Exam 2 Multiple Choice Semester 1

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1) report fire 2) extinguish fire 3) protect the clients 4) contain the fire

Protect the clients

The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP? 1) uses a clean portion of the washcloth for each stroke 2) wipes from the pubis to the rectum 3) uses clean gloves 4) does not retract the foreskin

Does not retract the foreskin

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. 1) increase muscle tone and improve circulation 2) increase blood pressure 3) increase muscle mass and strength 4) decrease heart rate and cardiac output 5) maintain joint range of motion

Increase muscle tone and improve circulation, Increase muscle mass and strength, Maintain joint range of motion

Which of the following nursing intervention is the highest priority for a client at risk for falls in a hospital setting? 1) keep all of the side rails up 2) review the prescribed medications 3) complete the "get up and go" test 4) place the bed in the lowest position

Place the bed in the lowest position

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching? 1) "I am going to use a mirror to check my feet" 2) "I enjoy walking barefoot around the house" 3) "I will file my nails" 4) "I will increase the time that I wear new shoes each day"

"I enjoy walking barefoot around the house"

Which of the following items are used to perform wound irrigation? Select all that apply. 1) clean gloves 2) sterile gloves 3) refrigerated irrigating solution 4) 60 mL syringe 5) forceps

Clean gloves, Sterile gloves, 60 mL syringe

Proper technique for performing a wound culture included which of the following? 1) cleansing the wound prior to obtaining the specimen 2) swabbing for the specimen in the area with the largest collection of drainage 3) removing crusts or scabs with sterile forceps and then culturing the site beneath 4) waiting 8 hours following a dose of antibiotic to obtain the specimen

Cleansing the wound prior to obtaining specimen

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions to do which of the following? 1) eliminate the reservoir 2) block the portal of exit from the reservoir 3) block the portal of entry into the host 4) decrease the susceptibility of the host

Block the portal of exit from the reservoir

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? 1) place a padded tongue depressor at the head of the bed 2) pad the bed with blankets 3) inform the client about the importance of wearing a medical identification tag 4) teach the client about epilepsy 5) test oral suction equipment

Pad the bed with blankets, Test oral suction equipment

An 87-year old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1) leave the bathroom light on 2) withhold the clients diuretic information 3) provide a bedside commode 4) keep the side rails up

Provide a bedside commode

The nurse evaluates the chart of a 65-year old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply. 1) last tetanus booster was at age 50 2) receives a flu shot every year 3) has not received the hepatitis B vaccine 4) has not received the hepatitis A vaccine 5) has not received the herpes zoster vaccine

Receives a flu shot every year, Has not received the hepatitis B vaccine, Has not received the hepatitis A vaccine

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? 1) heart rate 86 beats/min 2) reddened area on sacrum 3) nonproductive cough 4) urine output of 50 mL /h

Reddened area on sacrum

Medication errors can place the client at significant risk. Which of the following practice(s) will help decrease the possibility of errors? Select all that apply. 1) hire only competent nurses 2) improve the nurse's ability to multitask 3) establish a reporting system for "near misses" 4) communicate effectively 5) create a culture of trust

Establish a reporting system for "near misses", Communicate effectively, Create a culture of trust

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1) wear a mask during dressing changes 2) provide disposable meal trays and silverware 3) follow standard precautions in all interactions with the client 4) use surgical aseptic technique for all direct contact with the client

Follow standard precautions in all interactions with the client

The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position? 1) Fowler's 2) semi-Fowler's 3) trendelenburg 4) reverse trendelenburg

Fowler's

The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? 1) presence of pain 2) condition of skin 3) gag reflex 4) range of motion

Gag reflex

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1) goggles 2) gown 3) surgical mask 4) clean gloves

Goggles

When planning the teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1) sports contribute to an adolescent's self esteem 2) sunbathing and tanning bed can be dangerous 3) guns are the most frequently used weapon for adolescent suicide

Guns are the most frequently used weapon for adolescent suicide

Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client: 1) heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation) 2) it will be acceptable to leave the pad in place if the temperature is reduced 3) it will be acceptable to leave the pad in place for another 30 minutes of the site appears satisfactory when assessed 4) it will be acceptable to leave the pad in place as long as it is moist heat

Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation)

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1) alginate 2) dry gauze 3) hydrocolloid 4) no dressing is indicated

Hydrocolloid

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is... 1) risk for impaired skin integrity 2) impaired skin integrity 3) impaired tissue integrity 4) risk for infection

Impaired skin integrity

Your client has a Braden scale score of 17. Which is the appropriate nursing action? 1) assess the client again in 24 hours; the score is within normal limits 2) implement a turning schedule; the client is at increased risk of skin breakdown 3) apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown 4) request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown

Implement a turning schedule; the client is at increased risk of skin breakdown

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in). What is the best action for the nurse to take? 1) remove the glove and start over with a new pair 2) wait until the second glove is in place and then unroll the cuff with the other sterile hand 3) ask a colleague to assist by unrolling the cuff 4) leave the cuff rolled under

Leave the cuff rolled under

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1) low protein diet 2) insomnia 3) lengthy surgical procedures 4) fever

Low protein diet, Lengthy surgical procedures, Fever

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be — ?

Risk for infection

A mother and her 3-year old love in a home built in 1932. Which of the following NANDA nursing diagnosis is most applicable for this child? 1) risk for suffocation 2) risk for injury 3) risk for poisoning 3) risk for disuse syndrome

Risk for poisoning

A client can bath most of her body except for the back, hands, and feet. She can also walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1) totally dependent (+4) 2) moderately dependent (+3) 4) semi-dependent (+2) 5) independent (0)

Semi-dependent (+2)

To increase stability during client transfer, the nurse increases the base of support by performing which action? 1) leaning slightly forward 2) spacing the feet further apart 3) tensing the abdominal muscles 4) bending the knees

Spacing the feet further apart

The nurse determines that a field remains sterile if which of the following conditions exist? 1) tips of wet forceps are held upward when held in ungloved hands 2) the field was set up 1 hour before the procedure 3) sterile items are 2 inches from the edge of the field 4) the nurse reaches over the field rather than around the edges

Sterile items are 2 inches from the edge of the field

The client is In surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client? 1) open bed in low position 2) occupied bed in low position 3) closed bed in high position 4) surgical bed in high position

Surgical bed in high position

Which of the following indicates proper use of a triangle arm sling? 1) the elbow is kept flexed at 90 degrees or more 2) the knot is placed on either side of the vertebrae of the neck 3) the sling extends to just proximal of the hand 4) the sling is removed every 2 hours to check for circulation and skin integrity

The knot is placed on either side of the vertebrae of the neck

When assessing the client's gait, which does the nurse look for and encourage? 1) the spine rotates, initiating locomotion 2) gaze is slightly downward 3) toes strike the ground before the heel 4) arm on the same side as the swing-through foot moves forward at the same time

The spine to rotates, initiating locomotion

Which is the most effective nursing action for preventing and controlling the spread of infection? 1) thorough hand hygiene 2) wearing gloves and masks when providing direct client care 3) implementing appropriate isolation precautions 4) administering broad spectrum prophylactic antibiotics

Thorough hand hygiene

The client wears an in-the-ear hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client's hearing aid? 1) turn the hearing aid off 2) soak the hearing aid in soapy solution to clean it 3) turn the volume all the way up 4) remove the batteries

Turn the hearing aid off

A 75-year old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulated without help. What is the most appropriate safety measure? 1) restrain the client 2) ask a family member to stay with the client 3) check the client every 15 minutes 4) use a bed exit safety monitoring device

Use a bed exit safety monitoring device

A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin? 1) soak her feet frequently 2) use a nonperfumed lotion 3) apply foot powder 4) avoid knee-high elastic stockings

Use a nonperfumed lotion

A nurse is teaching a client about active range of motion exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1) exercises past the point of resistance 2) performs each exercise one time 3) performs each series of exercises once a day 4) uses the same sequence during each exercise session

Used the same sequence during each exercise session

The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply. 1) using a bottle during naps and bedtime can cause dental caries in a toddler 2) schedule a visit to the dentist when your child is ready to go to school 3) it is important for parents to supervise a child's brushing of their teeth 4) most older adults have dentures and don't need to worry about oral care 5) most older adults are at risk for periodontal disease

Using a bottle during naps and bedtime can cause dental caries in a toddler, It is important for parents to supervise a child's brushing of their teeth, Older adults are at risk for periodontal disease

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? 1) activity intolerance 2) risk for activity intolerance 3) impaired physical mobility 4) risk for disuse syndrome

Activity intolerance

Your client is only comfortable lying on the right or left side (not on the back or stomach). List potential sites of pressure ulcers you must assess.

Ankles, Knees, Hips ( ilia), Trochanter, Shoulders, Ears

Which statement, of made by the client or family member, would indicate the need for further teaching? 1) "if skin area gets red but then the red goes away after turning, I should report it to the nurse" 2) "putting foam pads under my heels or other bony areas can help decrease pressure" 3) "if my father cannot turn himself in bed, I should help him change position every four hours" 4) "the skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet"

"If my father cannot turn himself in bed, I should help his change position every 4 hours"

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1) "going up, the strong leg goes first, then the weaker leg with both crutches" 2) "going down, the weaker leg goes first with both crutches, then the strong leg" 3) "the weaker leg always goes first with both crutches" 4) "a cane or single crutch may be used instead of both crutches if held on the weaker side"

"The weaker leg always goes first with both crutches"

A client weighs 200 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1) "using proper body mechanics will prevent you from injuring yourself" 2) "you are physically fit and at lesser risk for injury when transferring the client" 3) "use the mechanical lift and another person to transfer the client from bed to the chair" 4) "use the back belt to avoid hurting your back"

"Use the mechanical lift and another person to transfer the client from bed to the chair"

After teaching a client and family strategies for infection prevention, which statement by the client would indicate effective learning has occurred? 1) "we will use antimicrobial soap and hot water to wash our hands at least three times per day" 2) "we must wash or peel all raw fruits and vegetables before eating" 3) "a wound or sore is not infected unless we see it draining pus" 4) "we should not share toothbrushes but it is okay to share towels and wash cloths"

"We must wash and peel all raw fruits and vegetables before eating"

The client is ambulatory for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? 1) find another nurse for help 2) return the client to her room as quickly as possible 3) tell the client to take rapid, shallow breaths 4) assist the client to a nearby chair

Assist the client to a nearby chair

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1) automobile crashes 2) drowning and firearms 3) falls 4) suicide and homicide

Automobile crashes

The nurse is discussing strategies with the unlicensed assistive personnel (UAP) Dor bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply. 1) cover the client as much as possible 2) sing and talk to the client 3) compete the bath as quickly as possible 4) be organized

Cover the client as much as possible, Sing and talk to the client, Be organized

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1) document the behavior(s) that require continued use of the restraints 2) ensure that the restraints are tied to the side rails 3) provide range of motion exercises when the restraints are removed 4) orient the client 5) assess the tightness of the restraints

Document the behavior(s) that require continued use of the restraints, Provide range of motion exercises when the restraints are removed, Orient the client, Assess the tightness of the restraints

Performance of activities of daily living and active range of motion exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1) elbow flexion with eating and bathing 2) elbow extension with shaving and eating 3) wrist hyper extension with writing 4) thumb ROM with eating and writing 5) hip flexion with walking

Elbow flexion with eating and bathing, Thumb ROM with eating and writing, Hip flexion with walking