PrepU - Seminar Quiz 2

If the client touches the sterile field, the nurse should discard the supplies and prepare a new sterile field.

What is a recommended guideline for maintaining a sterile field?

-physiologic reflexes(coughing, sneezing, vomiting) -skin and mucous membranes -macrophages

What would be considered a mechanical defense mechanism?

an older adult can have an infection without a fever

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:

a thorough, mechanical cleaning

When providing oral care, what does the nurse recognize as the most important component of the oral care process?

assessment of tissues

When the nurse observes slight bruising on the client's left thigh during the bed bath, he takes a closer look and palpates a lump on the anterior surface of the thigh. The nurse has used the bath activity for:

provides slippers for ambulation

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

a client recovering from a bone marrow transplant

Which client is most likely to require neutropenic precautions?

• client with gastric tube feeding • client with an indwelling catheter • client with an IV catheter

Which clients are at a heightened risk for infection? Select all that apply.

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

Which nursing action is appropriate when providing foot care for a client?

Antigen

Which term describes foreign particles that enter a host and stimulate the body's immune response?

tepid water

A client is in the fever phase. His temperature remains significantly elevated. The nurse is preparing to implement sponge bathing. Which type of water would the nurse most likely use?

a client had a transfusion reaction because of a labeling error in the hospital's blood bank

A hospital administrator is preparing a report that will be submitted to the relevant authorities regarding a sentinel event. Which of these events is the most likely subject of the report?

Joint Commission 2015 Hospital National Safety Goals

A memorandum has been distributed in a hospital reminding staff of the need to respond promptly to audible alarms and to never disable the audible alarm capabilities of equipment. This memorandum directly addresses:

fever, increased HR, pain, increased RR, and lymph node enlargement

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

-pneumonia -skin infection -influenza -UTI -TB

A nurse is caring for an older adult client at a long-term health care facility. Which infections pose a risk to long-term care residents and older adult clients admitted to health care facilities? Select all that apply.

"I need to soak them frequently in water."

A nurse is educating a client with diabetes on how to care for his feet. The nurse determines that additional education is needed when the client states:

waiting outside of the closed bathroom door while the client uses the toilet

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which action by the new nurse would require the charge nurse to intervene?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

remove gloves, remove gown, wash hands

The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?

client is more difficult to arouse

The nurse is caring for an older adult with pneumonia. Which assessment finding requires immediate nursing intervention?

principles of body alignment

The occupational health nurse is planning a safety in-service for a group of clerical workers. Which topic would be most beneficial?

superinfection

A client is receiving prescribed antibiotic therapy to treat an infection. On the fourth day of therapy, the client comes to the clinic and tells the nurse that she has developed a really sore mouth. After inspection, the nurse suspects that the client has developed a fungal oral infection. The nurse identifies this as:

Introduce a checklist that specifies each relevant component of pretest preparation.

A client was sent to radiology from an inpatient unit for computed tomography (CT) but the test had to be cancelled because the client was not adequately prepped. How can the management of the inpatient unit ensure that future clients receive all of the necessary preparation before their tests?

care of clients with indwelling catheters will be tracked more closely to reduce the incidence of UTIs.

A hospital's policies and procedures are being reviewed in light of the Joint Commission 2015 Hospital National Patient Safety Goals. What change in practice most directly addresses these goals?

place the specimens into plastic biohazard bags

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

A client with vascular dementia exited the hospital unnoticed and suffered a fall.

A nurse is a member of a hospital's quality improvement committee, which has reaffirmed the hospital's commitment to eliminating "never events." Which of these clinical events would the committee address?

neuromuscular status

A nurse is assessing a client who recently had a stroke. What is one area of assessment necessary to promote safety?

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

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

fan-fold soiled linens as close to client as possible

A nurse is making a bed occupied by a client. What is a recommended step for this procedure?

place bath blanket over the client, have client hold blanket, remove top linens, fan-fold soiled linens as close to the client as possible

A nurse is making the bed of a client whose limited mobility prevents her from leaving the bed. What should the nurse do when performing this procedure?

Don gloves

A nurse is providing oral care to a client with dentures. What action would the nurse perform first?

take a physician's order for restraining

A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints?

• Use of a tub/shower seat may be necessary if balance problems are present. • Water temp. should be monitored carefully due to decreased temperature sensation. • Use a long-handled shower brush or attachment to help with limited mobility.

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.

whenever hands are visibly soiled

A nurse should perform hand hygiene in which circumstance?

Report the event using the appropriate documentation so processes can be examined to promote safety.

A nurse was covering for a colleague during the colleague's scheduled break and nearly administered an intravenous antibiotic to the wrong client, catching the error while programming the IV pump. What is the nurse's best response to this adverse incident?

involving family members in the clients care

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls?

a nurse regularly ask clients and their families about their preference for care

A nursing educator is encouraging nurses on a unit to evaluate their practice in light of the Quality and Safety Education for Nurses (QSEN) project. What nursing action best demonstrates the QSEN competencies?

Cleanse to remove secretions from less soiled to more soiled areas.

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care?

"Inverting the gloves entraps the soiled surface and prevents the spread of microorganisms."

Following insertion of a foley catheter, the nurse instructs the unlicensed assistive personnel (UAP) to remove the sterile gloves by inverting one glove into the other. The UAP asks, "Why is that important?" Which response by the nurse is most appropriate?

profuse diaphoresis

The nurse assessing a client who had an elevated temperature 1 hour ago determines that the client is in the crisis phase of fever. What would lead the nurse to this conclusion?

partial care

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?

contact precautions (gown and gloves)

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?

A= Assessment

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into?

"I will rescue clients from harm before doing anything else."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"Only certain members of the health care team can extinguish a fire."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

Class C

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify?

discussing a recent event when a newly-admitted client went into cardiac and respiratory arrest

The nurse manager on a medical unit has scheduled a debriefing session. Which of the following is the most likely subject of this meeting?

the nurse washes at least 1 in (2.5 cm) above the area of contamination if present

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?