NURS intervention EXAM 2 PrepU & lecture quizzes
__________ refers to a disease occurrence that clearly exceeds the normal or expected frequency in a community or region.
Epidemic
A public health nurse has been assigned the task of finding the cause of a recent salmonella outbreak in the area. The nurse will use an epidemiologic method to complete this task. What is the nurse's best rationale for utilizing this method?
Epidemiology is used to identify patterns and trends in disease occurrence.
You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises.
Which term refers to the protrusion of abdominal organs through the surgical incision?
Evisceration
True or false. Herd immunity refers to a situation in which a person's immunity to one agent provides immunity to a related agent as well.
False
True or false: Passive immunity is protection produced by the person's own immune system
False
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:
First intention
The nurse is instructing the family on home care of a client with shingles. The family member asks whether their teenage children should stay in a different room. What is the best response by the nurse?
"Have they had chickenpox or the varicella vaccine?"
The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective?
"I am not permitted to drive myself home after surgery."
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?
"I can resume my usual activities as soon as I get home."
The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective?
"I'll eat plenty of fruits and vegetables."
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?
"It assists in preventing infection."
The nurse is talking to a client who has come to the doctor's office to ensure that the client's sexually transmitted infection (STI) has been successfully treated. Which statement by the client requires further instruction?
"It's great that I don't have to worry about having this infection again because I'm now immune to it."
The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections?
"Make sure your family has all their childhood immunizations."
The parent of a child diagnosed with chickenpox asks when the child can go to play group again. What is the best response by the nurse?
"When the vesicles and pustules have crusted."
A nurse is working in the postanesthesia unit (PACU). What evidence indicates that a client is ready for discharge from the PACU? Select all that apply.
-- The client is arousable, but falls back to sleep rapidly. -- he client is arousable, but falls back to sleep rapidly. -- The client is arousable, but falls back to sleep rapidly.
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg
The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?
A temporary loss of peristalsis and gas accumulation in the intestines
The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?
Absence of peristalsis
__________ immunity is a long-term and sometimes lifelong resistance that is acquired either naturally or artificially.
Active
The nurse in the postanesthesia care unit (PACU) is preparing to receive a client from the operating room. The nurse knows that which information would need to be communicated?
Allergies, Surgical procedure, Estimated blood loss, Medical comorbidities, Anesthetic agents used
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?
Assessing WBC count, temperature, and wound appearance
The community nurse is providing education to a group of older teens at the local recreation center on how using chewing tobacco increases the risk of oral, esophageal, and pancreatic cancer. The nurse is utilizing which element of causation of noninfectious disease?
Biologic gradient
The nurse is discussing childhood immunization recommendations with a pediatric patient's parent. Where would the nurse find the most current information on this topic?
CDC
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?
Call the health care provider.
__________ refers to the relationship between a cause and its effect.
Causality
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?
Central venous pressure
Which epidemiologic causal attribution model was too linear in scope to adequately analyze patterns in disease and wellness?
Chain of causation
The nurse is providing care to a client who has been diagnosed with gonorrhea. The nurse also prepares the client for treatment of which of the following?
Chlamydia
Which term refers to a state of microorganisms being present within a host without causing host interference or interaction?
Colonization
A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute?
Contact
A nursing measure for evisceration is to:
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline
A male client comes to the clinic and is diagnosed with gonorrhea. Which symptom most likely prompted him to seek medical attention?
Discharge from the penis and burning during urination
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:
Empty and measure the drainage and compress the Hemovac.
A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
Encourage the client to ambulate as soon as possible after surgery.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
The community health nurse is using epidemiologic methods to conduct an investigation of a recent Escherichia coli (E. coli)-related sickness causing diarrhea in infants that were fed baby formula. Who investigated the relationship between sanitation and disease? (Select all that apply.)
Florence Nightingale, John Snow
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?
Foul-smelling discharge from the penis
The nurse observes a nursing assistant leave the room of client diagnosed with Clostridium difficile infection without washing hands. Which is the priority action by the nurse?
Have the nursing assistant wash hands with soap and water.
Which type of sexually transmitted disease is the nurse most accurate to highlight in the client's history as it remains dormant in the body and can reoccur at any time?
Herpes infection
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis?
Hourly leg exercises
The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority?
Impaired Skin Integrity
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
Ineffective thermoregulation
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply.
Listening to music, Watching television, Changing position
A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area?
Maintain patient safety.
Corticosteroids have which effect on wound healing?
Mask the presence of infection
Unless contraindicated, how should the nurse position an unconscious client?
On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?
Oxygen saturation of 82%
Which is a classic sign of hypovolemic shock?
Pallor
A nurse would implement droplet precautions for a client with which condition? Select all that apply.
Parvovirus B 19, Pertussis, Mumps
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
Pink to red and soft, noting that it bleeds easily
The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery?
Place sterile dressings moistened with normal saline over the protruding organs and tissues.
A nurse working in the immunization clinic is performing research to determine if there has been a decrease in the incidence of COVID-19 since COVID-19 vaccines began to be administered in the community. In which step of the epidemiological process is the nurse involved?
Planning, implementation, evaluating
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients
Pneumonia
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?
Position the client in the side-lying position.
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
Position the client to maintain a patent airway.
What complication is the nurse aware of that is associated with deep venous thrombosis?
Pulmonary embolism
The nurse recognizes which symptom as a clinical manifestation of shock?
Rapid, weak, thready pulse
The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?
Reinforce the importance of early mobility in preventing complications.
Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?
Reinforce the need to perform leg exercises every hour when awake.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing the dressing or applying pressure if bleeding is frank
After providing care for a patient with Clostridium difficile, the nurse is preparing to wash the hands before leaving the room. What is the best method of cleaning the hands in order to prevent spreading the bacteria?
Remove gloves and wash the hands with soap and water.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?
Report early calf pain.
A 2-year-old is brought to the clinic by her mother who tells the nurse her daughter has diarrhea and the child is complaining of pain in her stomach. The mother says that the little girl had not eaten anything unusual, consuming homemade chicken strips and carrot sticks the evening prior. Which bacterial infection would the nurse suspect this little girl of contracting?
Salmonella
A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care?
Shoulder and upper arm range-of-motion exercises
Which of the following stimulates the wound healing process?
Sufficient oxygenation
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
The Hemovac drain isn't compressed; instead it's fully expanded.
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?
The client can be discharged from the PACU.
A client with a Staphylococcus aureus infection present in a sacral pressure ulcer has received treatment with three courses of antibiotics without eliminating the infection. What does the nurse understand has occurred with the client?
The client has a multidrug-resistant strain of bacteria.
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?
The client has an absence of bowel sounds.
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?
The client is displaying early signs of shock.
When a hospitalized client requires contact precautions, which responses is necessary?
The client should be placed in a private room when possible
Which statement reflects what is known about the Ebola virus?
The diagnosis should be considered in a client who has a febrile, hemorrhagic illness after traveling to Asia or Africa.
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.
You are teaching a health class in the local public health center. What instructions should you provide as the single most important measure to prevent the spread of infection?
Thorough hand washing
Nursing students are reviewing information about infectious diseases and events associated with infection. Students demonstrate understanding of the information when they identify the incubation period as which of the following?
Time between exposure and onset of symptoms
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?
Tolerance
True or false: Stating conclusions is an outcome of analysis and interpretation
True
True or false: The goal of descriptive studies is to identify the patterns of occurrence of any health-related condition.
True
True or false: The simplest measure of description is a count.
True
A client vomits postoperatively. What is the most important nursing intervention?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
Urine retention
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?
Wound dehiscence
The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?
Wound infection
A(n) __________ is a factor that causes or contributes to a health problem or condition.
agent
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds.
The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?
chlorpromazine
A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound
dehisced
A term used to describe a partial or complete separation of wound edges is
dehiscence.
The __________ refers to all the external factors surrounding the host that might influence vulnerability or resistance.
environment
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?
experiences pain within tolerable limits
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:
first intention.
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation.
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
ondansetron
A nurse is teaching a client with genital herpes. Education for this client should include an explanation of:
the importance of informing his partners of the disease.
A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
thirst or irritability.
After demonstrating to a group of nursing students the proper technique for handwashing using soap and water, the nursing instructor determines that the teaching has been successful when the students demonstrate which of the following?
vigorously scrubbing between the fingers