Quiz 1 Funds

A nurse is assisting a provider with a sterile procedure and prepares to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution. 1. Remove the bottle Cap 2. Place the bottle cap up on a clean surface 3. Pick the bottle with the label facing his palm (prevents from liquid wetting the label) 4. Pour 1 to 2 mL into a receptable 5. Pour the solution onto the gauze

*

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? A. Gloves B. Gown C. face shield D. Mask

A

A nurse in an emergency deprartment is caring for an infant who has a 2 day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. Body weight B. Skin integrity C. Blood pressure D. Respiratory rate

A

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findsings should the nurse expect? A. Lethargy B. High grade fever C. Weight gain D. Dry cough

A

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute B. Assess the apical pulse with a Doppler device C. Assess the pedal pulses for a full minute D. Assess the pedal pulses with a Doppler device

A

A nurse is caring for for a client who is in preterm labor at 32 weeks of gestation. the client asks the nurse, "Will my bay be okay?" Which of the following responses should the nurse offer? A. You must be feeling scared and powerless B. Everyone worries about her baby when she's in labor C. Your pregnancy is advanced so your baby should be fine D. We have a neonatal unit here that's equipped to handle emergencies

A

A nurse is measuring a clients oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? A. Wait 30 mins and return to measure the oral temperature B. Provide the client a sip of warm water, wait 5 min, and measure the temperature C. Document that the nurse was unable to measure the client temperature D. Proceed to measure the oral temperature

A

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? A. I will call for pain medication before the previous dose wears off B. I will call for pain medication as my pain starts to increase again C. I will wait for you to evaluate m pain before asking for more medication D. I will ask for less medication to avoid addiction

A

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the AP's indicates a need for further teaching? A. As long as I change gloves between patients, it is not neccessary to wash my hands B. I should wash my hands before I provide client care C. I will not wear artifice nails when providing care D. It is acceptable to use alcohol based products after most client contact

A

A nurse is teaching a client about how to use a patient-controlled analgesia (CA) pump. Which of the following instructions should the nurse include in the teaching? A. Use the pain scale to determine if you need to self-administer B. Ask a family member to push the patient-control button when the client is sleeping C. There is a 30 minute lock out limit programmed on your PCA pump D. Several bolts doses are infused if the button is pushed repeatedly within a 5 o 10 minute timeframe before lock out

A

A nurse receives report about assigned clients at the start of the shift. Which of the following client should the nurse plan to see first? A. A client who experienced a cesarean birth 4 hr ago and reports pain B. A client who has pre-eclampsia with a BP of 138/90mm Hg C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding D. A client who is scheduled for discharge following a laparoscopic tubal ligation

A

An assistive persinnel (AP) reports a clients vital signs as tympanic temp (98.8) pulse 92 min , RR 18 min, BP 95/58 mm Hg. Which of the following vital signs should the nurse re-measure? A. BP B. RR C. Pulse rate D. Temp

A

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply) A. offer the client a back rub B. Remind the client to use incisional splinting C. Identify the clients pain level D. Assist the client to ambulated E. hange the client position

A, B ,C, E

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) A. Night sweats B. Low grade fever C. Weight gain D. Flushed cheeks E. Blood in the sputum

A, B, E

A nurse is caring for a client within the intimate zone of the client's personal Spence. The nurse should perform which of the following activities in this space? (Select all that apply) A. Auscultations heart sounds B. Teaching about a medication C. Changing a dressing D. Discussing intake and output E. Taking with the client's partner

A, C

A client who lost his belongings in a hurricane says. Why should i start over? It will probably happen again anyway. Which of the following responses should the nurse make? A. I am sure everything will workout B. It appears that you are feeling hopeless C. It is probably not as bad as you think D. I would not worry about what you cant change

B

A nurse accidentally sticks her hand with a syringe needle after administration an IM injection to a client. Which of the following actions should the nurse take first? A. Report the incident to the charge nurse B. Wash the area of the puncture thoroughly with soap and water C. Complete an incident report D. Go to employee health services

B

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? A. Ask the x-ray tech to come to the clients room to obtain a portable x-ray B. Have the client wear a mask C. Notify the x-ray department that the client requires airborne precautions D. Wear a filtration mask and gloves during the transport

B

A nurse is caring for a client who has shingles with multiple skin leasions. Which of the following actions by the nurse require intervention by the nurse's supervisor? A. The nurse wears an N95 respirator mask B. The nurse admits another client who has shingles to the client's double room C. Thee nurse wears gloves when providing ire to care to the client D. the nurse wears a gown when bathing the client

B

A nurse is caring for a toddler. Which of the statements should the nurse use when preparing to obtain the child's vital signs? A. Can I listen to your lungs? B. I am going to listen to your heart C. I am going to take your blood pressure now D. Can you stand very still while I feel how warm you are?

B

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the irking phase of a therapeutic relationship? A. Determine the reason the client sought care B. Instruct the client about methods to achieve goals C. Discuss the client's new skill sets D. Review the clients demographic information

B

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene? A. Positions the wrapped package not he bedside table so the outer flap is away from her B. Holds. Bottle of solution with the label away from the palm of the hand C. Holds gauze packages 15 cm (6 in) above the sterile field D. Wears sterile gloves when moving sterile on the sterile field

B

A nurse is obtaining vital signs from 2 month old infant. The infants heart rate is 190/min And his temperature is 40 C (104 F). The father asks the nurse why the infants heart is beating so fast. Which of the following responses by the nurse is appropriate? A. This is within the expected range for your baby B. The fever is causing an increase in your baby's heart rate C. As your baby begins to fall asleep, his heart rate will decrease D. Your abby's heart is beating fast in an attempt to cool down his body

B

A nurse is performing a pain Assesment for a client who is alert. The nurse should recognize that which of the following measure is the most reliable indicator of pain? A. Vital signs B. self-report of pain C. Severity of condition D. Nonverbal behavior

B

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? A. Place the pack on a sterile work force B. Reach around the pack and open the top flap away from the body C. Open the right flap with the left hand D. Move to the opposite side of the pack to open the fourth flap

B

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust the water temperature to feel hot B. Apply 4 to 5 mL of liquid soap to the hands C. Hold the hands higher than the elbows D. Rub hands and arms to dry

B

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instructions? A. Wraps the blood pressure cuff snugly around the client's arm B. Places the client's arm above the level of the client's heart C. Checks the instrument gauge to ensure the reading starts at zero D. Centers the cuff bladder over the clients brachial artery

B

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. If you wear gloves, you do not have to wash our hands B. Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds C. Use an alcohol rub when your hands are visibly soiled D. If you don't have an infection, your hands wont infect others

B

A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, " Go away; no one can help me." Which of the following responses should the nurse make? A. Everything will be okay B. I will come back later and we can talk C. Why are you crying? D. Do you think crying will help?

B

Nurse caring for a client who ha an infected wound removes a dressing saturated with blood and prudent drainage. how should the nurse dispose of the dressing material? A. Discard the dressing in the bedside trash receptacle B. Dispose of the dressing in a biohazard waste container C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash D. Double bag the dressing in clear bags and label it

B

a nurse is caring for a client who requires removal of surgical sutures. Which of the following actions should the nurse take? A. Remove sutures by starting in the middle of the wound and working outward B. Cut sutures as close to the skin as possible C. Remove the sutures using clean bandages scissors D. Apply clean gloves prior to beginning the suture removal

B

a nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understand the instructions? A. I will wear gloves whenever i am in contact with clients B. I will wear gloves and a gow when bathing a client who has open skin lesions C. I will wear gloves to minimie the number of times i have to wash my hands D. I will wear gloves when measuring a clients blood pressure

B

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply) A. Use of analgesics will eventually lead to addiction B. Each clients expression of pain may be different and individual C. Patient-controlled analgesic (PCA) offers a constant level of opioids within therapeutic D. Pain level and pain tolerance can be assess using a scale from 0 to 10 E. The client will express the feeling of pain both verbally and non verbally

B, C, D

A nurse is planning care for a group of clients. The nurse should delegate obtaining vital signs to an assistive personnel for which of the following clients? (Select all that apply) A. A middle adult client who as status asthmaticus B. An older adult client who has a history of heart failure and is ready to discharge C. A young adult who is 24 hr postoperative following an appendectomy D. An older adult client who is 36 hr postoperative from a traditional cholecystectomy E. A young adult client receiving a continuous IV infusion of regular insulin for diabetic keto acidosis

B, C, D

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. Inspecting the site for reduced swelling B. Monitoring the client's pulse rate C. Asking the client to rate the pain D. Having the client perform range-of-motion of the affected arm

C

A nurse is caring for a client who has methicillin resistant Staphylococcus aureus (MRSA) in an abdominal wound. the nurse enters the room to check the clients pulse. Which of the following actions should the nurse take? A. Wear an N95 respirator mask B. Wear sterile gloves C. Wear clean gloves D. wear protective eyewear

C

A nurse is caring for a client who is HIV positive and i one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? A. Talking to the client at the bedside B. Administering an intermittent IV Bolus medication C. Completing a dressing change D. Administering an IM injection

C

A nurse is caring for a client who is using a patient -controlled analgesia (PCA) pump for a postoperative pain management. The nurse enters the room to ding the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make? A. Next time you think he needs more medication, call me and I'll push the button B. It's a good idea to help make sure your husband can sleep comfortably C. Why do you think your husband needs more medication D. Your husband should decide when more medication is needed

C

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client B. Administer the medication C. Determine the location of the pain D. Review the effects of the pain medication

C

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I dot think I can tell them I have this kind of infection. Which of the following responses should the nurse make? A. Give your parents a chance; they'll understand B. If you want me to, I can tell your parents for you C. You seem scared to talk to your parents D. Your parents will have to be told why you are being admitted

C

A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan? A. Initiate standard precaution B. Initiate airborne precautions C. Initiate droplet precaution D. Initiate contact precaution

C

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? A. Hold gauze packages 7.6 cm (3 in) border of the sterile field B. Place sterile supplies within the 2.54 cm (1 in) in border of the sterile field C. Use sterile forceps to move the sterile items on the sterile field D. Position the warapped package on the bedside table so the outer flap opens toward her

C

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? A. Placing a sterile dressing 5 cm (2 in) from the border of the sterile field B. holding a sterile item at just above the waist level C. Opening a sterile package over the middle of the sterile field D. Opening the sterile tray by first unfolding the flap farthest from his body

C

A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include? A. Return any fresh linen not used for a client to the linen supply area B. Use double bagging to remove soiled linen from the client's room C. Tie linen bags securely at the top D. Fill linen bags with as much soiled linen as possible

C

A clinical nurse educator is preparing an educational program about transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program? A. Place clients who have MRSA on airborne precautions B. MRSA can be effectively treated with an antiviral medication C. MRSA can live on the hand for 1 hr D. Bathe clients with warm water and chlorhexidine gluconate

D

A nurse in a long term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the priciples of infection control? A. Shakes the soiled linen to remove any toilet paper remains B. Places the soiled linen on the floor before bagging it C. Holds the soiled linen against her body while carrying it to the linen bag D. PLaces clean linen that touched the floor in the soiled linen bag

D

A nurse is a caring for a 6 month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure? A. Decreased heart rate B. Decreased respiratory rate C. Increased formula consumption D. Increased crying episodes

D

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects? A. Diarrhea B. Heartburn C. Hiccups D. Orthostatic hypotension

D

A nurse is admitting a client who has TB and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? A. Contact B. Droplet C. Protective D. Airborne

D

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. Pulse and blood pressure B. Behavioral indicators and effort C. Scheduled treatments and client illness D. A self-report pain rating scale

D

A nurse is preparing a client for a hip arthoplasty. for which of the following reasons should the nurse assess the client's vital signs? A. To prevent postoperative hypotension B. To determine how the client will tolerate the procedure C. To assess the clients pain level D. To establish a baseline for postoperative assessment

D

A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching? A. I will apply elastic bandages to cuts B. I will use dishwashing gloves when cleaning the dishes C. I will buy balloons for my sons birthday D. I will use unk pens for writing

D

A nurse is teaching a client who had a total knee arthoplasty about self-administering morphine via a patient-controlled (PCA) infusion device. Which of the following clients statements indicates an understanding of the teaching? A. I should only use the device when it's absolutely necessary B. I will ask my family to push the dose button when i am sleeping C. I'll be careful about pushing the button so I don't overdose D. I should tell the ruse if i can't control my pain with this device

D

A nurse is teaching a client who has a new prescription for codpiece. Which of the following instructions should the nurse include in the teaching? A. You should take the medication on an empty stomach to prevent nausea B. You should limit the alcohol intake to 12 ounces daily C. You should expect to experience diarrhea while taking this medication D. You should change positions slowly

D

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during the client care? A.Properly disposing of contaminated equipment B. Discarding used syringes in appropriate containers C. Changing soiled linens daily for clients who have draining wounds D. Performing hand hygiene frequently and consistently

D

PPE Removal Sequence

Perform hand hygiene 1. Gloves 2. eyewear 3. Gown 4. Face mask