Exam 1 review questions

The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response? 1. "I need to find out the client's preferences first." 2. "Shave him only after you have bathed him." 3. "Use the electric razor when you shave him.? 4. "Avoid shaving him. I need a doctor's order?"

1

The nurse is observing the UAP prepare a shower for the client who requires assistance with ambulation and hygiene. Which action(s) by the UAP indicate understanding of the procedure? Select all that apply. 1. Sets the water temperature at 100°F to 105°F (37°C to 40°C) 2. Locks the door to provide the client with privacy 3. Uses a chair for the client to sit on in the shower 4. Ensures a nonskid surface is in the shower 5. Helps to wash areas the client cannot reach

1

The nurse is to obtain a medical history for the client who has a tracheostomy. The client's spouse states that the client does not use a speaking valve. Which actions should be taken by the nurse to communicate with the client? Select all that apply. 1. Make eye contact and speak to the client directly. 2. Ask only the spouse for information about the client. 3. Provide the client with a writing board and pen. 4. Place a speaking valve over the client's tracheostomy. 5. Assess the client's preferred communication method. 6. Ask the client only "yes" and "no" questions.

1, 3, 5

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eye wear or goggles. 4. Untie bottom and then top mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling It onto itself without touching the contaminated side.

1, 3, 5, 4

A patient who has been placed on Contact Precautions for Clostrid-ium difficile (C. difficile) asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of the patient teaching? (Select all that apply.) 1. "The organism is usually transmitted through the fecal-oral route." 2. "Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer." 3. "Everyone coming into the room must wear a gown and gloves. 4. "While I am in Contact Precautions, I cannot leave the room" 5. "C. difficile dies quickly once outside the body."

1. "The organism is usually transmitted through the fecal-oral route." 2. "Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer." 3. "Everyone coming into the room must wear a gown and gloves

The chain of infection is a cycle. What are all of the elements of the chain of infection.

1. Agent 2. Reservior 3. Portal of exit 4. Mode of transmission 5. Portal of entry

The client is placed on contact precautions. When should the nurse plan to put on disposable examination gloves? 1. As soon as the nurse enters the client's room 2. Only if anticipating contact with the client's wound 3. Only if anticipating contact with blood or body fluids 4. Only if providing care within 3 feet of the client

1. As soon as the nurse enters the client's room

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.

1. Check for needed adaptive equipment. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point.

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

1. Collaboration between staff members from sending and receiving departments 3. Using a standardized transfer policy and transfer tool

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves

1. Disposable gown 2. N95 respirator mask 5. Gloves

The nurse is aware of the American Nurses Association's nursing-sensitive quality indicators regarding the management and prevention of hospital- acquired infections. Which nursing action is most likely to reduce hospital-acquired infection rates? 1. Ensuring appropriate nurse-to-client ratios 2. Improving functioning of the team 3. Monitoring medication safety events 4. Ensuring adequate supplies are available for care delivery

1. Ensuring appropriate nurse-to-client ratios

A nurse is using motivational interviewing with a patient. What outcomes does the nurse expect? (Select all that apply.) 1. Gain an understanding of the patient's health goals. 2. Direct the patient to avoid poor health choices. 3. Recognize the patient's strengths and support the patient's efforts. 4. Provide assessment data that can be shared with families to promote change. 5. identify differences in patient's health outcomes and current behaviors.

1. Gain an understanding of the patient's health goals. 3. Recognize the patient's strengths and support the patient's efforts 5. identify differences in patient's health outcomes and current behaviors.

The nurse is teaching the client who is hard of hearing and wears bilateral hearing aids. Which action by the nurse would best evaluate the teaching on how to change a urinary drainage bag? 1. Have the client demonstrate how to change the bag. 2. Ask during teaching if the client has any questions. 3. Ask the client to state the steps for changing the bag. 4. Provide a handout with instructions of the procedure.

1. Have the client demonstrate how to change the bag.

When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure? (Select all that apply.) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

1. Oxygen saturation 3. Respirations 4. Gag reflex

What are the four phases of the nurse client relationship?

1. Preorientation 2. Orientation 3. Working 4. Termination

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. Routine environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. Routine environmental cleaning is an example of medical asepsis. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

4 functions of the skin

1. Protection 2. Barrier 3. Temperature regulation 4. Excretion and secretion

The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints? 1. Restraint strap is tied to the bed frame next to the client. 2. Restraint straps are secured using a half-bow slipknot. 3. Two fingers can be inserted between the restraint and client's skin. 4. Mesh portion of the mitten restraint is on the back of the hand.

1. Restraint strap is tied to the bed frame next to the client

The nurse will delegate hygiene care for two patients of different cultures to the assistive personnel (AP). What cultural information does the nurse need to provide to the AP? (Select all that apply.) 1. Specific hygiene products 2. Timing of hygiene care 3. Socioeconomic status 4. The need for gender congruent caregiver 5. Religious practices

1. Specific hygiene products 2. Timing of hygiene care 4. The need for gender congruent caregiver 5. Religious practices

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on the nurses' part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient on antibiotics who has been having loose stool for 24 hours 5. Decreasing a patient's environmental stimuli to decrease nausea

1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter

A patient states, "I don't have confidence in my doctor. She looks so young. What is the nurse's therapeutic response? 1. Tell me more about your concern. 2. You have nothing to worry about. Your doctor is perfectly competent. 3. You can go online and see how others have rated your doctor. I do that. 4. You should ask your doctor to tell you her background.

1. Tell me more about your concern.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) 1. Use fluoride toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high- risk patients. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

1. Use fluoride toothpaste. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high- risk patients. 4. Use a soft toothbrush for oral care.

The nurse is observing the UAP providing oral hygiene to clients. Which action by the UAP requires follow-up? Select all that apply. 1. Replaces the upper denture before the lower one 2. Places the unconscious client in a supine position 3. Inserts a foam swab to pry a lower denture loose 4. Brushes the tongue with a soft-bristled toothbrush 5. Dons exam gloves to perform oral hygiene 6. Uses gauze to move and remove an upper denture

2, 3

The nurse is developing guidelines to assist personnel in meeting the hygiene needs of clients with dementia. Which guidelines are appropriate for the nurse to include? Select all that apply. 1. To limit the client's ability to physically resist, two staff should quickly bathe the client. 2. Include music and dim lighting to create a calm environment when giving a bed bath. 3. Allow clients who are willing and able to participate in some of the hygienic activities. 4. Assess for and treat the client's pain before initiating hygienic cares with the client. 5. Wash the client's hair and body separately if either activity causes the client distress.

2, 3, 4, 5

The nurse surveys the client's hospital room. Which findings require the nurse's immediate attention to remove possible sources of infection? Select all that apply. 1. A capped bottle of saline with the notation "opened 10 hours ago" 2. The bed has bloody drainage from the saturated abdominal dressing 3. An infusing IV tubing has no notation of the date when it was last changed 4. An empty container in the bathroom that is labeled urine and has the client's initials 5. Opened packages of gauze and abdominal pads sitting on the windowsill 6. An uncovered cup of figs on the bedside table brought by a family member

2, 3, 5, 6

The nurse sees multiple items on the client's bedside table. Which items should the nurse remove because they pose a risk of infection for the client? Select all that apply. 1. The menu from the client's last meal 2. A glass of water without a cover 3. An empty urinal that had been rinsed 4. A sealed package of soda crackers 5. A pitcher of water covered with a lid 6. A bloody alcohol swab from an injection

2, 3, 6

A nurse works with a patient using therapeutic communication during all phases of the therapeutic relationship. Place the nurse's statements in order according to these phases. 1. The nurse states, "Let's work on learning injection techniques." 2. The nurse is mindful of biases and knowledge in working with the patient with Bi deficiency. 3. The nurse summarizes progress made during the nursing relationship. 4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship.

2, 4, 1, 3

The nurse is wearing PPE. Place the steps to removing the PPE in the correct sequence. 1. Remove gown 2. Remove gloves and perform hand hygiene 3. Remove mask 4. Remove eye protection 5. Perform hand hygiene

2, 4, 1, 3, 5

The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply. 1. Offering the client sterile disposable tissues 2. Wearing a mask while examining the client 3. Offering the client water to drink while waiting 4. Teaching how to cover the mouth when coughing 5. Performing hand hygiene before and after client contact 6. Separating the client by at least 3 feet from others in the area

2, 4, 5, 6

The nurse asks the UAP to change the soiled bed linens of the client with acute diarrhea of unknown origin. Which interventions should the nurse direct the UAP to implement? Select all that apply. 1. Wear a mask while changing the soiled linens. 2. Wear gown and gloves while in the room. 3. Use alcohol-based hand wash before and after care. 4. Request that the HCP prescribe a stool culture. 5. Post an enteric precaution sign outside the room.

2, 5

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex.

2, 5, 1, 3, 6, 4

The hospitalized client has protective precautions (reverse isolation) in place because of severe neutropenia. Which statement by the nurse to the NA is correct regarding the use of protective precautions? 1. "You should don gloves as soon as you enter the client's room." 2. "Minimize the amount of time the client spends outside the room." 3. "The client needs to be moved to a private room with negative air pressure." 4. "Everyone entering the client's room should be sure to put on a mask."

2. "Minimize the amount of time the client spends outside the room."

The client who has airborne precautions states, Please do not shut my door." Which response is most appropriate? 1. "If I open the door, you will need to always wear a mask." 2. "The door must be kept closed, but I can open the curtains." 3. "Don't worry; I can leave the door open if it's bothering you." 4. "I'm sorry, but I can only leave the door partially open."

2. "The door must be kept closed, but I can open the curtains."

An adult daughter is sitting at the bedside of her mother, a devoutly religious person, who developed a serious postoperative infection. Which statement by the nurse to the daughter demonstrates empathy? 1. "I know how you feel. We also prayed at my grandmother's bedside when she was sick.? 2. "You've been here a long time and look exhausted. Tell me how things are going for you?" 3. "You might as well go home because your mother is sleepy. Maybe tomorrow will go better." 4. "The new antibiotic was started this morning. We will pray that your mother gets well."

2. "You've been here a long time and look exhausted. Tell me how things are going for you?"

The clinic nurse is caring for four clients. Which interaction demonstrates the use of the communication technique of reflection? 1. Child: "Don't turn out the light. I don't like the dark" Nurse: "I will have your mommy hold you while I turnout the light to check your eye." 2. Adolescent: "My mom won't let me pierce my tongue." Nurse: "What would it be like to have a pierced tongue?" 3. Adult: "My blood sugar was really out of control yesterday." Nurse: "Was your blood sugar high or low yesterday?" 4. Older Adult: "My life means nothing anymore." Nurse: "Socializing more allows you to reflect back on good times and will help you feel better about your life."

2. Adolescent: "My mom won't let me pierce my tongue." Nurse: "What would it be like to have a pierced tongue?"

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes mellitus. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing

2. Assess skin for redness, abrasions, and open areas daily. 4. Apply lotion to feet daily

The experienced nurse is observing the new nurse providing care to the hospitalized client. Which action requires the experienced nurse to intervene to ensure client safety? 1. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep 2. Checks the room number and name band to verify the client's identity before giving a medication 3. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia 4. Delays the HCP from performing a thoracentesis by calling "a timeout' to verify the client's identity, consent, procedure, and site

2. Checks the room number and name band to verify the client's identity before giving a medication

While the nurse transfers the client who has Clostridtum difficile from the bed to the commode, the client has loose stool that falls on the floor. After wiping up the stool, how should the nurse proceed to cleanse the floor? 1. Clean the area with soap and water. 2. Clean the area with a 1:10 bleach-water solution. 3. Ask the housekeeper to use the unit's mop and bucket. 4. Clean the area with alcohol-based hand wash.

2. Clean the area with a 1:10 bleach-water solution.

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet Precautions 3. Standard Precautions 4. Contact Precautions

2. Droplet Precautions

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1. The front and sides of the sterile gown are considered sterile from the waist up. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. After cleansing the hands with antiseptic rub, apply clean disposable gloves.

2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) 1. Prone position 2. Modified left lateral recumbent position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position

2. Modified left lateral recumbent position 3. Semi-Fowler's position with head to side

The client is admitted with a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which precaution should be implemented to prevent spreading the infection to health care workers and other clients? 1. Wearing a mask within 3 feet of the client 2. Placing the client in a private room 3. Wearing an N95 respirator mask 4. Ensuring a negative-air-pressure room

2. Placing the client in a private room

Which techniques demonstrate a therapeutic response to an adult patient who is anxious? (Select all that apply.) 1. Matching the rate of speech to be the same as that of the patient 2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient 5. Assuring the patient that all will be well

2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient

The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who had a stroke. Which intervention(s) would be appropriate for the assistive personnel to accomplish during the bath? (Select all that apply.) 1. Checking distal pulses 2. Providing range-of-motion (ROM) exercises to extremities 3. Determining type of treatment for Stage 1 pressure injury 4. Changing the dressing over an intravenous site 5. Providing special skin care as indicated by nurse

2. Providing range-of-motion (ROM) exercises to extremities 5. Providing special skin care as indicated by nurse

The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse? 1. Vesicular breath sounds in the lung bases 2. Temperature 38.5° C (101.4° F) 3. Incision pain rating of 6 out of 10 4. Blood glucose of 164 mg/dI

2. Temperature 38.5° C (101.4° F)

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad- spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection

2. The antibiotics the patient has received are not strong enough to kill the organism 4. The organism has developed a resistance to one or more broad- spectrum antibiotics, indicating that the organism will be hard to treat effectively.

A patient has gone through a number of treatment changes during a shift of care. During the hand-off report, the nurse plans to communicate effectively with the nurse who will be caring next for the patient for which of the following reasons? (Select all that apply.) 1. To improve the nurse's status with the health team members 2. To reduce the risk of errors to the patient 3. To provide an optimum level of patient care 4. To improve patient outcomes 5. To prevent issues that need to be reported to outside agencies

2. To reduce the risk of errors to the patient 3. To provide an optimum level of patient care 4. To improve patient outcomes

The newly hospitalized 90-year-old client has difficulty answering the nurse's questions and reports progressive hearing loss. Which nursing action would best aid in communication between the nurse and client? 1. Overexaggerating facial expressions 2. Using simple sentences 3. Overenunciating longer words 4. Speaking quickly in a higher-pitched voice

2. Using simple sentences

The nurse and NA are caring for the client with hepatitis A. The nurse determines that the NA understands correct infectious precautions for this client when observing what action? 1. Wears a mask, gown, and gloves when taking the client's vital signs 2. Wears a gown and gloves when changing the client's incontinent briefs 3. Wears gloves when providing urinary catheter and perineal care 4. Wears a gown and gloves when asking the client about snack food options

2. Wears a gown and gloves when changing the client's incontinent briefs

The nurse is observing the nursing student caring for the client with a prosthetic eyeball. What action by the student nurse would require intervention? 1. Has the client lie down to remove the eyeball 2. Cleans the prosthetic eye with saline solution 3. Dries the prosthetic eye thoroughly with gauze 4. Teaches to remove and clean the eyeball weekly

3

The nurse is demonstrating the use of a fire extinguisher during a fire drill. Place the steps for using a fire extinguisher in the correct order. 1. Squeeze the handle. 2. Sweep from side to side. 3. Pull the pin. 4. Aim at the base of the fire.

3, 4, 1, 2

The hospitalized client with limited mobility is at risk for skin breakdown. Which interventions should the nurse include in the plan of care to maintain the client's skin integrity? Select all that apply. 1. Massage vigorously over bony prominences daily. 2. Wear sterile gloves when doing skin inspection. 3. Apply a moisturizing lotion to bony prominences. 4. Teach the client to change position every 2 hours. 5. Apply an overhead trapeze to the client's bed. 6. Apply barrier cream if stool incontinence occurs.

3, 4, 5, 6

The nurse is establishing a therapeutic nurse-client relationship. In what order will the nurse progress through initiating and ending the therapeutic relationship? 1. Termination phase 2. Working phase 3. Preinteraction phase 4. Conclusion of relationship 5. Orientation phase

3, 5, 2, 1, 4

The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP? 1. "The wrist restraint must remain on at all times but can be loosened if needed." 2. "The client attempted to harm staff; only enter the room with another person." 3. "Ask the client about the need for toileting and offer liquids every 2 hours." 4. "Assess the client's skin condition and provide hand exercises every 2 hours."

3. "Ask the client about the need for toileting and offer liquids every 2 hours."

The new NA is caring for the client who is at risk for a fall. Which statement by the nurse to the new NA is most important? 1. "Remind the client to call for assistance before getting out of bed." 2. "Clip the call light to the bedcovers so the client can find it easily." 3. "Be sure the bed is in the lowest position when you leave the room." 4. "Check that you have all four siderails up after you provide care."

3. "Be sure the bed is in the lowest position when you leave the room."

While planning morning care, which of the following patients would have the highest priority to receive a bath first? 1. A patient who just returned to the nursing unit from a diagnostic test 2. A patient with a fever who just finished a dose of intravenous antibiotics. 3. A patient who is experiencing frequent incontinent diarrheal stools and urine 4. A patient who has been awake all night because of pain 8/10

3. A patient who is experiencing frequent incontinent diarrheal stools and urine

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but the nurse recognizes that this is a normal response to isolation. Which is the nurse's best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3. Explain the reasons for isolation procedures and provide meaningful stimulation

The nurse is evaluating the performance of the UAP. The nurse should provide feedback to the UAP about which unsafe action? 1. Cleanses and returns a wheelchair to a storage area after being used by the client. 2. Ties the confused client's wrist restraint ties to the bed frame using a quick-release knot. 3. Grasps the cord to unplug an intravenous infusion pump for the client's transport to x-ray. 4. Turns on a bed exit alarm for the confused client who was talking incoherently to the UAP.

3. Grasps the cord to unplug an intravenous infusion pump for the client's transport to x-ray.

Which of the following factors directly impairs salivary gland secretion? (Select all that apply.) 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

3. Radiation therapy 4. Dehydration

The nurse realizes that a fire has started in the client's room. Which action should be taken by the nurse first? 1. Find the nearest fire alarm to activate. 2. Extinguish the fire with a blanket. 3. Remove the client from the room. 4. Telephone the operator to announce a fire.

3. Remove the client from the room.

What outcome demonstrates the effective use of silence as a therapeutic communication technique? 1. The nurse feels like there was enough time to be therapeutic when communicating with the patient. 2. The patient states a preference to talk with another staff member. 3. The patient perceives having gained insight into the issue after the conversation. 4. The patient was able to drift off to sleep more easily.

3. The patient perceives having gained insight into the issue after the conversation.

The nurse is using contact precautions to change the soiled bed sheet of the client with Clostridium difficile. In the process, the nurse's right glove and skin on a finger is torn. After removing the soiled gloves, which action is priority? 1. Hold pressure to stop any bleeding. 2. Use a bleach wipe to clean the hands. 3. Wash the hands with soap and water. 4. Cleanse hands using alcohol-based hand rub

3. Wash the hands with soap and water

The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) 1. Validate health care needs through verbal discussion with the patient. 2. Compare actual and expected patient care outcomes with the patient. 3. Provide support through therapeutic communication techniques. 4. Complete a nursing history using verbal communication techniques.

4, 1, 3, 2

A nurse is assigned to care for the following patients. Which patients most at risk for developing skin problems that will require thorough bathing and skin care? 1. A 44-year-old female patient who has had removal of a breast lesion and is in pain and unwilling to ambulate postoperatively 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration. 3. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and stool

4. A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and stool

The nurse learns that the hospitalized client has a history of chronic hepatitis C. Which precaution should the nurse plan to implement? 1. Airborne 2. Contact 3. Droplet 4. Standard

4. Standard

You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? A. Explain to the patient that, because of her symptoms, you need to observe the perineal area. B. Insist that you are supposed to complete the care. C. Honor the patient's request to complete her own perineal care to avoid any embarrassment. D, Ask the patient if a family member can complete the care instead

A. Explain to the patient that, because of her symptoms, you need to observe the perineal area.

A nurse is planning care for a client who develops shortness of breath and feels tired after completing morning care. Which action should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinued morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client.

A. Schedule rest periods during morning care.

The nurse is preparing to perform denture care for a client. Which action should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them

B. Brush the dentures with a toothbrush and denture cleaner.

Which strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts at feelings. C. Give the nurse-client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse-client relationship.

B. Encourage the client to communicate their thoughts at feelings.

____ is the single most effective way to prevent the spread of infection. A. changing linen twice a day B. handwashing before, after and between patient contact C. cleaning equipment daily D. cleaning patients room daily

B. handwashing before, after and between patient contact

The nurse is communicating with a well-oriented adult client in a long-term care setting. Which statement best reflects respectful and caring communication? A. Are you ready for our shower? B. It's time to go to the dining room, honey. C. Are you comfortable, Mrs. Smith? D. You would rather wear the slacks, wouldn't you?

C. Are you comfortable, Mrs. Smith?

The nurse is observing unlicensed assistive personnel (UAP) perform perineal care for client. Which action indicates that nurse needs to discuss additional teaching with UAP? A. Uses a clean portion of washcloth for each stroke. B. Wipes from pubis to rectum. C. Uses clean gloves. D. Does not retract foreskin.

D. Does not retract foreskin

Explain the difference between a localized versus a system infection.

Localized is in one area with swelling redness System infection is When it spreads from one area to more areas thus causing more issues.

Health care personnel use the acronym RACE and PASS to remember their duties in case of a fire. What does RACE and PASS stand for?

R-rescue A- alert C- contain E- extingush P-Pull A-Aim S-Squeeze S- Sweep

A nurse prepares to contact a patient's health care provider about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old woman who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 p.m. yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days." 2. "The patient reported feeling very nauseated after her dose of levofloxacin an hour ago." 3. "Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started to complain of nausea yesterday evening and vomited several times during the night."

S: 4 B: 1 A: 2 R: 3

Nosocomial infections or healthcare associated infections are: a. medical asepsis b. negative pressure c. hospital-acquired d. surgical asepsis

c. hospital-acquired

A type of hospital acquired infection caused by an invasive diagnostic or therapeutic procedure is called? a. Airborne Precautions b. Exogenous Infection c. latrogenic Infection d. Endogenous Infection

c. latrogenic Infection