out to the primary healthcare provider c. be aware that following an inappropriate order doesn't make the nurse legally responsible for any harm to the client d. inform the nursing supervisor if the order looks inappropriate, but the primary healthcare provider is required to confirm the order e. document that the primary healthcare provider was notified about an incorrect order, along with his/her response, follow up, and the clients response
a, b, c
which important points would the nurse keep in mind when witnessing consent forms? (select all that apply) a. confirm that the clients signature is authentic b. ensure that the client has given the consent voluntarily c. refrain from asking the student nurse to witness consent forms d. instruct the family member to assist if the client denies understanding of the procedure e. check if the clients caregiver has understood the procedures written in the consent form.
a
which information about infection prevention would the nurse include when planning discharge teaching for a client being treated with chemotherapy for leukemia? a. "wash hands before eating and after using the toilet" b. "take your temperature daily and report elevations of 1 degree F" c. "avoid use of antimicrobial soaps when showering of bathing" d. "increase your daily intake of fresh fruits and vegetables" e. "read food labels to avoid sodium in your diet"
a, c, e
which information would the RN provide to a student nurse about the importance of nursing documentation for risk management? (select all that apply) a. "a nurses documentation is the evidence of care that a client receives" b. "nurses notes would not be given to attorneys in the event of a lawsuit" c. "the nurse would note assessments and significant changes in the clients health" d. "in case an occurrence report is filed, nurses would enter the information in the clients charts" e. "nurses would always document the primary health care providers responses whenever they are contacted"
d
which level ramification wouldd be indicated when a newly admitted male client with bipolar disorder who has a history of hyperactivity and combativeness is found later in the evening beating another client? a. the client should have been placed in restraints on admission b. keeping the client seated is necessary for a client who is known to be combative. c. a client with bipolar disorder who is in contact with reality does not require supervision d. because it was known that the client was frequently combative, close observation by the nursing staff was indicated.
c
which nursing action would have the highest priority for a client with a leg in traction? a. assessing mobility b. assessing the injured bone c. assessing skin integrity d. assessing the muscle spasm
a, b, e
which of these actions would the nurse perform to provide preventative and primary care to adults during a health camp? (select all that apply) a. discussing vaccinations b. discussing family planning c. mentioning adult daycare services d. instructing the health camp about self-care at home e. instructing the health camp about road safety measures
d
which of these records can the nurse use to document information specific to the clients health in a story like format? a. acuity record b. source record c. hand off reports d. narrative documentation
c
which piece of equipment must the nurse ensure remains sterile during the care of the client? a. bedpan b. stethoscope c. suction catheter d. BP cuff
a, b, c, e
which points about restorative care are accurate? (select all that apply) a. the restorative healthcare team consists of healthcare professionals, the client, and the caregiver (s) b. success depends on effective and early collaboration with clients and their families c. clients and families follow treatment plans better hone they're involved in restorative care d. clients who are disabled or who are suffering from terminal diseases need restorative care e. restorative care is provided through home healthcare, rehabilitation, or extended care facilities.
a, b, d
which points would the nurse remember when caring for a patient who has a history of suicide attempts? (select all that apply) a. document the measures taken to prevent suicides b. if the client makes a suicide attempt in the hospital, this action may lead to a lawsuit c. the client may be detained for 21 days if a judge grants an involuntary detention d. the primary healthcare facility will be responsible for failing to provide adequate supervision e. file paperwork with the court within 96 hours of the clients admission to the facility
a
which scenario mentioned by the nurse is an example of continuing care? a. caring for a patient with Parkinson's who requires day care service b. explaining to a family member the frisks and benefits of screening for cancer c. teaching a couple about the proper use of contraceptives and promotion of sexual health d. teaching a teenager about the importance of eating nutritious foods to prevent health issues.
a
which scenarios mentioned by the RN is considered secondary acute care? a. prepares a client who has suffered from repeated cerebral attacks for a CT scan b. performing physical examinations and monitoring fetal movement in a pregnant woman c. teaching family members about the importance of being vaccinated and the risks associated with a lack of vaccinations. d. checking a clients HR and BP before administering entacapone and isoproterenol concurrently.
a, e
which statement is correct regarding negative pressure wound therapy? (select all that apply) a. suction pump is used b. necrotizing infections are treated c. O2 is administered under high pressure d. a low voltage current is applied to a wound area e. chronic ulcers are reduced by removing fluids from the wound
b
which statement made by the nurse indicates the need for further teaching when assessing clients with dark skin? a. "I will touch the skin to feel it's consistency" b. "I will use fluorescent light to assess the skin color" c. "I will place my hand on the skin to assess the temperature" d. "I will look for any changes in skin color darker than surrounding skin"
b. c. d
which statements are appropriate for a nursing instructor to include when teaching group of students about Hugh quality healthcare? (select all that apply) a. expensive b. competent c. meets clients needs d. meets established care standards e. involves minimal use of hospitals resources
a
which step should the nurse take to alert the risk of management system after notifying the primary healthcare provider of a clients fall? a. document the incident in the occurrence report tool b. provide information in the medical record about the occurrence c. document in the clients medical report that an occurrence report as been filled d. provide information in the clients medical report that the primary healthcare provider has been contacted
a, b, d
which steps would the nurse take when caring for a client to prevent nursing malpractice? (select all that apply) a. be alert about common sources of client injuries b. gain knowledge regarding current nursing practices c. refrain from speaking falsely about a clients medical condition d. communicate with the client regarding tests and treatment plans e. refrain from divulging medical information to unauthorized persons
a
which written statement made by the nurse while documenting factual records indicates a need for additional training? a. "the client seems restless" b. "the client states 'I am worried' " c. "the clients pulse rate is 90 beats/min" d. "the client has a body temp of 102.2 degrees F"
b
while providing care for a patient with a 2nd degree left ankle pain, the nurse raises the injured part above the level of the heart. which statement provides the reason behind this nursing intervention? a. promote bone density b. prevent further edema c. reduce pain perception d. increase muscle strength