Nursing I: Module 7

All of the following are risk factors for delayed wound healing except:

1. Inadequate nutrition 2. Repetitive injury 3. Tissue ischemia 4. Maintaining a moist environment (4) Rationale: This is not a risk factor for delayed wound healing.

The first leukocytes attracted to an injured tissue are the:

1. Mast cells 2. Neutrophils 3. Lymphocytes 4. Eosinophils (2) Rationale: Neutrophils are the first leukocytes attracted to an injured tissue.

A client with a known infection must be managed by using which identified method of precaution?

1. Strict asepsis 2. Standard precautions 3. Droplet precautions 4. Transmission-based precautions (2) Rationale: A client with a known infection must be managed by using standard precautions.

A nursing teaching strategy to reduce the develop- ment of an antibiotic-resistant organism is to:

1. Wash hands before and after all client contact 2. Keep people with a known infection in an isolation room 3. Stress the importance of taking all doses of an antibiotic when ordered 4. Have a client with a known infection wear a mask when in public areas (3) Rationale: This is a nursing teaching strategy to re- duce the development of an antibiotic resistant organism.

Primary Infection

Any type of infection

Secondary Infection

Caused from something else. Ex: A patient was vented and now he has vented pneumonia. Or Bedsores on someone who recently had surgery.

Endogenous Infection

Coming from the inside. Ex: Chickenpox can turn into shingles

While administering IV cefotetan to a patient to treat bacterial meningitis, the nurse finds the IV insertion site warm and reddened. Which of the following action should the nurse take?

Stop the infusion

A patient who is taking imipenam (primaxin) to treat bacterial infection contacts the provider to report an inability to eat because of mouth pain. Recognizing the adverse side effects of imipenem, the nurse should suspect what?

Suprainfection

A nurse is caring for a patient who is about to being taking Chloroquine (arelan) to treat malaria. When talking with the patient about taking the drug, the nurse should include which of the following? Select all that apply.

Wear sunglasses outside, Avoid driving, take with food.

A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate?

1. "Everyone who enters your room must wear a mask to protect themselves from tuberculosis." 2. "Masks would not be necessary for visitors who have had tuberculosis before." 3. "It is less important for your family to wear masks, since they live in close contact with you." 4. "Only visitors who are at risk for tuberculosis need to wear a mask. Answer: 1 Rationale: Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask. Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease again. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Look for similarities among the options in order to eliminate choices. In this case, the incor- rect options are similar in that they suggest certain individuals would not be required to wear masks.

A client asks, "How did I get scarlet fever?" What would be the nurse's best response?

1. "Scarlet fever is transmitted through sexual intercourse." 2. "You can get scarlet fever if you share contaminated needle or get a blood transfusion." 3. "Most people get it by eating contaminated food." 4. "You inhaled infected droplets in the air. Answer: 4 Rationale: Scarlet fever is transmitted by particle droplets larger than 5 microns. Scarlet fever is not transmitted through sexual intercourse or the blood, or by consuming contaminated food. Cognitive Level: Applying Client Need: Safe and Infection Control Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Begin by recalling that scarlet fever is transmitted by drop- lets. With this in mind, use the process of elimination to select the client situation that is compatible with the mode of transmission.

Which precaution would the nurse implement when admitting a client with herpes zoster to the nursing unit?

1. Airborne precautions 2. Contact precautions 3. Droplet precautions 4. Neutropenic precautions Answer: 2 Rationale: Herpes zoster is caused by the herpes virus varicella zoster. It can be transmitted by the airborne route until lesions have crusted over. It is not transmitted by droplets. Neutropenic precautions are not indicated, because the client is not at risk for contracting an infection from the nurse or other individuals. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Herpes zoster is a viral skin infection. Specific knowledge of the types of transmission-based precautions is needed to select the correct answer. Eliminate airborne and droplet precautions because herpes zoster is not transmitted on air currents. Next eliminate neutropenic precaution, which are are used with immunocompromised clients.

The nurse is preparing to irrigate a wound infected with vancomycin-resistant enterococci. What personal protective equipment (PPE) would the nurse wear?

1. Gloves, gown, and particulate respirator 2. Gloves and surgical mask 3. Gloves, eye protection, and shoe covers 4. Gloves, gown, eye protection, and surgical mask Answer: 4 Rationale: An infection with vancomycin-resistant enterococci requires transmission-based contact precautions. Since the nurse will be irrigating the wound and splatters of body fluids or exudates are possible, eye protection and surgical mask should be worn to protect the mucous membranes of the eyes, nose, and mouth. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. Shoe covers are unnecessary. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Wound infections require contact precautions. Look for the option that identifies the correct PPE to be used with contact precautions. Eliminate options with particulate respirator and shoe covers, since these are unnec- essary. Choose the option containing eye protection because the risk for splatters exists.

In healing by primary intention the wound fills in from:

1. Granulation tissue from the bottom of the wound 2. Suturing layers of granulation tissue 3. Cell migration from the borders of the wound 4. All of these (3) Rationale: This fills the wound in healing by primary intention."

The nurse is restarting an IV line on a client known to have hepatitis B. Which precautions should the nurse use to protect against exposure? Select all that apply.

1. Handwashing 2. Gloves 3. Mask 4. Face shield 5. Gown Answer: 1, 2 Rationale: Handwashing and gloves are the only precautions needed for starting an IV. Masks, face shields, and gowns are appropriate for procedures that may result in body fluids splashing. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: Recall standard precautions and infectious disease precautions. Handwashing and use of gloves are appropriate for any procedure.

The nurse is assessing a client with a mobility problem to determine an appropriate assistance device. The client's lower extremities have no paralysis, but are very weak. Upper-body strength is also reduced. The nurse should suggest which device for this client?

1. Cane 2. Four-wheeled walker 3. Canadian or elbow extension crutch 4. Lofstrand crutch" Answer: 2 Rationale: The client has bilateral weakness of the lower extremities, and the proper assistive device is one that will provide bilateral support. In this case, a walker provides the most support. Additionally, a four-wheeled walker does not require the client to lift the walker as steps are taken. A cane would provide only limited support for a client with very weak lower extremities. Canadian or elbow extension crutches and Loftstand crutches require upper body strength, an identified deficiency with this client. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is the assistive device that will provide the safest support to the client. The critical points of upper and lower extremity weakness in the stem of the question guide you to look for an option that provides bilateral support and minimal upper body strength.

All of the following clients appear in the emergency room during one shift. For which clients should the nurse expect the health care provider to order an antibiotic? Select all that apply.

1. Cat bite to the hand of an elderly client 2. Laceration from broken glass in a 6-year-old client 3. Stab wound in the arm of a 37-year-old client 4. Closed fracture to the ankle of a 40-year-old soccer player 5. A wrist sprain in a 17-year-old who was playing basketball Answer: 1, 2, 3 Rationale: A closed fracture or a sprain has no break in the skin. A cat bite, a laceration, and a stab wound all impair skin integrity, which could lead to infection, and thus may require prophylactic use of an antibiotic. Cognitive Level: Analyzing Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is appropriate use of antibiotic therapy. Restate this question in the following way: "Which client is not at risk for infection?" Use the process of elimination and nursing knowledge to make selections that pose little risk of infection.

The nurse is evaluating a client using a cane. Which assessment made by the nurse would indicate that the client is using the cane appropriately?

1. Client holds the cane with the hand on the stronger side. 2. Client holds the cane with the hand on the affected side. 3. Client moves the cane and the affected leg together. 4. The cane tip is made of aluminum to prevent slippage. Answer: 1 Rationale: To provide maximum support and appro- priate body alignment while walking, the cane is held in the hand on the stronger side. The cane and the strongest leg should be advanced together in order to provide a stable stance when the weak leg is advanced. The tip of the cane should have rubber tip to prevent slipping. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is the proper use of a cane as an assistive aid. Use the process of elimination and basic nursing knowledge to make a selection.

The nurse would implement which of the following as a requirement of care specific to the client who has tuberculosis?

1. Disposal of needles and syringes in a rigid, puncture-proof container 2. Handwashing after removing contaminated gloves 3. Wearing a gown if splashing is possible 4. A private room with negative air flow Answer: 4 Rationale: The client with tuberculosis can spread the infection by breathing, and requires a private room and airborne precautions. Proper equipment disposal, hand washing, and wearing protective equipment as indicated are precautions that would be implemented with any client, regardless of medical diagnosis. Cognitive Level: Applying Client Need: Safe Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical word specific suggests that the correct option must apply to a client with tuberculosis and is not a general measure used for all clients. Next consider that this is transmitted by the airborne route to make the correct selection.

The nurse is leaving the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) microorganisms in a wound and the urine. Place the fol- lowing personal protective equipment in order of removal.

1. Eye protection 2. Gloves 3. Mask 4. Gown Fill in your answer below:____________ Answer: 2, 3, 4, 1 Rationale: Gloves are removed first because they would be most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by washing the hands. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Remember that removal of PPE should occur in order of most contaminated to least contaminated items.

The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant Streptococcus pneumoniae (PRSP). The client has a tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning.

1. Eye protection 2. Gloves 3. Mask 4. Gown Fill in your answer below:______________ Answer: 4, 3, 1, 2 Rationale: The gown is applied first, as it takes the most time to don. The mask is donned next, followed by eye protection. These items can be more securely applied with ungloved hands. Gloves are donned last, so the gloves can be pulled up to cover the cuffs of the gown. Cognitive Level: Applying Client Need: Safty Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Rationalize the ordering based on nursing knowledge of standard precautions and surgical asepsis. Visualize the procedure to aid in choosing correctly.

A postoperative client tells the nurse that he developed dehiscence after his last surgery and wants to make sure it doesn't happen this time. Which nursing intervention is most effective for attempting to prevent dehiscence in a postoperative client?

1. Helping the client lose weight 2. Preventing vomiting 3. Administering antibiotics 4. Keeping the wound dry Answer: 2 Rationale: Activities that are likely to lead to dehiscence include vomiting and coughing because they increase intraabdominal pressure. Clients who are obese and those with poor nutrition are candidates for dehiscence. Since the client is already postoperative, encouraging weight loss at this time would not affect risk for dehiscence, and there is no indication that the client is overweight. Administering antibiotics is effective in pre- venting or treating infection. Antibiotic therapy alone can- not prevent dehiscence. Keeping a wound dry will promote healing and prevent infection; however, this action alone will not prevent dehiscence. Cognitive Level: Analysis Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The core issue of the question is knowledge of risk factors for dehiscence. Recall that dehiscence is most likely to occur when there is some type of stress on the incision line. Consider that vomiting puts sudden tension on the suture line to select it as the option that is most likely to be harmful to the client.

The nurse is changing the abdominal dressing of a client who is 4 days postoperative. The nurse notes a moderate amount of serosanguineous drainage, wound edges not approximated, and puffy tissue protruding through the wound. What condition should the nurse suspect from the- ses manifestations?

1. Hemorrhage 2. Normal healing by primary intention 3. Normal healing by secondary intention 4. Evisceration Answer: 4 Rationale: Evisceration occurs when internal viscera protrude from an incision that is dehiscing. In this situation, the nurse notes changes in wound appearance such as increased serosanguineous drainage, edges lacking approximation, and the protruding viscera. The nurse notes a moderate amount of serosanguineous drainage, which should be nearly diminished by the 4th day postoperative. However, this description does not fit hemorrhage. Healing by primary intention includes well-approximated incision edges and no signs of infection or complication. Secondary healing is when the wound is extensive and the edges cannot or should not be approximated; healing time is prolonged. Cognitive Level: Analyzing Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of this question is the ability to draw accurate conclusions about the status of a surgical wound. Use the process of elimination and basic nursing knowledge to make a selection.

NCLEX Ch. 27: While completing a nursing assessment, the client states he is 70 years old, has a history of staphylococcus infections, increased intraocular pressure, and blurry vision. The nurse concludes that which item reported by the client is a risk factor for the development of cataracts?

1. History of staphylococcus infections 2. Increased intraocular pressure 3. Stated age of client 4. Long complaint of blurry vision Answer: 3 Rationale: Age above 65 is a risk factor for cataracts. Double vision, increased intraocular pressure, and blurry vision are signs of glaucoma. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: The core issue of the question is knowledge of factors that increase client risk for conditions affecting sensory percep- tion. Use the process of elimination and nursing knowledge to make a selection.

In assessing a client who has been immobilized because of illness, the nurse would most likely document the client's muscles as which of the following?

1. Hypertrophied 2. Atrophied 3. Flexible 4. Hardened Answer: 2 Rationale: After immobilization, unexercised mus- cles will atrophy. Hypertrophy is the opposite of atrophy. Flexibility is a term most frequently applied to joint movement. Hardened is a term which describes muscles that have been developed by exercise or activity. Cognitive Level: Knowledge Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: This question requires application of basic nursing knowledge and terminology to a client situa- tion. Select the term that is a common finding in clients who are immobilized.

If a client has been taking a steroid drug, wound healing will be delayed because the steroid drug:

1. Impedes macrophage migration 2. Reduces body temperature 3. Reduces appetite and thus results in poor nutrition 4. Prevents fluid from reaching the involved area (1) Rationale: The steroid drug impedes macrophage mi- gration, which delays wound healing if a person has been taking a steroid drug.

Rest and immobilization are important to wound healing because they:

1. Increase circulation to involved area 2. Increase the metabolic rate 3. Prevent further injury to area 4. Prevent contractures in the involved area (3) Rationale: Rest and immobilization are important to wound healing because they prevent further injury to the area.

Fever that is seen in a client with an infectious disease is most likely caused by:

1. Increased release of histamine 2. Increased release of interleukin 3. Increased number of bacteria in the body 4. Increased vasodilation in the area of injury (2) Rationale: This is the most likely cause of fever that is seen in a client with an infectious disease.

An adult client who, after being hospitalized 3 days ago, is having trouble sleeping. The nurse also notes some confusion during waking hours. What is the most appropriate nursing diagnosis for this client?

1. Ineffective Health Maintenance 2. Ineffective Individual Coping 3. Disturbed Sensory Perception 4. Disturbed Sleep Pattern Answer: 4 Rationale: The client is in a new environment. Changes in environment bring about uncertainty, and the client may be unable to sleep or may sleep less well than at home. Although the client is confused, there is no other data presented that could be the cause, making disturbed sleep pattern a more appropriate selection than disturbed sensory perception which relates to one of the five senses. Ineffective health maintenance and ineffective individual coping are more global nursing diagnoses, which do not address the client's specific manifestations of inability to sleep and daytime confusion. Cognitive Level: Analyzing Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: Exercise the ability to draw correct conclusions about client assessment data and translate it to a nursing diagnosis. In this case, the original problem is sleeping, and the correct answer is one that focuses on this problem.

The classic sign of swelling seen in the inflammatory process results from:

1. Leakage of plasma into the injured area 2. Increased blood circulation to the area 3. The presence of phagocytic activity in the area 4. Response to the cytokines released (1) Rationale: The classic sign of swelling seen in the inflammatory process results from leakage of plasma into the injured area.

The correct order of these events in an inflammatory response is:

1. Mast cell degranulation, diapedesis of leukocytes, increased vascular permeability, and capillary dilatation 2. Mast cell degranulation, capillary dilatation, increased vascular permeability, and diapedesis of leukocytes 3. Diapedesis of leukocytes, increased capillary dilatation, increased vascular permeability, and mast cell degranulation 4. Increased capillary dilatation, mast cell degranu- lation, diapedesis of leukocytes, and increased capillary permeability (2) Rationale: This is the correct order for these events in an inflammatory response.

The nurse must apply an elastic bandage to support a client's sprained ankle. Which action should the nurse take during this procedure?

1. Moderately stretch the bandage and wrap it from distal extremity to proximal. 2. Wrap the extremity loosely enough to insert two fingers beneath the bandage. 3. Maintain a tight stretch with each wrap of the bandage. 4. Start proximal to the injury site and work distally. Answer: 1 Rationale: To prevent vascular impairment, proper application of elastic bandages is required. Wrapping distal to proximal is compatible with the flow of venous return. Wrapping the bandage evenly while stretching it moderately ensures that there will be even tension applied to the extremity while not occluding circulation. Wrapping the bandage loosely enough to be able to insert two fingers will not secure the bandage in place or provide adequate support for the injury. Excessive tension when applying an elastic bandage would cause circulation to be compromised. Wrapping in a proximal to distal direction would inhibit venous return. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is knowledge of basic wound care procedures. Use nursing knowledge of these procedures and concepts related to blood flow to make your selection.

The nurse is assisting a client who has methicillin-resistant Staphylococcus aureus in collecting a clean-catch urine specimen. Which protective equipment is unnecessary?

1. N95 particulate respirator 2. Gown 3. Eye protection 4. Sterile gloves Answer: 3 Rationale: Methicillin-resistant Staphylococcus aureus requires transmission-based contact precautions. Eye protection would be worn to protect the mucous membranes of the eyes when splatters of body fluids or excretions are possible. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. N95 respirators are needed when caring for the client with tuberculosis, so it is inappropriate for this scenario. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The critical word unnecessary suggests that all but one of the answers are correct. Using the process of elimination, look for the choice that identifies personal protective equipment that is not needed for contact precautions.

The nurse assigned to the respiratory care unit is working with four clients who have pneumonia. The nurse should assign the only remaining private room on the nursing unit to the client infected with which organism?

1. Penicillin-resistant Streptococcus pneumoniae pneumonia 2. Pseudomonas aeruginosa pneumonia 3. Pneumocystis carinii pneumonia 4. Legionella pneumophila pneumonia Answer: 1 Rationale: While each option contains "pneumonia," the causative agent is different for each. An organism that is "resistant" is a pathogenic microorganism that is difficult to treat and requires droplet precautions. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Note the critical word resistant in the correct option. This provides a clue that the infection is difficult to treat and requires specific additional infection control practices, in this instance droplet precautions. The pneumonias in the other options do not require transmission based precautions.

The nurse would take which action to protect the client from infection at the portal of entry?

1. Place sputum specimen in a biohazard bag for transport to the lab. 2. Empty Jackson-Pratt drain using sterile technique. 3. Dispose of soiled gloves in waste container. 4. Wash hands after providing client care. Answer: 2 Rationale: Using sterile technique to empty wound drains is aimed at interrupting the portal-of-entry link in the chain of infection. By using sterile technique, the nurse reduces the risk of introducing pathogens into the client's wound via the drain. Proper handling of specimens interrupts the chain of infection at the reservoir link. Disposing of gloves properly and washing hands after providing care break the chain of infection at the mode of transmission link. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Knowledge of the chain of infection is required. The portal of entry has to be a route whereby micro- organisms can enter the client, so select the option that is directly in contact with the client.

A charge nurse is discussing the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will need to monitor the client's serum antimicrobial levels during the course of therapy." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile." A. INCORRECT: The nurse should obtain a specimen for culture and sensitivity prior to the initiation of antimicrobial therapy. B. INCORRECT: MRSA is resistant to all antibiotics, except vancomycin. C. CoRRECT: Monitoring antimicrobial levels ensures that therapeutic levels are maintained. D. INCORRECT: Discontinuing antimicrobial therapy prior to completing a full course of treatment increases the risk of producing resistant pathogens.

The nurse would expect to institute transmission-based precautions for a client with which infection?

1. Pneumonia caused by Pseudomonas aeruginosa 2. Pneumocystis carinii pneumonia 3. A sacral wound contaminated by Escherichia coli 4. A draining leg wound with methicillin-resistant Staphylococcus aureus Answer: 4 Rationale: Transmission-based precautions are required for all antibiotic-resistant microorganisms regardless of their mode of transmission. The other options indicate the need for medical and surgical asepsis in the care of the client but not the use of transmission-based precautions. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The critical words methicillin- resistant indicate a microorganism that is difficult to eradicate. Eliminate each of the incorrect options after visualizing each situation because they can be managed by use of stan- dard precautions.

A nurse is discussing the infection process at a staff education session. Which of the following examples are appropriate for the nurse to include when discussing the direct contact mode of transmission? (Select all that apply.)

A. A client vomits on a nurse's uniform. B. A nurse has a needle stick injury. C. A mosquito bites a hiker in the woods. D. A nurse finds a hole in his glove while handling a soiled dressing. E. A person fails to wash her hands after using the bathroom. A. CoRRECT: Transmission from a client's emesis is identified as person-to-person or direct contact. B. INCORRECT: Transmission from a needle or other inanimate object is identified as indirect contact. C. INCORRECT: Transmission from an insect is identified as vector-borne. D. INCORRECT: Transmission from a soiled dressing or other inanimate object is identified as indirect contact. E. CoRRECT: Transmission from a client's contaminated hands is identified as person-to-person or direct contact.

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect?

A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster A. INCORRECT: A pink body rash can indicate an allergic reaction. B. INCORRECT: Red circles with white centers occur with ringworm. C. INCORRECT: A red edematous rash bilaterally on the cheeks can indicate systemic lupus erythematosus. D. CoRRECT: Vesicles that follow along a unilateral dermatome can indicate herpes zoster

A client on complete bed rest is at risk for disuse syndrome. The nurse should consider which client goal as appropriate?

1. The client has shorter periods of immobility. 2. The client remains free of contractures in lower extremities. 3. The nurse turns the client every 2 hours. 4. The nurse performs passive range of motion to lower extremities every 4 hours. Answer: 2 Rationale: Disuse syndrome is a result of prolonged immobility. Stating "the client remains free of contractures" describes in active terms the desired outcome for the client. Using "shorter periods of immobility" does not provide a specific expectation or outcome for the client. Stating that the nurse will turn the client every 2 hours is an interven- tion and not a goal. A goal needs to state a specific expecta- tion or outcome for the client. Stating that the nurse will perform passive range of motion every 4 hours is an inter- vention and not a goal. A goal needs to state a specific expectation or outcome for the client. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: Apply knowledge related to the nursing process, the pathophysiology of disuse syndrome, and appropriate client goals. Recall that goal statements are indicators of what the nurse wants to happen as a result of care. With these general principles in mind, eliminate each of the incorrect responses.

A client has a pressure ulcer on the left hip. The nursing staff has written a nursing diagnosis of Impaired Skin Integrity with a client goal of "skin heals by 6/12." Prior to June 12, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal?

1. Turned every 2 hours; avoided positioning on left side 2. Wet to moist dressing changed every 4 hours 3. No additional areas of skin breakdown noted 4. Wound less reddened; granulation tissue noted Answer: 4 Rationale: The description refers to the wound itself and is the best indication of the wound's current status. A decrease in redness and the presence of granulation are indicators that the goal of ulcer healing is evident. The other options do not address progress toward the goal of ulcer healing. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Apply knowledge regarding the nursing process and the concepts of documentation. Distinguish which option most accurately answers the question.

A client, admitted to the hospital for gallbladder surgery, is diagnosed as having a vitamin C deficiency. The nurse places high priority on assessing this client for which development postoperatively?

1. Unusual muscle weakness 2. Mental confusion 3. Delayed wound healing 4. Ataxia upon ambulating Answer: 3 Rationale: Protein and vitamin C are necessary for building and maintaining tissues. A deficiency of vitamin C would prolong wound healing. The other options are not manifestations of a vitamin C deficiency. Cognitive Level: Understanding Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of this question is the role of vitamin C in wound healing. Use nursing knowledge and the process of elimination to make a selection.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.)

A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with his hips and knees bent. E. Offer the client a warm beverage, such as herbal tea. A. CoRRECT: The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. B. INCORRECT: An abdominal binder can help prevent, not treat, a wound evisceration. C. INCORRECT: The nurse should not handle or apply pressure to any exposed organs or tissues because these actions increase the risks of trauma and perforation. D. CoRRECT: This position minimizes pressure on the abdominal area. E. INCORRECT: The nurse must keep the client NPO in anticipation of the surgical team taking him back to the surgical suite for repair of the evisceration.

An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.)

A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care A. INCORRECT: The client is not at either extreme of the age spectrum. B. CoRRECT: Diabetes mellitus places this client at risk for impaired circulation. C. CoRRECT: Diabetes mellitus places this client at risk for impaired immune system function. D. INCORRECT: There is no indication that the client is malnourished. E. INCORRECT: There is no indication that there have been any breaches in aseptic technique during wound care.

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.)

A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate A. CoRRECT: A fever indicates that the infection is affecting the whole body, and therefore systemic. B. CoRRECT: Malaise indicates that the infection is affecting the whole body, and therefore systemic. C. INCORRECT: Edema is a localized symptom indicating a localized, not systemic, infection. D. INCORRECT: Pain and tenderness is a localized symptom indicating a localized, not systemic, infection. E. CoRRECT: An increase in pulse and respiratory rate indicates that the infection is affecting the whole body, and therefore systemic.

A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first?

A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer prescribed antituberculosis medications. D. Recommend a screening test for family members. A. CoRRECT: The safety risk to the nurse and others is transmission of the infection. The first action is to place the client on airborne precautions. B. INCORRECT: Obtaining a sputum culture is an appropriate action, but it does not address the safety risk and therefore is not the first action the nurse should take. C. INCORRECT: Administering prescribed medications is an appropriate action, but it does not address the safety risk and therefore is not the first action the nurse should take. D. INCORRECT: Recommending screening tests for those in close contact with the client is an appropriate action, but it does not address the safety risk and therefore is not the first action the nurse should take.

A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.)

A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst A. CoRRECT: Pain and tenderness at the wound site are expected findings with an incisional infection. B. CoRRECT: Fever and chills are expected findings with an incisional infection. C. CoRRECT: Reddened or inflamed wound edges are expected findings with an incisional infection. D. INCORRECT: Serosanguineous drainage is more common immediately after surgery. Purulent drainage is an expected finding with an incisional infection. E. INCORRECT: Changes in thirst have many causes. That finding alone does not indicate an incisional infection.

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.

A. Keep the head of the bed elevated 30 degrees. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed. A. CoRRECT: Slight elevation reduces shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. B. INCORRECT: Massaging the skin over bony prominences can traumatize deep tissues. C. INCORRECT: Cornstarch can create gritty particles that can abrade sensitive skin. D. CoRRECT: The client should sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. E. INCORRECT: Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough. The nurse should reposition the client at least every 2 hr.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.)

A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that may result in contamination from secretions A. INCORRECT: A nurse should place a client in a private room and initiate droplet precautions if he has pertussis. The client's room does not need to have negative air pressure. B. CoRRECT: The nurse should wear a mask when within 3 ft of the client. C. CoRRECT: The nurse should place a surgical mask on the client during transport to another area of the facility. D. INCORRECT: The nurse should wear a gown when performing care that may result in contamination from body fluids. E. CoRRECT: A gown should be worn if the nurse's clothing or skin may be contaminated with body secretions or excretions.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A. CoRRECT: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies. B. CoRRECT: Reporting of communicable and infectious diseases assists with determining public health policies. C. CoRRECT: Reporting of communicable and infectious diseases assists with ensuring proper medical treatment is available. D. INCORRECT: Endemic disease is already prevalent within a population, so reporting is not necessary. E. CoRRECT: Reporting of communicable and infectious diseases assists with monitoring for common-source outbreaks.

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A. Prodromal B. Incubation C. Convalescence D. Illness A. INCORRECT: The prodromal stage consists of nonspecific clinical manifestations of the infection. B. INCORRECT: The incubation period consists of the time when the pathogen first enters the body prior to the appearance of any symptoms of infection. C. INCORRECT: Convalescence is when acute symptoms of the infection fade. D. CoRRECT: The illness stage is when the client experiences signs and symptoms specific to the infection

A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.)

A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area A. CoRRECT: Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. B. INCORRECT: Sutured surgical incisions heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. C. INCORRECT: Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. D. INCORRECT: Lacerations sealed with tissue adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. E. CoRRECT: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges

Nursing Assessment for risk factors of infection

Age, breaks in skin, illness or injury, substance abuse, environmental factors, chronic disease, medications, medical procedures, lifestyle factors(immunizations, stress, foods) Perform Physical Assessment: General appearance, integumentary system, lymph nodes, site of medical procedures (IV, catheter, etc).

Diseases caused by inflammatory effect:

Arthritis, myocardial, obesity

A patient who is taking amoixicillin to treat URI contacts the nurse to report rash and wheezing. Which of the instructions should the nurse provide?

Call emergency services right away.

When administering erythromycin to a patient who has pneumococcal pneumonia, the nurse should monitor for which of the following adverse effects of the drug?

Cardiac dysrythmias

A primary is considering the various pharmacologic options for a patient who has a gynecologic infection and history of alcohol use disorder. Which medication can cause a reaction similar to Antabuse if the patient drinks while taking the medication? Select all that apply.

Cefotetan, Flagyl

A nurs is caring for a patient who is about to begin taking keflex to treat bacterial meningitis. The nurse shoudl explain to the patient the need to monitor which of the following lab tests?

Creatinine

NCLEX: The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply.

1. Wash hands with the hands held higher than the elbows. 2. Adjust temperature of water to the hottest possible. 3. Scrub hands and nails with a scrub brush for 5 minutes. 4. Use a clean paper towel to turn water off. 5. Rub vigorously using firm circular motions. Answer: 4, 5 Rationale: A paper towel is used to shut off the faucet because the faucet is considered contaminated. Rubbing vigorously using firm circular motions creates fric- tion on the skin to assist in cleansing. The hands are consid- ered to be more contaminated than the elbows, and the hands should be held down so water flows from least con- taminated to most contaminated. Hot water can result in burns to the nurse. Warm water protects from burns and removes less protective skin oil than hot water. A surgical scrub is performed over 5 minutes while in medical asepsis hands are washed for at least 10-15 seconds. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is utilization of medical asepsis. Recall basic principles of care and use the process of elimination to make a selection.

A nurse is caring for a patient who is about to receive gentamycin to treat systemic infection. The nurse should question the use of the drug for a patient who is also taking which drug?

Lasix (furosemide)

Wound Healing

Primary Intention: Wound edges are approximated Secondary Intention: Tissue loss, not approximated Tertiary Intention: Wound vac

A nurse is caring for a patient who is about to begin nystatin to treat organ candida that resulted from tetracycline. Which of the following instructions should the nurse include about the preparation?

Swish before swallowing.

Body's Defense Mechanisms

Primary defense: Skin Secondary Defense: WBCs Tertiary Defence: Cell and humoral mediated

A primary care provider should prescribe a lower dose of Azectam for a patient who has a URI and also has which of the following?

Renal impairment

A nurse is caring for a patient who is about to begin Flagyl to treat anaerobic intra-abdominal infection. The nurse should recognize that cautious use of the drug is indicated if the patient also has which of the following?

Seizure disorder

A patient who is taking cipro to treat URI contacts the nurse to report dyspepsia. The nurse should recommend which instruction?

Take the antacid 2 hours after taking the drug

A nurse is caring for a patient who is taking Cipro to treat UTI and has rheumatoid arthritis, for which he takes Prednisolone. Recognizing the adverse effects of cipro, the nurse should tell the patient to report?

Tendon pain

A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests the client is experiencing postherpetic neuralgia?

A. Linear clusters of vesicles present on the client's right shoulder B. Purulent drainage from both of the client's eyes C. Decreased white blood cell count D. Report of continued pain following resolution of rash A. INCORRECT: Localized linear clusters of vesicles are an expected finding of herpes zoster rather than postherpetic neuralgia. B. INCORRECT: Eye infection is a potential complication of herpes zoster but does not suggest postherpetic neuralgia. C. INCORRECT: Immunosuppression increases the client's risk for herpes zoster but does not suggest postherpetic neuralgia. D. CoRRECT: Pain that persists following resolution of the vesicular rash is an indication of postherpetic neuralgia.

A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse recognize as atypical indications of an infection? (Select all that apply.)

A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation A. CoRRECT: Urinary incontinence is an atypical indication of infection in an older adult client. B. INCORRECT: Malaise is a typical indication of infection. C. CoRRECT: Acute confusion is an atypical indication of infection in an older adult client. D. INCORRECT: Fever is a typical indication of infection. E. CoRRECT: Agitation is an atypical indication of infection in an older adult client.

Exogenous Infection

Coming from the outside source

A patient is taking tetracycline orally to treat chlamydia, contacts the provider to report severe blood-tinged diarrhea. Recognizing the side effects, the nurse should suspect what?

Pseudomembranous enterocolitis

A nurse is caring for a patient who is about to begin taking zovirax to treat herpes simplex. The nurse shoudl monitor for which labs?

BUN

A nurse is caring for a patient who is taking coumadin and about to start bactrim to treat UTI. the nurse should question the drug regimen because the two drugs together could increase the patient's risk for?

Bleeding

Diagnostic Tests for Infection

CBC with Diff, blood culture, urine culture, throat/wound cultures, disease titres (rubella), Immunoglobulins (IGG and IGM), Sed rate (ESR), Iron level

Infection Control Precautions

Contact precautions Airborne precautions: N95 mask. TB and measles Droplet precautions: Flu, Strep, etc

A nurse is caring for a patient who is about to begin taking macrodantin to treat URI. The nurse should tell the patient to report which of the following adverse effects?

Cough

A nurse is caring for a patint who is about to begin zovirax IV to treat a viral infection. The nurse should recognize the cautious use of the drug is essential if the patient also has which of the following?

Dehydration

A nurse is preparing to admin Amphotericin B IV to a patient who has systemic fungal infection. Which of the following should the nurse admin prior to infusion to minimize adverse reactions? Select all that apply.

Diphenhydramine, ibuprofen

ATI: Pharm-Infection: Which of the following drugs should a provider prescribe for a patient who has streptocococcal pharyngitis and is allergic to PCN?

Erythrymycin

A nurse is caring for a patient who is about to begin taking ketoconazole to treat fungal infection. The nurse should tell the patient to report which adverse reaction?

Gynecomastia

Lecture: How does infection occur?

Host, Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry

Stages of Infection

Incubation: 1day-months or a year depending on infection Prodromal: 1st vague symptom Illness Decline Convalescence: Repairing time. Wound repairs itself, immune system increases and gets better.

A nurse is caring for a patient who is about to begin taking INH to treat TB. The nurse should tell the patient to report which adverse effect of the drug? Select all that apply.

Jaundice, Numbness in hands, Dizziness

Staging of ulcers

Stage I: Reddened area Stage 2: blistering. Partial thickness loss of dermis. Stage 3: Full thickness skin loss with damage to subcutaneous tissue. Stage 4: bone and muscle involved. Necrosis might be involved. Unstagable: Due to eschar or bruising

A nurse is caring for a patient who is about about to begin gentamycin therapy to treat infection. The nurse should monitor for which of the following?

Urine output

A nurse is caring for a patient who takes oral contraceptives and is about to begin rifampin therapy to treat TB. The nurse should include which of the following instructions?

Use back up methods

A primary provider is prescibing drug therapy for a patient whose sputum culture indicate methicillin-resistant Staph-Aureas (MRSA). Which of the folling drugs should be administered?

Vancomycin

A client is at risk for the developing a pressure ulcer and is placed on a repositioning regimen. The client does not like to lie on his side and complains about the need to turn. Which explanation by the nurse may enhance compliance? Select all that apply.

1. "Turning helps maintain skin integrity by alternating areas of pressure." 2. "Excess pressure interferes with skin absorption of vitamin D." 3. "Changing positions will promote circulation and prevent contractures." 4. "Changing position prevents tissue breakdown that could ultimately become infected." 5. "A repositioning schedule is a standard part of hospital policy. Answer: 1, 3, 4 Rationale: Turning a client is one of the principle methods of preventing skin breakdown. When a client's position is changed, circulation to the previous areas of pressure is restored and the joints can be moved and aligned to prevent development of contractures. A loss of skin integrity places the client at risk for bacterial invasion and subsequent infection. Unless the skin loss is extensive, the skin will continue to absorb vitamin D. Making a reference to policy does not promote client understanding or compliance. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Teaching and Learning Content Area: Fundamentals Strategy: The core issue of the question is promoting compliance through client teaching about the benefits of turning and repo- sitioning. Because there is more than one correct answer, look at each option as a true/false statement.

The nurse is caring for a client with hepatitis A. Which client statements indicate that teaching conducted by the nurse about disease transmission was effective? Select all that apply.

1. "We must avoid kissing." 2. "We can use the same bath towels." 3. "We must avoid eating with the same utensils." 4. "We must wear masks." 5. "No special precautions are needed. Answer: 1, 3 Rationale: Hepatitis A is an infectious disease transmitted by the fecal-oral route. Standard precautions are mandatory. Contact precautions are instituted if the client is incontinent of stool. Family members should avoid close contact with the client. They should not kiss the client or use the same eating utensils and bath towels. Masks are not necessary because the disease is not transmitted by the respiratory tract. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Planning Content Area: Fundamentals Strategy: The critical words methicillin-resistant indicate a microorganism that is difficult to eradicate. Eliminate each of the incorrect options after visualizing each situation because they can be managed by use of standard precautions.

Chronic inflammation can be caused by all of these except:

1. A foreign body such as a bullet lodged in the tissue 2. A response to a normal body substance such as low-density lipoprotein lodged in excess in an arteriole wall 3. Use of an arthritic joint 4. A walled off tubercle (2) Rationale: Chronic inflammation is not caused by a response to a normal body substance such as low density lipoprotein lodged in excess in an arteriole wall.

A male client suffered numerous types of wounds when he lost control of his motorcycle and was thrown onto the pavement. The client asks the nurse which wounds will scar more. The nurse's reply will be based on analysis that which wounds would generally be least likely to scar?

1. A wound that heals by primary intention 2. A wound that heals by secondary intention 3. A wound that becomes infected 4. A wound to an extremity Answer: 1 Rationale: Primary intention healing occurs when the wound edges are well approximated; wounds that heal by primary intention are least likely to scar. Wounds that heal by secondary intention have edges that cannot be approximated. The chance for scarring is greater for wounds that heal by secondary intention. Wounds that become infected are more likely to scar due to prolonged healing time, decreased probability of approximated wound edges, and increased chance of tissue loss. The fur- ther away from the heart, the longer the wound may take to heal. However, the location of a wound is not significant in regards to the likelihood of scarring. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Diagnosis Content Area: Fundamentals Strategy: The core issue of this question is knowledge of physiological wound healing. The question should be read carefully because the client asks which wounds will scar more and the stem asks which wound is least likely to scar.

A female client can move her right arm and leg but has hemiplegia on the left. What should the nurse instruct the nursing assistant to do on the client's left side during care?

1. Active range of motion 2. Passive range of motion 3. Isotonic exercises 4. Isometric exercises Answer: 2 Rationale: Passive range of motion is most appropri- ate because the client is unable to move that side of the body on her own. Active range of motion requires the client to move the body independently, isotonic exercises require the ability to tighten the muscles on the left side, and isometric exercises require the ability to perform resistance with the muscles on the left side all of which the client cannot do due to hemiplegia on the left side. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical words in the question are hemiplegia on the left side. This indicates that the client cannot move the left side of the body and is unable to actively participate in exercising the joints. The wording of the question tells you that there is only one correct answer.

A client with suspected severe acute respiratory syndrome (SARS) arrives at the emergency department. Which physician order should the nurse implement first?

1. Airborne and contact precautions 2. IV D5NS at 100 mL/hr 3. Nasopharyngeal culture for reverse-transcription polymerase chain reaction 4. Sputum for enzyme immunoassay testing Answer: 1 Rationale: SARS is a highly contagious viral respiratory illness that is spread by close person-to-person contact. SARS is transmitted by airborne respiratory route and by touching surfaces and objects contaminated with the virus. Instituting infection-control measures would be the first priority of the nurse. This action would protect both health care workers and other clients in the emergency department. Then all other interventions can be safely implemented. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical word first indicates all of the answers are correct and the nurse needs to set priorities. The first priority is to implement measures that protect the client and/or nurse—instituting airborne and contact precautions.

The nurse needs to conduct an admission interview with a 74-year-old client who is hearing impaired. What should the nurse do to enhance the client's ability to hear? Select all that apply.

1. Position self to be within the client's line of vision 2. Dim the lights in the room 3. Over articulate words 4. Turn down the television in the room 5. Use a moderate rate and the same tone for all words Answer: 1, 4, 5 Rationale: The nurse should select a position within the client's line of vision to enable the client to read lips during the conversation. It is good to decrease back- ground noises that interfere with the client's ability to hear the nurse. It is also helpful to speak at a moderate rate and use the same voice tone throughout each sentence, not dropping the tone at the end of a sentence. The lighting should not be dimmed because doing so would interfere "with the client's ability to see the nurse clearly in order to read lips. Words should not be over articulated; exaggerated, unnatural movement of the lips can distort words for the client who relies on lip reading to compensate for hearing loss. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: The core issue of the question is effective communication strategies with a client whose hearing is impaired. Remember to focus on enhancing the client's vision during communication and use a moderate overall approach (i.e., not excessive or insufficient). When there are multiple correct answers to a question, consider each option as a true/false statement.

An 80-year-old client has been admitted to the nursing unit with Parkinson's disease. Which of the following activities would be most appropriate in preventing disuse syndrome?

1. Providing for the nutritional needs of the client 2. Promoting weight-bearing exercises 3. Encouraging 8 glasses of fluid in 24 hours 4. Turning and positioning every 2 hours Answer: 2 Rationale: Weight-bearing exercise is the best approach to preventing disuse syndrome. Disuse syndrome occurs because the stresses of weight bearing are absent and the bone releases calcium. While nutritional needs of a client with Parkinson's is an appropriate nursing intervention, it does not address the prevention of disuse syndrome. Encouraging fluids is important for the elderly client because they become easily dehydrated due to a decreased sense of thirst; however, it does not address the prevention of disuse syndrome. Turning and repositioning every 2 hours is an important nursing intervention to prevent skin breakdown; this action does not specifically address the prevention of disuse syndrome. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Apply knowledge related to the cause of disuse syndrome and the nursing interventions that will minimize it. Use concepts of basic nursing care to answer the question

A 72-year-old client has been in the ICU for the past 2 days. Which intervention would be the most appropriate in decreasing the risk for sensory deprivation? Select all that apply.

1. Remove equipment from the room. 2. Explain procedures and routines to the client upon admission. 3. Provide a clock and calendar in the client's room. 4. Maintain a balance of activity and rest periods. 5. Maintain constant conversation when in the client's room. Answer: 3, 4 Rationale: Providing the client with a clock and calendar helps the client to be oriented to time and date. These would be meaningful stimuli for the client and decrease the chance for sensory deprivation. Activities and rest periods should be spaced and planned to balance high and low levels of sensory stimuli. It may not be realistic in an ICU to remove equipment from the room. Explaining all procedures and routines would increase the risk of overload. Continuous conversation is not therapeutic and could place the client at risk for sensory overload as a different problem. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is nursing actions that can prevent the client from experiencing sensory deprivation. Use knowledge of basic nursing mea- sures to help a client stay oriented to time, place, and person make appropriate selections.

The nurse is preparing to leave the room of a client on transmission-based precautions. Place in the correct order the steps the nurse would follow to remove personal pro- tective equipment and perform hand hygiene.

1. Remove gown. 2. Remove gloves. 3. Remove mask. 4. Remove eye protection. 5. Wash hands. Fill in your answer below:_________ Answer: 2, 3, 1, 4, 5 Rationale: Gloves are removed first, as they would be the most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by hand washing. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Washing the hands is last. Removal of gloves is first, as the gloves would be the most contaminated.

A client with vancomycin-intermediate-resistant Staphylococcus aureus (VISA) is admitted to the nursing unit. What type of precautions should the nurse institute?

1. Standard precautions 2. Neutropenic precautions 3. Droplet precautions 4. Contact precautions Answer: 4 Rationale: Clients with antibiotic-resistant microorganisms must be isolated with transmission-based precautions. The organism is transmitted via close person- to-person direct contact and by touching contaminated sur- faces and objects. Standard precautions are used with all clients, regardless of medical diagnosis. Reverse isolation is instituted for immunocompromised clients. This organism is not transmitted via droplet nuclei. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The critical words vancomycin-intermediate-resistant suggest the microorganism is difficult to eradicate, indicating it is highly contagious. Eliminate standard and neutropenic, as they are not disease-specific precautions. Select contact over droplet, recalling that Staphylococcus aureus is a micro- organism that is commonly found on skin.

Which actions by the nurse comply with core principles of surgical asepsis? Select all that apply.

1. Wash hands before and after client care. 2. Keep sterile field in view at all times. 3. Wear personal protective equipment. 4. Add contents to sterile field holding package 6 inches above field. Answer: 2, 4 Rationale: Keeping the sterile field in view and holding items 6 inches above the sterile field are core princi- ples of surgical asepsis. Washing hands after providing care and wearing personal protective equipment are core princi- ples of medical asepsis. The outer 1 inch of a sterile field is considered contaminated, not 1.5 inches. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is the ability to discriminate between medical and surgical asepsis and to choose correct interventions that support surgical asepsis. Use these principles and the process of elimination to make a selection.

A 92-year-old client is in the hospital. The client is very hard of hearing, and the nurse needs to do the admission interview. Which action is appropriate for the nurse when assessing the client?

1. Use a cotton swab to clean cerumen in the client's ear before the interview. 2. Speak louder into the client's ear determined to have better hearing. 3. Lower the pitch of the voice and face the client during the interview. 4. Put new batteries in the hearing aid to ensure proper functioning. Answer: 3 Rationale: Hearing loss, especially of upper-range tones, is common in the elderly. Speaking to the client slowly and in a lower-pitched voice while facing the client is the best means of communication. Cleaning cerumen from the client's ears will not overcome age-related hearing loss. Depending on the level of hearing loss, speaking louder into the ear with the better hearing may still not be an effective action. The question states that the client is hard of hearing without reference to a hearing aid; if a hearing aid is used, changing the batteries may not be an effective action. Cognitive Level: Applying Client Need: Basic Care and Comfort Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Apply knowledge related to communicating with a client who is hearing impaired. Remember that if the age of the client is included in the stem, it important in determining the cor- rect option. Consider the question as it is written and do not make assumptions.

A client has weakness of the lower extremities and uses crutches for mobility. What client behavior should indicate to the nurse that the client needs further teaching about using crutches?

1. Uses the swing-to gait 2. Uses axillary crutches 3. Bears weight on the armpits 4. Replaces rubber tips on the crutches "nswer: 3 Rationale: The weight of the body should be borne on the arms, not the axillae. When clients allow the axillae to bear the weight of the body, they are at risk of developing crutch palsy, a nerve damage. This behavior would require additional client teaching. The ability to perform the swing-to gait represents correct use of crutches, and therefore no further teaching is needed on those points. Axillary crutches are crutches that are appropriately positioned beneath the axilla of the body. If a cli- ent is able to use axillary crutches without bearing weight on the armpits, no further teaching is needed. Placing new rubber tips on the crutches indicates an awareness of equipment safety that requires no further teaching. Worn crutch tips can cause a client to slip or fall. Cognitive Level: Analyzing Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Evaluation Content Area:Fundamentals Strategy: The core issue of the question is proper use of crutches. Keep in mind that this question has a negative stem and the correct answer is the option that reflects incorrect information.

An elderly postoperative client's abdominal wound is still healing weeks after the surgery. The client asks the clinic nurse why the wound is healing so slowly. Which factors should the nurse identify that negatively affect healing in the elderly? Select all that apply.

1. Vascular changes 2. Nutritional status 3. Decreased activity 4. Keloid formation 5. Nutrient absorption Answer: 1, 2, 5 Rationale: Vascular changes in the elderly client, such as atherosclerosis and atrophy of capillaries, impair blood flow to the wound and negatively affect healing. Wound healing requires increased dietary intake of protein and vitamin C. The diet of an elderly may be inadequate for a variety of reasons such as: difficulty with chewing or swallowing; lack of access to food sources; or food choices restricted by finan- cial status. In the elderly client, deficient absorption of nutrients can occur because of chewing difficulties, decreased peristalsis, and/or reduced secretion of digestive enzymes; all of which can contribute to a delay in healing. A decreased activity level with aging does not diminish local blood supply to a healing wound. Keloid formation is an abnormal type of healing of a wound which is not specific to the elderly client. Cognitive Level: Analysis Client Need: Basic Care and Comfort Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: The core issue of the question is age- related changes that have a negative impact on wound heal- ing. This question has more than one correct answer and each option should be approached as a true/false statement before selecting the answer.

The nurse's forearm becomes splattered with blood while inserting an intravenous catheter. What action should the nurse take?

1. Wash blood away with isopropyl alcohol. 2. Wipe blood away with a tissue. 3. Flush forearm with hot water, letting water flow from elbow toward fingers. 4. Wash forearm with soap and water. Answer: 4 Rationale: Washing the skin with the combination of soap and water will remove the blood through mechanical friction. While alcohol can kill bacteria, it cannot kill viruses and fungi. Tissues would not adequately remove the blood. Hot water can burn the nurse, and water alone is inadequate in removing the blood. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is the most effective means of reducing the risk of bloodborne disease transmission after contact with the skin. Recall principles of medical asepsis and use the process of elimination to make a selection.

The nurse would take which actions to comply with principles of medical asepsis? Select all that apply.

1. Wash hands before and after assisting client with personal hygiene. 2. Wear gown and gloves when working with client on contact precautions. 3. Re-cap needle after administering insulin. 4. Insert needle into rubber port of a previously used multidose vial without swabbing it with alcohol. 5. Use surgical facemask while working with client who has tuberculosis. Answer: 1, 2 Rationale: Washing hands before and after assisting a client with personal hygiene, and wearing a gown and gloves when working with a client on contact precautions are core principles of medical asepsis. Recapping the needle after administering insulin violates principles of medical asepsis. Inserting a needle into the rubber port of a previously used multidose vial without swabbing it with alcohol violates principles of surgical asepsis. Using a surgical facemask while working with a client who has tuberculosis violates principles of transmission-based precautions for a client with tuberculosis. The nurse should wear an N95 (fit-tested) mask instead of a simple surgical mask. Cognitive Level: Analyzing Client Need: Safety and Infection Control Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Knowledge of medical versus surgical asepsis is essential to answer this question. Note that hand hygiene, gown and gloves use medical aseptic technique, while capping and not wiping do not. Also discard surgical face mask because it addresses transmission-based precautions and is an incorrect statement.