Fundmentals EXAM 1 practice test
Define Clinical Judgement
Problem-solving and decision making that requires nursing knowledge
A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?
Prodromal
A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?
Prone
The spatial zone that is 12 or more feet
Public
Describe clinical reasoning
Similar to critical thinking it requires nursing specific knowledge base. You use specific nursing knowledge, and patterns of thinking in decision making.
What does SBAR stand for?
Situation Background Assessment Recommendation
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile (CONTACT ISOLATION). Which of the following hand hygiene methods should the nurse use?
Soap and water
The spatial zone that is 4 to 12 feet
Social-consultative
Define personal health literacy?
The ability to access, understand, and use health information and services
Define Therapeutic Communication
The purposeful use of communication to build and maintain helping relationships with clients' families, and significant others. Therapeutic communication is client-centered, purposeful, planned, and goal directed.
When does discharge planning begin?
Upon admission
What information is included in the Recommendation part of SBAR?
Use of clinical judgment to recommend interventions to benefit the patient and help achieve their daily health goals
Universal precautions are
a. Gloves b. PPE c. Masks if needed d. Biohazard sharps containers e. Washing hands f. Gown
What are the elements of the morse fall scale?
a. History of falling b. Secondary diagnosis c. Ambulatory aid d. IV/Heparin lock or saline e. Gait/Transferring f. Mental status
What are ADLS?
activities of daily living
Describe clinical judgment
assist nurses in using evidence-based practice to think critically and make decisions.
Why is oral care important?
cleans the mouth of harmful bacteria buildup
Describe the prone position
client lies flat on their abdomen with their head turned to the side
ADLS include
dressing, bathing, feeding, brushing teeth, and toileting
What does the nursing process do?
helps nurse integrate critical thinking creatively to base nursing judgements on reason
When do you use AIDET?
in every patient encounter
Lateral positions helps
reduce pressure on the sacrum and prevent a pressure injury
Describe Fowler's position
the client is seated in a semi-sitting position at 45 degree angle and can have the knees bent or straight.
Describe Semi-Fowler's position
the client is seated in a semi-sitting position at a 30-45 degree angle and can have the knees bent or straight.
Describe High Fowler's position
the client is seated in a sitting position at a 60-90 degree angle and can have the knees bent or straight.
Describe the supine position
the client lies flat on their back.
Describe critical thinking
the skill of learning to analyze and interpret data and is an element of the NCSBN's Clinical Judgment Model for nurses.
When securing restraints why is important to not have restraint too tight?
to make sure the restraint does not constrict the client's circulation.
Where should restraints be tied?
to the client's bedframe
What does AIDET stand for?
1. Acknowledge 2. Introduce 3. Duration 4. Explain 5. Thank you
Factors influencing infection, prevention, and control
1. Age, 2. nutritional status 3. stress 4. disease processes 5. Surgery 6. treatments or conditions that compromise the immune response
Define surgical asepsis
1. Eliminates all microorganisms 2. Sterile technique
A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system? 1. Increased curvature of the thoracic spin 2. Reduced depth perception 3. Narrower stance when standing 4. Quick steps when ambulating
1. Increased curvature of the thoracic spin
Stages of infection
1. Incubation 2. Prodromal 3. Acute illness 4. Decline 5. Convalescence
Goals of discharge planning
1. Promote independence and self-care, increase adherence to care, identify home health needs, prevent reentry into system, decrease the cost of healthcare 2. Understanding the client's community health status and needs 3. Involvement of the client family as much as possible in the discharge planning process
A charge nurse is teaching a newly licensed nurse about fall prevention strategies when caring for clients. What information should the nurse include in the teaching?
1. Provide under-bed lighting at night. 2. Lock the wheels on the bed. 3. Keep the bed in the lowest position. 4. Apply non slip socks on clients when ambulating. 5. Place breaks on the clients' wheelchairs.
A nurse is performing a throat culture on a client. Which of the following actions should the nurse take? 1. Swab the back of the client's pharyngeal wall. 2. Place the swab in a clean container after obtaining the culture. 3. Insert the swab in the culture medium within 1 hr of obtaining the sample. 4. Don sterile gloves to obtain the culture from the client.
1. Swab the back of the client's pharyngeal wall.
A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene? 1. Places a removable cover over the sling 2. Leaves the bed in the lowest position throughout the procedure 3. Locks the hydraulic valve before attaching the sling to the lift 4. Raises the head of the bed to a sitting position just before transfer
2. Leaves the bed in the lowest position throughout the procedure
A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion? (Select all that apply.) 1. Inspection 2. Implementation 3. Inference 4. Creativity 5. Inductive reasoning
3. Inference 4. Creativity 5. Inductive reasoning
A nurse is performing foot care for a client. Which of the following actions should the nurse take? 1. Soak the feet prior to washing the feet. 2. Use hot water when performing foot care. 3. Use a towel to completely dry between the toes. 4. File the nail edges straight across with a file.
3. Use a towel to completely dry between the toes.
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make? 1. "You can wear artificial fingernails if they are kept short." 2. "Leave rings on your fingers when performing surgical hand asepsis." 3. "Keep your fingernails less than half an inch in length." 4. "Remove nail polish on your fingernails if it is chipped."
4. "Remove nail polish on your fingernails if it is chipped."
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? 1. Extinguish the fire. 2. Close the windows in the client's room. 3. Close the client's door. 4. Activate the fire alarm.
4. Activate the fire alarm.
A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process? 1. Evaluation 2. Implementation 3. Analysis 4. Planning
4. Planning
A nurse is preparing to teach a client who has visual impairment. Which of the following actions should the nurse take? 1. Identify your presence in the client's room by tapping the client's arm. 2. Turn on the television in the client's room during the educational session. 3. Use a loud tone of voice during the educational session. 4. Use reading material written with a large print.
4. Use reading material written with a large print.
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?
C-reactive protein
A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?
Contact
A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement
Contact
The spatial zone that is up to 18 inches
Intimate
Define Organizational health literacy?
The ability of the provider, clinic, hospital, or organization to provide access to/communicate clearly and engage with patients and their caregivers
Describe lateral position
client lies on their left or right side with their knees bent.
Characteristics of Therapeutic Communication
client-centered - not social or reciprocal; purposeful, planned, and goal-directed
the first stage of infection in which the client might not feel sick yet or have visible manifestations.
incubation stage
Prone position helps
promote postural drainage
What type of a knot is used to secure a restraint?
quick release knot
Name the barriers of communication.
1. Client's hearing deficit 2. Volume of the client's television 4. Numerous visitors in the client's room 5. Increase in pain after ambulation 6. Adverse effects of opioid analgesic 7. Using earphones while listening to music 8. language barriers 9. environmental factors, 10. pain or distress 11. lighting
A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN® model that can assist the nurse with critical thinking and decision making? 1. Clinical judgment 2. Critical thinking 3. Clinical reasoning 4. SMART goal
1. Clinical judgment
Describe interpersonal communication
1. Communication between two people 2. Most common in nursing and requires an exchange of information with another individual 3. Messages the receiver perceives can differ from what sender intended
Describe Public communication
1. Communication to, within, or between large groups of people 2. Using this type is done by nurses with teaching, giving presentations, or write about nursing or health care topics and issues
Describe Small group communication
1. Communication within a group of people often working toward a mutual goal
Describe intrapersonal communication
1. Communication within the individual 2. A persons "self-talk" when we think internally and not outwardly verbalizing our thoughts 4. It helps nurses assess clients and situations while also thinking critically about them before communicating verbally
What can we do as nurses to improve health literacy?
1. Creating a welcoming environment 2. Make use of printed information 3. Use basic Language 4. Speaking at a measured pace 5. Ask and encourage questions 6. Teach-back
Name assistive devices
1. Gait belt, 2. cane, 3. walker, 4. crutches, 5. lifts
What are the signs and symptoms of infection?
1. Localized is erythema (redness), 2. exudate(oozing) 3. pain 4. tenderness 5. Systemic is changes in vital signs or system functions 6. Lab values would include increase white blood cell counts and cultures
A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (Select all that apply.) 1. Locks the brakes on the client's bed 2. Checks the maximum weight of the lift before using it 3. Places the client on the edge of the sling 4. Uses the lift without assistance from another team member 5. Performs a safety check before lifting the client
1. Locks the brakes on the client's bed 2. Checks the maximum weight of the lift before using it 5. Performs a safety check before lifting the client
Low health literacy correlates with?
1. Patient disengagement 2. Less adherence to self-care behaviors and management of illness 3. Risk for medication errors 4. Poorer health status 5. Increased mortality 6. Less likely to see provider in timely fashion 7. Poor health historian
What is correct alignment?
1. Positioning the patient so that no excessive strain is placed on their ligaments, joints, tendons, or muscles to help balance
When are patients assessed for falls?
1. Within eight hours of admission 2. Every shift 3. After any fall 4. With any change in level of care with or without transfer
When do we use universal precautions?
1. in patient care and can vary depending on patient present illnesses and suspected illnesses 2. Also can vary based on tasks at hand
What is the nursing process?
1. is a dynamic, continuous, client-centered, problem-solving, and decision-making framework that is fundamental to nursing practice.
RACE stands for
1. rescue 2. alarm 3. contain 4. extinguish
A person should wash their hands for ___ to ___ seconds
15 to 30 seconds
How many fingers should fit under the restraints?
2 fingers
A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed? 1. Lateral 2. Supine 3. Prone 4. High-Fowler
2. Supine
A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? 1. "Lean on the crutches to support your body weight when standing." 2. "Fully extend your arms when holding onto the hand grips." 3. "Hold the crutches on your unaffected side when preparing to sit in a chair." 4. "Hold the crutches 9 inches in front of and to the side of each foot."
3. "Hold the crutches on your unaffected side when preparing to sit in a chair."
A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make? 1. "Tilt your head toward your chest." 2. "Loosen your abdominal muscles." 3. "Keep your back straight." 4. "Keep your knees straight."
3. "Keep your back straight."
A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include? 1. Offering approval or disapproval 2. Offering sympathy 3. Asking open-ended questions 4. Asking for explanations
3. Asking open-ended questions
A nurse is assisting with teaching a group of nurses on the process that cam trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger? 1. Burn 2. Frostbite 3. Bacteria 4. Radiation
3. Bacteria
A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following componnents contains needed elements for fire to occur? (Select all that apply.) 1. Carbon dioxide 2. Nitrogen 3. Cooking oil 4. Oxygen 5. Heat
3. Cooking oil 4. Oxygen 5. Heat
A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make? 1. "Advance the cane 12 inches forward when walking." 2."Move your unaffected leg before your affected leg when walking." 3."Keep the cane at the same level as the affected leg when climbing stairs." 4."Hold the cane on the side of your affected leg when walking."
3."Keep the cane at the same level as the affected leg when climbing stairs."
A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches? 1. The hand grips of the crutches are at the level of the client's umbilicus. 2. The client's elbows are bent 45° when holding the crutches. 3. The client places their weight on their axilla when using the crutches. 4. The client has the crutches resting 5 cm (2 in) below their axilla.
4. The client has the crutches resting 5 cm (2 in) below their axilla.
A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include? 1. The most common oral hygiene problem is gingivitis. 2. The client's ability to obtain dental care is unaffected by their visual impairment. 3. The visually impaired client has better oral hygiene than those clients without visual impairment. 4. The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.
4. The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.
A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take? 1. Trim the nails to a length that reaches beyond the edge of the finger. 2. Perform hand hygiene once nail hygiene is complete. 3. Avoid the use of wooden orange sticks. 4. Trim the nails straight across.
4. Trim the nails straight across.
When practicing universal precautions you should do all of the following EXCEPT: 1. Wear gloves when there is a potential for contact with patient bodily fluids. 2. Change gloves when moving from one patient to another. 3. Wash hands immediately after gloves are removed. 4. Wear face masks or eye protection whenever there is a possibility of blood splashing into your face. 5. Wash gloves between exams for re-use from one patient to another.
5. Wash gloves between exams for re-use from one patient to another.
What happens in Incubation stage of infection?
An infection enters the host and begins to multiply
Define Handoff
An interactive process of transferring patient specific information from one caregiver to another or from one team to another for the purpose of ensuring the continuity and safety of patient care
A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?
Droplet
A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?
Foot drop
A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis (complete or partial collapse of the lung)?
Fowlers
A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?
Gloves
What does the muscles help do?
Helps maintain balance, posture, and body alignment when performing a physical task
Describe the direct contact
Infectious agents that are transmitted directly from person to person
Describe indirect contact.
Infectious agents that are transmitted from an infected person to another person via a contaminated object
What happens in Decline stage of infection?
Manifestations begin to wane as the degree of the infectious disease decreases
What happens in Acute illness stage of infection?
Manifestations of the specific disease are obvious and may become severe
A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?
Mechanical lift
A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?
Muscles
What puts the patient at risks for injury in the healthcare setting?
1. Falls 2. Hospital acquired infections 3. Aspiration 4. Suffocation 5. Poisoning 6. Accidents 7. Fire
A nurse is preparing a client for a procedure. Name three acceptable identifiers to use to identify the patient.
1. Name 2. DOB 3. Telephone Number 4. Medical Record Number
What are the elements of establishing a safe environment?
1. Use of nursing health history 2. Past medical history 3. Mental status 4. Developmental age 5. Medication
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take? 1. Cleanse their hands with an alcohol-based gel. 2. Wash their hands with soap and water. 3. Brush off the soil against a cloth surface. 4. Use a wet paper towel to remove the soil.
2. Wash their hands with soap and water.
A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? 1. Wrap both arms around the client's arms and shoulders. 2. Move both feet together when the client begins to fall. 3. Protect the client's extremities while lowering them to the floor. 4. Extend one leg and allow the client to slide down the leg to the floor.
4. Extend one leg and allow the client to slide down the leg to the floor.
A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics? 1. Twisting the torso when transferring the client 2. Bending at the waist when transferring the client 3. Placing the bed in the high position before transferring the client 4. Looking at the client face-to-face when transferring the client
4. Looking at the client face-to-face when transferring the client
A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? 1. Place the stockings on the client after the client ambulates to the restroom. 2. Ensure the client's toes are visible after placing the stockings on the client. 3. After applying the stockings, place two fingers between the client's leg and stocking to check the fit. 4. Measure the client's calf circumference and leg length from heel to knee.
4. Measure the client's calf circumference and leg length from heel to knee.
A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the client's care requires clinical reasoning when it is complicated by which of the following factors? (Select all that apply.) 1. Complex clinical situations 2. Ongoing client and family concerns 3. Cost of health care 4. Decreased need for advanced health care practitioner intervention 5. Availability of computerized medical records
1. Complex clinical situations 2. Ongoing client and family concerns
To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? 1. Drying provides the full antiseptic effect. 2. Residual alcohol can easily stain clothing. 3. Excess gel could transfer to the client. 4. Slippery gel can make the nurse drop supplies.
1. Drying provides the full antiseptic effect.
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply.) 1. Fall history 2. Medical diagnosis 3. Use of assistive devices 4. Mental status 5. Do-not-resuscitate status
1. Fall history 2. Medical diagnosis 3. Use of assistive devices 4. Mental status
How should nurses provide patient education to patients with impairments?
1. Have patience 2. Attention 3. Minimize background noise 4. Voices at normal level 5. Simple communication, 6. Time to speak 7. Communicate with drawings 8. Praise all attempts to speak 9. Engage in normal activities 10. Encourage independence
When are restraints used?
1. In situations when they are clearly necessary for the purpose of preventing harm by a patient to themselves or others 2. when less restrictive methods have been evaluated and determined to be unsuccessful or inappropriate
A nurse is teaching a class about the effects of bathing in warm water. Which of the following information should the nurse include? Select all that apply 1. Increases vasodilation 2. Decreases retention of carbon monoxide. 3. decreases stress 4. Increases oxygen supply to tissues 5. decreases vasoconstriction 6. decreases vasodilation 7. Increases stress
1. Increases vasodilation 2. Decreases retention of carbon monoxide. 3. decreases stress 4. Increases oxygen supply to tissues 5. decreases vasoconstriction
Order of Chain of Infection
1. Infectious agent- Bacteria, virus, Protozoa, fungi, any pathogen 2. reservoir- Humans, insects, food, water, animals 3. portal of exit-Respiratory tract, skin, blood 4. mode of transmission-airborne, droplet, or contact 5. portal of entry-Cuts, mouth, eyes 6. susceptible host- New person that is infected/sick
What information should be included in Handoff
1. Information that should be included should be factual, accurate, complete, current, and relevant information 2. Information should include relevant information about the patient health history, chief complaint, the assessment of the patient currently, any recommendations 3. Should be done in front of the patient
Name the spatial zones.
1. Intimate 2. Personal 3. Social-consultative 4. Public
Name the levels of communication
1. Intrapersonal 2. Interpersonal 3. Public 4. Small group
Which of the following is an advantage of using alcohol-based gel? 1. It takes less time to use than washing with soap and water. 2. It removes gross contamination better than soap and water does. 3. Its protective nature reduces the need for frequent handwashing. 4. It provides adequate protection before surgical applications.
1. It takes less time to use than washing with soap and water.
Safety measures of the patient and nurse during linen change
1. Maintain aseptic technique 2. Use gloves as a barrier 3. If linen is soiled, keep off the floor and do not shake the linen 4. Placed soiled linens in designated container 5. Do not share linen between patients 6. Do not bring unused linen brought to room back to clean linen cart
A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool? 1. Medical condition 2. Treatment 3. List of medications 4. Vital signs
1. Medical condition
A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? 1. Move their leg behind their body. 2. Move their leg forward and up. 3. Move their leg medially toward their other leg. 4.urn their foot and leg away from their other leg.
1. Move their leg behind their body.
What are Non-restraint safety measures
1. Must exhaust alternative method before using restraints 2. Increase assessment of patient 3. Orient patient 4. Provide sensory stimulation 5. Review medications 6. Answer call lights immediately 7. Organize and schedule care 8. Move patient closer to the nurses station
A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include? 1. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care. 2. Hearing loss is considered a development factor that has minimal effect on nurse-client communication. 3. Clients who have developmental deficits are less distracted by environmental noises than client who do not have these deficits. 4. Nurses caring for clients experiencing a highly emotional situation report that communication is rarely affected.
1. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care.
Who is at risk for low health literacy?
1. Older adults 2. Medicaid 3. Race/Ethnicity 4. Non-English speaking 5. Low income
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? 1. Open the first flap on the sterile package away from their body. 2. Place objects on the sterile field at least 1.3 cm (0.5 in) from the edge. 3. Unwrap both sides of the sterile package at the same time. 4. Set up the sterile field next to a wall in the client's room.
1. Open the first flap on the sterile package away from their body.
what are interventions that may prevent falls?
1. Patient and family education, e 2. exercise, 3. adequate nutrition, 4. adequate lighting, 5. bed in low position and locked, 6. clear pathways, 7. personal items near patient, 8. nonskid footwear, 10. sign on door, 11. arm band, 12. assistive devices near bed, 13. bed alarms, 14. sitters
Define medical asepsis
1. Reduce of the number of organisms and prevent the transfer of organisms 2. Standard precautions
Name the functional components of Therapeutic Communication
1. Referent 2. Receiver 3. Channel 4. Environment 5. Feedback 6. Interpersonal variables
A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent? 1. Reservoir 2. Susceptible host 3. Portal of entry 4, Portal of exit
1. Reservoir
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (Select all that apply.) 1. The client's full name 2. The client's date of birth 3. The client's telephone number 4. The client's diagnosis 5. The client's room number
1. The client's full name 2. The client's date of birth 3. The client's telephone number
Components of therapeutic communication
1. Time 2. Attentive behavior or active listening 3. Honesty 4. Trust 5. Empathy 6. Nonjudgmental attitude
Bathing Helps
1. To promote an increase in venous return and arterial circulation 2. Also gives a chance to assess patient skin and look for any injuries or skin tears that might be present
What is the purpose of restraints?
1. To reduce risk of injury to self, others, risk of falling, or to prevent the interruption of therapy 2. Never used for staff convenience or punishment
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle? 1. Try to use alternatives before inserting indwelling urinary catheters. 2. Use clean technique for insertion of indwelling urinary catheters. 3. Check clients every 2 days to evaluate the need for indwelling urinary catheters. 4. Disconnect the system to obtain urine samples from indwelling urinary catheters.
1. Try to use alternatives before inserting indwelling urinary catheters.
A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take? 1. Turn the client to the side. 2. Vigorously brush the client's teeth. 3. Hold the toothbrush at a 90° angle. 4. Place two fingers in the client's mouth.
1. Turn the client to the side.
how to maintain aseptic technique when performing a bed bath and linen change (WESEDR)
1. Wash hands 2. Use of gloves 3. Replace or clean equipment 4. Educate on hygiene needs 5. Document interventions 6. Reevaluate
List the order of hand washing
1. Wet hands with warm water 2. Apply the amount of soap recommended by the manufacturer 3. Rub hands together vigorously for at least 15 seconds 4. Rinse hands with water 5. Use a disposable towel 6. Use a towel to turn off the faucet
Why it is important to engage the patient in mobility?
1. helps reduce the risk of blood clots (thrombus) 2. increases blood flow 3. it helps maintain and improve mobility 4. decreases skin and MSK risks and weaknesses
A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include? 1. "A standard toothbrush is more effective than a battery-operated toothbrush in decreasing plaque." 2. "Clean the tongue with the toothbrush or tongue scraper during oral hygiene." 3. "Floss the teeth at least three times each day." 4. "Have the client use mouthwash after brushing their teeth."
2. "Clean the tongue with the toothbrush or tongue scraper during oral hygiene."
A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting? 1. "It is not important to wash your hands after removing gloves." 2. "Effective handwashing can decrease hospital infection rates." 3. "Infections in health care staff are not considered health care-associated infections." 4. "Health care-associated infections are a rare event in health care delivery."
2. "Effective handwashing can decrease hospital infection rates."
A nurse caring for a client who states " I am feeling so much better. My fever is gone and I have a good appetite" The nurse should identify the client is likely in which stage of infection? 1. Incubation 2. Convalescence 3. Acute infection 4. Prodromal
2. Convalescence
A nurse is caring for a client who has been wheezing. The nurse asks an assistive personnel (AP) to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts? 1. Delegation of the right circumstance 2. Delegation of the wrong task 3. Delegation to the right person 4. Delegation of the wrong time
2. Delegation of the wrong task
A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? 1. Wear a respirator. 2. Protect their eyes. 3. Put on clean gloves. 4. Wear shoe covers.
2. Protect their eyes.
A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? 1. Tie the restraints to the siderails on the client's bed. 2. Remove the restraints with each vital sign check. 3. Use a square knot to secure the restraints. 4. Make sure one finger can fit under the restraints.
2. Remove the restraints with each vital sign check.
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? 1. An extension cord is secured under a rug. 2. The edges of stairs are marked with brightly colored tape. 3. A toaster is plugged in when not in use. 4. The water heater is set to 55° C (131° F).
2. The edges of stairs are marked with brightly colored tape.
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? 1. Washes their hands for 10 sec 2. Turns off the faucet with a towel 3. Uses hot water to wash their hands 4. Holds their hands above their elbows while rinsing off the soap
2. Turns off the faucet with a towel
A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client? 1. Bathing the client completely in bed preserves the client's dignity. 2. Washing the client in bed is less effective than taking a shower. 3. A complete bed bath should be performed using a basin, soap, and water. 4. Perform this type of bath early in the morning.
2. Washing the client in bed is less effective than taking a shower.
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear? 1. A sterile gown 2. Goggles 3. A face shield 4. An N95 respirator
3. A face shield
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? 1. Positioning the chair slightly behind the nurse so that the seat faces the client's bed 2. Placing the client's left leg in front of the right leg just prior to the transfer 3. Aligning the nurse's knees with the client's knees just before the transfer 4. Grasping the client under the axillae to assist them to their feet
3. Aligning the nurse's knees with the client's knees just before the transfer
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? 1. Use a brush to scrub the surface of the hands. 2. Rinse antiseptic solution from the hands before it dries. 3. Apply chlorhexidine and ethanol to the hands. 4. Leave jewelry on the hands when cleansing them.
3. Apply chlorhexidine and ethanol to the hands.
A nurse is teaching a newly licensed nurse about client education. The nurse should include that which of the following is the role of the nurse in client education? 1. Describe the steps of a surgical procedure 2. Prescribe medications 3. Encourage clients to advocate for themselves. 4. Diagnose client illnesses
3. Encourage clients to advocate for themselves.
A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include? 1. Gowns can be reused on the same client. 2. Masks should be removed after leaving a client's room. 3. Gloves should be removed from the inside out. 4. Eyeglasses can be used in place of goggles.
3. Gloves should be removed from the inside out.
A nurse is preparing to change the linens on a client's bed. Which of the following actions should the nurse take? 1. Shake soiled linens before placing them in a bag. 2. Place the client's bed height in the lowest position. 3. Hold soiled linen away from the nurse's clothing. 4. Place soiled linens on the floor while changing the client's bed.
3. Hold soiled linen away from the nurse's clothing.
A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? 1. Wipe down the client's bedside table with an antiseptic wipe. 2. Conduct informal audits of medical records to identify the number of healthcare-associated infections. 3. Perform hand hygiene. 4. Instruct the client on ways to reduce the risk for infection.
3. Perform hand hygiene.
A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. Which of the following actions should the nurse take? ( number In the correct order) 1. Remove the mask. 2. Remove the protective eyewear. 3. Remove the gloves. 4. Remove the gown.
3. Remove the gloves. 2. Remove the protective eyewear. 4. Remove the gown. 1. Remove the mask.
A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include? 1. The use of ergonomics improves blood circulation in the body. 2. The use of ergonomics eliminates costs related to workers' compensation. 3. The use of ergonomics increases job satisfaction. 4. The use of ergonomics maintains the body's balance and a lower center of gravity.
3. The use of ergonomics increases job satisfaction.
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? 1. Contact 2. ?Drople 3. ?Protective 4. ?Airborne
4. ?Airborne
A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves? 1. After donning a gown and before collecting vital signs on the client 2. After removing food items off the client's tray and before removing soiled linens from the client's bed 3. After helping the client stand up and before helping them brush their teeth 4. After changing a dressing on the client and before documenting findings on a computer
4. After changing a dressing on the client and before documenting findings on a computer
A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? 1. Evaluation 2. Implementation 3. Analysis 4. Assessment
4. Assessment
A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include? (Select all that apply.) 1. Appropriate delegation 2. Cost of client care 3. Available resources 4. Awareness of client status 5. Support from other staff
4. Awareness of client status 5. Support from other staff
A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? 1. "Critical thinking is the foundation for clinical decision making." 2. "Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." 3. "Critical thinking is the visible or observed outcome while using evidence-based practice." 4. "Critical thinking is necessary for the nurse to collect objective client data."
1. "Critical thinking is the foundation for clinical decision making."
A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include? 1. "The top of the walker should be at the level of your wrist." 2. "When using the stairs, place the walker before taking a step." 3."When holding the walker, bend your elbows 30°." 4."Take a step first before moving the walker."
1. "The top of the walker should be at the level of your wrist."
A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI? 1. A Salmonella infection that occurs after eating contaminated food from the cafeteria 2. An infection that occurs during a therapeutic procedure 3. A yeast infection that occurs while receiving broad spectrum antibiotics 4. A urinary tract infection that occurs after a sterile catheter insertion
1. A Salmonella infection that occurs after eating contaminated food from the cafeteria
A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.) 1. A fluoride mouthwash should be used to promote oral health. 2. The teeth should be brushed twice daily for 2 min. 3. Poor oral hygiene can lead to gingivitis. 4. Teeth should be flossed every other day. 5. Use a soft-bristled toothbrush for brushing the teeth.
1. A fluoride mouthwash should be used to promote oral health. 2. The teeth should be brushed twice daily for 2 min. 3. Poor oral hygiene can lead to gingivitis. 5. Use a soft-bristled toothbrush for brushing the teeth.
Steps of the Nursing Process
1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation.
A nurse is preparing to teach a client who has impaired cognition. Which of the following actions should the nurse include in the plan? 1. Involve the client's family in the educational session. 2. Provide long educational sessions. 3. Avoid making eye contact with the client during the educational session. 4. Speak quickly to the client.
1. Involve the client's family in the educational session.
A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.) 1. The nurse's hands become visibly soiled. 2. The nurse removes the meal tray of a client who has infectious diarrhea. 3. the nurse moves the cell phone of a client who has pneumococcal pneumonia from the bedside table. 4. The nurse empties the urinal of a client who has Clostridium difficile. 5. The nurse is preparing to insert an intravenous catheter.
1. The nurse's hands become visibly soiled. 2. The nurse removes the meal tray of a client who has infectious diarrhea. 4. The nurse empties the urinal of a client who has Clostridium difficile.
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include? 1. Empty sharps containers when they become full. 2. Report needlestick injuries to the nursing supervisor. 3. Engage the safety device on a needle after documenting the medication administration. 4. Recap needles after medication administration.
2. Report needlestick injuries to the nursing supervisor.
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? 1. Reservoir 2. Susceptible host 3. Portal of entry 4. Portal of exit
2. Susceptible host
A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk? 1. Hyperthyroidism 2. Hyperlipidemia 3. Inguinal hernia 4. Multiple sclerosis
4. Multiple sclerosis
The second stage of infection. In this stage, the client begins having vague, nonspecific manifestations, such as fever, chills, headache, and malaise, as the infectious agent replicates. 1. Incubation 2. Convalescence 3. Acute illness 4. Prodromal
4. Prodromal
A nurse is planning to implement the Transforming Care at the Beside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan? 1. Require nurses to spend 50% of their time at the bedside of clients. 2.Perform change-of-shift report at the nurses' stations. 3.Complete client rounds every 4 hr. 4. Use a standardized communication tool.
4. Use a standardized communication tool.
Whats involved in the Nursing Process (AAPIE)
A: Assessment/Data Collection A: Analysis/Data Collection P: Planning I: Implementation E: Evaluation
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?
Airborne
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?
Airborne
A nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?
Deep vein Thrombosis
A nurse is caring for a client who requires total assistance with mobility. Which of the following pieces of equipment should the nurse use to transfer the client?
Mechanical lift
Describe droplet transmission.
Occurs when infectious agents are transmitted through large droplets in the air. short distances (less than 3 feet) by a person coughing, sneezing, or talking.
What information is included in the Assessment part of SBAR?
Patient condition currently based on situation, background, and treatments
Patients at risk for oral care are
Patients with a history of aspiration, dysphagia, unconscious
The spatial zone that is 18 inches up to 4 feet
Personal
What happens in Prodromal stage of infection?
The patient begins having symptoms
What happens in Convalescence stage of infection?
The patient returns to a normal or new normal state of health
The use of proper body mechanics helps?
Used to prevent musculoskeletal injuries
A nurse is caring for a client who is on airborne precautions. Which of the following actions should the nurse take?
Wear an N95 respirator when caring for the client.
What is the clinical judgment model
1. A multi-layered model 2. Outlines the cognitive aspects of clinical decision making that are directly measurable 3. Environmental factors and individual factors that affect healthcare are present in this layer
A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? (Select all that apply.) 1. A stable center of gravity increases stability and balance. 2. A wide base lowers the center of gravity. 3. Proper body alignment involves tightening the abdomen. 4. Leaning slightly back while carrying an object equalizes the center of gravity. 5. Bending at the waist when picking up objects stabilizes the spine.
1. A stable center of gravity increases stability and balance. 2. A wide base lowers the center of gravity. 3. Proper body alignment involves tightening the abdomen.
What are some ways to maintain good hand hygiene
1. Artificial fingernails should not be worn 2. Fingernails less than 0.6 cm (0.25 in) in length 3. Remove chipped Nail Polish
A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take? 1. Assist the client as needed to ensure proper hygiene is performed. 2. Aggressively rub the skinfolds dry to manage moisture. 3. Use a lye soap bar to cleanse the skinfolds and the rash area. 4. Apply moisturizer to the skinfolds and rash area.
1. Assist the client as needed to ensure proper hygiene is performed.
What information is included in the Situation part of SBAR?
1. Clear and brief description the situation 2. Chief complaint
What information is included in the Background part of SBAR?
1. Clear, relevant background information on the patient 2. HPI - (History of Present Illness) 3. Medications 4. Allergies
A nurse asks a client to rate their current level of pain using a scale of 0 to 10 after administering pain medication 30 min ago. Which of the following steps of the nursing process is the nurse performing? 1. Evaluation 2. Implementation 3. Analysis 4. Planning
1. Evaluation
What is the purpose of handoff?
1. Increase patient safety, i 2. Improve quality of care, 3. strengthen teamwork, 4. Increase accountability
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include? 1. The door to the AIIR should remain closed. 2. Clients who are on contact precautions require AIIR. 3. An AIIR has at least 4 air exchanges each hr. 4. A mask is not needed to care for clients who are in an AIIR.
1. The door to the AIIR should remain closed.
A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client? 1. Changes in skin integrity decrease the risk of infection. 2. Urinary incontinence can cause a yeast infection. 3. Mild soap is contraindicated for cleansing the skin. 4. A pH-balanced cleanser increases skin irritation.
2. Urinary incontinence can cause a yeast infection.
A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which of the following actions? 1. Make sure that the water is hot. 2. Wash for at least 20 seconds. 3. Use a liquid soap preparation. 4. Remove rings and watches first.
2. Wash for at least 20 seconds.
What should the nurse do to maintain standard precautions? 1. Rinse gloves that become visibly soiled during use. 2. Use an antimicrobial soap for routine handwashing. 3. Disinfect hands immediately after removing gloves. 4. Keep gloves on when touching environmental surfaces.
3. Disinfect hands immediately after removing gloves.
A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? 1. Look straight ahead with shoulders raised up. 2. Keep abdominal muscles contracted and the lower back straight. 3. Stand as close to the object as possible. 4. Bend hips slightly and squat. 5. Push up from the knees when lifting the object.
3. Stand as close to the object as possible. 2. Keep abdominal muscles contracted and the lower back straight. 1. Look straight ahead with shoulders raised up. 4. Bend hips slightly and squat. 5. Push up from the knees when lifting the object.
A nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR or SBAR? 1. The client's admitting diagnosis. 2. The client's medical history. 3. The client's laboratory test results 4. The client's response to treatment
3. The client's laboratory test results
A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client? 1. The nurse should perform personal hygiene tasks for the client. 2. The client has a minor loss of strength on the right side of the body. 3. The nurse should have the client remove clothing from the unaffected side first. 4. Oral care is much easier for the client to perform than bathing.
3. The nurse should have the client remove clothing from the unaffected side first.
A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?
Droplet
