Fundamentals Exam 1 set 3

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?

Decontaminate hands using an alcohol-based hand rub.

A nurse needs to visit the intensive care unit to administer an enema to a client. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit?

pour and discard a small amount of the solution

Assessment of a client who is bedridden due to hip fracture reveals atrophy of the leg muscles due to immobility. The nurse demonstrates understanding of muscle atrophy by identifying what as a characteristic?

reduction in muscle cell size

Which of the following is an accurate guideline for the use of PPE?

replace gloves if they are visibly soiled

An immobile person has decreased movement of respiratory secretions. Which condition is a greater risk as a result?

respiratory tract infection

The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client:

steps into the walker when walking

The latest CDC guidelines designate standard precautions for all substances except:

sweat

Why is it important for the nurse to teach and role model proper body mechanics?

to promoted health and prevent illness

(see full question) A nurse is assisting a client scheduled for appendicitis surgery with skin preparation. Which step is performed during skin preparation of a client?

washing the surgery site with soap and warm water before the planned procedure

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field?

with sterile forceps or hands wearing sterile gloves

Nurses use medical asepsis, or clean technique, in practice to reduce the number and transfer of pathogens. Which of the following are principles of this practice? Select all that apply.

• Clean the least soiled areas first and then move to the more soiled ones. • Use personal grooming habits, such as shampooing hair often, to prevent spreading microorganisms.

Nurses and other health care workers play a key role in reducing the spread of disease, minimizing complications, and reducing adverse outcomes for their clients. Which statement accurately describes this process? Select all that apply.

• Nurses practice asepsis, which includes all activities to prevent infection. • Nurses use medical asepsis, which involves procedures and practices that reduce the number and transfer of microorganisms. • Nurses perform surgical asepsis, which includes practices used to render and keep objects and areas free from microorganisms. • Nurses use standard precautions and transmission-based precautions as an important part of preventing infection.

A nurse recommends a regular exercise program for a client who has difficulty sleeping. The client asks how this will help. How would the nurse respond?

"Improved sleep is one benefit from exercise"

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

Hold sterile objects above waist level to prevent inadvertent contamination.

A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step?

Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm).

A middle-age man walks 2 miles each day. What type of exercise is he getting by this activity?

Isotonic; Explanation: Isotonic exercise involves muscle shortening and active movement. Examples include swimming, walking, jogging, and bicycling.

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?

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

(see full question) A nurse needs to check the vital signs of a client with an infectious disease who is receiving intravenous therapy through an IV pump. Before entering the client's room, the nurse follows airborne and contact precautions. Which infectious disease does the client have?

SARS

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

The nurse details the client's response and the examination and treatment of the client after the incident.

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high?

antimicrobial products

A nurse is changing the soiled bed linens of an older adult client who has urinary incontinence and is hospitalized. The nurse monitors the client closely based on the understanding that this client is at greater risk for:

bacteremia

(see full question) A nurse is caring for a client with arthritis, and isometric exercises have been recommended. How will isometric exercises help the client?

by improving muscle tone and strength Explanation: Isometric exercises are recommended to improve the muscle strength when preparing a client for ambulation

A nurse is assessing the musculoskeletal system of a client during an initial visit to the clinic. The assessment reveals insufficient joint lubrication in the knees. The nurse documents this finding as:

crepitus

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

maintain it according to agency policy

A nurse is assessing the muscles of an older adult. What will be assessed?

mass, tone, strength

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

discard the sterile field and supplies and start over

A nurse is assessing a client after knee surgery in a health care facility. Which intervention should the nurse follow to avoid complications associated with disuse syndrome?

encourage active exercise with bed trapeze

A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction?

facing away from the body

Which nursing action is a component of medical asepsis?

handwashing after removing gloves

Bed rest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system?

increased risk for contractures

A nurse is providing care to a client who has a cast on his leg. While educating the client on how to perform quadriceps setting exercises to strengthen the quadriceps muscle, he asks, "What kind of exercise is this?" The nurse identifies this type of exercise as:

isometric; Explanation: Quadriceps setting is an example of an isometric exercise, which is static exercise by which the client tenses a muscle, holding it stationary while maintaining the tension.

A physician has ordered an obese client to join an aerobic exercise class to promote cardiorespiratory conditioning. Which of the following fitness exercises is most suitable for the client?

isotonic exercise; Isotonic exercise is most suitable for an obese client, as it involves movement and work.

A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply.

• The nurse carries soiled items away from the body. • The nurse moves soiled equipment away from the body when cleaning it. • The nurse cleans least soiled areas first and then moves to more soiled ones.

Which body system effects would the nurse state as occurring due to immobility? Select all that apply.

• increased cardiac workload • increased risk for renal calculi • Increased risk for electrolyte imbalance