Skills questions

The charge nurse confronts a new nurse about not wearing gloves into a client's room. The client is not on transmission-based precautions. How does the new nurse best respond? "I don't think gloves are needed to care for this particular client." "It is not necessary to wear gloves for all client interactions." "The client is not on any precautions for infectious organisms." "Can you show me the hospital policy for when to wear gloves?"

"Can you show me the hospital policy for when to wear gloves?"

The nurse considers applying restraints to an agitated client. Which actions does the nurse take? -"Dim the lights and speak softly about something the client enjoys." -"Ensure the client cannot reach any objects in the room." -"Assess the client for existing injuries to the wrists and hands." -"Call a family member to come and sit with the client."

"Dim the lights and speak softly about something the client enjoys."

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client? -Purchase an exercise treadmill so that you can exercise indoors when the weather is bad." -"Begin walking at least 1 mile (1.6 km) per day around your neighborhood." -"Avoid cardiovascular exercise, as it increases your risk of falling." -"Consult with your health care provider about beginning an exercise program."

-"Consult with your health care provider about beginning an exercise program."

A client with diabetes asks the nurse what should be done for a large callus on the right great toe. What is the best response by the nurse? -"Rub lotion on your callus for 20 minutes and then use a clipper to cut the callus away." -"Soak your foot in warm water for 30 minutes and then gently file the callus." -"You could try an over-the-counter callus remover and then call your health care provider." -"I encourage you to see your podiatrist to get a recommendation for your callus."

-"I encourage you to see your podiatrist to get a recommendation for your callus."

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching? -"I will shave in the direction of hair growth to prevent discomfort." -"I will pull the skin taut to reduce the risk for ingrown hairs." -"I will shave in smooth, short strokes to prevent discomfort." -"I will use warm water and shave cream to soften the hair."

-"I will pull the skin taut to reduce the risk for ingrown hairs."

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse? -"We no longer carry baby powder here because it increases costs and evidence shows it is not effective." -"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow." -"We no longer supply baby powder, but I would be happy to use the powder you brought from home." -"It is recommended to avoid the use of baby powder in the perineal area because it increases the risk for an allergic reaction."

-"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow."

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate? -The patches are probably the result of ineffective brushing. I'll get you a new toothbrush." -"Let me assess the patches. They may indicate the development of a fungal infection." -"Is this the first time you noticed them@f0 These types of patches are a normal finding in most adults." -"What type of milk did you drink during your last meal@f1 These patches often occur after drinking whole milk.

-"Let me assess the patches. They may indicate the development of a fungal infection."

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member? -"Microbial contamination can occur when cleaning the anal area first." -"Change washcloths between the rectal area and the urinary meatus." -"It is best to use disposable personal hygiene cloths for perineal care." -"Urinary tract infections can cause a prolonged hospitalization for the client."

-"Microbial contamination can occur when cleaning the anal area first."

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond? -"Dental care is still important, even when not chewing." -"It is comforting to have moist oral mucosa during this time." -"Mouth care during this time helps prevent complications." -"Without swallowing, bacteria get trapped in the mouth."

-"Mouth care during this time helps prevent complications."

A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? -"Reaching over a sterile field contaminates the sterile field." -"Any items coming into contact with a sterile field must be sterile." -"Turning a back to a sterile field maintains the sterility of the field." -"Items below waist level are considered contaminated."

-"Turning a back to a sterile field maintains the sterility of the field."

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate? -"Use of special bathing products and avoidance of scrubbing help keep your skin intact." -"Can you tell me the name of the person who bathed you this morning? I will review proper bathing procedures with this person." -"When you feel well enough to bathe yourself, we can give you your favorite soap and a big, thick towel." -"It sounds as if you are not happy with the care you are receiving. Would you like me to bathe you again?"

-"Use of special bathing products and avoidance of scrubbing help keep your skin intact."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client? -"Do not get up without assistance for any reason." -"Use the call bell for any needs and wear nonslip footwear." -"You will mostly stay in bed while you are hospitalized." -"It is important to us that you remain free from injury."

-"Use the call bell for any needs and wear nonslip footwear."

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching? -"I will use a special denture cleaner to remove food that does not come off with brushing." -"I will store my dentures in cold water when I sleep." -"When I eat, I will remove my dentures and place them in a napkin." -"I will never place my dentures beside me in bed."

-"When I eat, I will remove my dentures and place them in a napkin."

When obtaining a pulse rate for a client with an irregular heart rhythm, how long does the nurse count? -5 minutes -30 seconds -1 minute -15 seconds

-1 minute

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client? -90oF (32oC) -120oF (49oC) -100oF (38oC) -110oF (43oC)

-100oF (38oC)

A client's apical-radial pulse reveals an apical pulse of 72 beats per minute and a radial pulse of 60 beats per minute. How does the nurse document the pulse deficit? -72 -132 -60 -12

-12

Prior to administering a heart medication, the nurse takes an apical pulse. For how long should the nurse count the pulse? -15 seconds and multiply by 4 -45 seconds and multiply by 2 -60 seconds and multiply by 1 -30 seconds and multiply by 2

-60 seconds and multiply by 1

Over the course of a day, a nurse encounters many different clients whose pulse rates she must measure. For which clients should she measure the apical pulse? Select all that apply. -A healthy 8-year-old girl -A middle-aged woman who has a fever -A client who is on a medication that has dysrhythmia as a side effect -A young, athletic man whose resting heart rate tends to be lower than normal -A young woman who is pregnant -An older adult client, whose pulse when measured peripherally is found to be extremely rapid

-A healthy 8-year-old girl -A client who is on a medication that has dysrhythmia as a side effect -An older adult client, whose pulse when measured peripherally is found to be extremely rapid

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client? -Provide a tub bath with bath oil every day. -Use skin lotion daily and avoid giving bed baths. -Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next. -Provide a full bed bath with soap and water every day.

-Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

The nurse is to assess the pulse rate in an 18-month-old child. Which location provides the most accurate result? -Radial -Brachial -Carotid -Apical

-Apical

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse? -Apply a thin barrier of skin protectant to the perineal area -Apply baby powder the perineal area -Apply betadine ointment to the foreskin and glans penis -Apply antibiotic ointment to the urinary meatus

-Apply a thin barrier of skin protectant to the perineal area

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure? -Place the removed dentures on a paper towel. -Use a rinse to clean the dentures, not a toothbrush and toothpaste. -Store the dentures in a cup filled with mouthwash. -Apply gentle pressure with a piece of gauze to remove the upper dentures.

-Apply gentle pressure with a piece of gauze to remove the upper dentures

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures? -Use sterile gloves to apply gentle pressure and grasp the denture plate. -Apply gentle pressure with gauze to grasp the denture plate. -Apply gentle pressure with a tongue blade to remove the denture plate. -Ask the client to take a deep breath and exhale while grasping the denture plate.

-Apply gentle pressure with gauze to grasp the denture plate.

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse? -Apply pressure with a gauze pad for 2 to 3 minutes. -Apply pressure with a towel to the area for 7 to 8 minutes. -Place a transparent dressing over the cut to enhance visualization. -Rinse the cut with warm water to remove shaving cream.

-Apply pressure with a gauze pad for 2 to 3 minutes.

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client? -Pull the client from side to side. -Use a client hydraulic lift. -Ask for help from a staff member. -Place pillows behind the client's back.

-Ask for help from a staff member.

Which methods can be used to remove a client's soft contact lenses? Select all that apply. -Ask the client to remove them, if able. -Use the pads of the index finger and thumb to gently pinch and remove the lens. -Use two cotton-tipped applicators to gently grasp the lens. -Apply gentle pressure to the lower eyelid until the lens pops out. -Use a commercially available tool with a small suction cup.

-Ask the client to remove them, if able. -Use the pads of the index finger and thumb to gently pinch and remove the lens.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time? -Ask the unlicensed assistive personnel (UAP) to remove the contact lenses. -Assess both eyes for contact lenses. -Contact the health care provider for a prescription to remove the contact lenses. -Contact the client's caregiver and ask if the client wears contacts.

-Assess both eyes for contact lenses.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate? -Assess for the need to urinate. -Raise the side rails. -Administer a prescribed dose of lorazepam. -Contact the health care provider for a prescription to apply a waist restraint.

-Assess for the need to urinate.

When assessing a client's respiratory rate, the nurse should take which action? -Count the number of respirations for 10 seconds. -Remind the client to breathe normally. -Assess immediately after the pulse assessment so the client is unaware of it. -Ask the client to breathe deeply.

-Assess immediately after the pulse assessment so the client is unaware of it.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? -Document the findings. -Assess the apical pulse. -Get another nurse for validation. -Assess the carotid pulse

-Assess the apical pulse.

The nurse is providing care for a newborn who is under the radiant heat warmer. The abdominal skin temperature reads 36.5°C. What should the nurse do next? -Assess if the skin probe is in proper position -Change the temperature setting on the warmer -Assess the baby's temperature -Document as a normal finding

-Assess the baby's temperature

After assisting a bed-bound client with oral care, what action does the nurse take? -Place the supplies on the edge of the overbed table. -Assist the client to a comfortable position in the bed. -Dispose of the used toothbrush, basin, and cups. -Inspect the oral cavity for dryness, erythema, or bleeding

-Assist the client to a comfortable position in the bed.

A client who is wearing soft contact lenses is unable to remove the lenses before bedtime. What action should the nurse take? -Allow the client to sleep with the contact lenses in place. -Assist the client to remove the lenses using a small suction cup. -Contact the health care provider to assist with the removal of the lenses. -Assist the client to remove the lenses using a small pair of rubber grippers.

-Assist the client to remove the lenses using a small pair of rubber grippers.

The nurse is providing nail care to a client. Which assessment findings require notification of the client's health care provider? Select all that apply. -Bleeding under the nail bed and from the sides of the toes -Red and swollen skin around the great toe -Chipped and cracked nail polish present to all toes -Blackened great toe nail -Nails curled around the tip of the toes

-Bleeding under the nail bed and from the sides of the toes

A group of students are reviewing information about taking an apical-radial pulse. Which information is accurate? -It is used routinely for any client with a heart problem. -Both rates are assessed simultaneously. -Each rate is counted over a period of 30 seconds. -It requires a total of three nurses to perform the skill.

-Both rates are assessed simultaneously.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? -Assessing the oral cavity for inflammation -Teaching the client about importance of denture care -Brushing the dentures -Planning when denture care will be implemented

-Brushing the dentures

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing. What action would be appropriate? -Leave the client and the room to obtain the missing item. -Skip the part of the care that requires the missing item. -Call someone to bring in the necessary item to the client's room. -Complete the care right up to the step of the missing item, then go get it.

-Call someone to bring in the necessary item to the client's room.

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate? -Cut the arm of the regular gown and replace it with a snap-arm gown at the end of the bath. -Carefully disconnect the IV tubing from the IV bag and quickly thread it through the arm of the gown. -Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath. -Leave the gown in place, taking care to keep it dry.

-Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath.

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next? -Dispose of the catheter kit and begin again. -Change into a new pair of sterile gloves. -Begin cleansing the meatus with antiseptic. -Position the catheter kit closer to the client.

-Change into a new pair of sterile gloves.

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client? -Change the bed linens from the bottom to the top. -Change the bed linens from the left to the right side. -Change the bed linens from the top to the bottom. -Do not change the bed linens until the client is experiencing less pain.

-Change the bed linens from the top to the bottom.

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take? -Flush cleansing wipes after perineal care is complete. -Alternate wipes with reusable wash cloths. -Use multiple wipes to create a thicker wipe. -Change to a clean wipe after each stroke.

-Change to a clean wipe after each stroke.

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure? -Identify the client. -Provide for privacy. -Check the client's chart. -Perform hand hygiene.

-Check the client's chart.

When preparing a sterile field, which action would be appropriate for the nurse to take first? -Check the packages for expiration date. -Open any sterile items to be used. -Place the work surface at chest height. -Put on sterile gloves.

-Check the packages for expiration date.

What action should the nurse take when changing a sterile dressing on a central venous access device? -Position the sterile dressing supplies on the table between the nurse and client. -Leave the bed in a low position if the side rail will need to be lowered. -Cleanse the central venous access device site while wearing sterile gloves. -Place sterile gloves on before removing the existing dressing.

-Cleanse the central venous access device site while wearing sterile gloves

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? -Clear clutter in the walkways of the new home. -Use the stairs in the new home. -Change the older adult's routine. -Take walks outside.

-Clear clutter in the walkways of the new home.

Which client would require the nurse to obtain an apical-radial pulse? -Client with atrial fibrillation -Client with heart failure -Client with sinus tachycardia -Client with aortic stenosis

-Client with atrial fibrillation

The nurse is preparing a sterile field using a pre-packaged kit. After performing hand hygiene, which action would the nurse take next? -Place the package in the center of the work surface -Confirm the client's identity -Remove the outer wrapper from the kit -Place the work surface at waist height

-Confirm the client's identity

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? -Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. -Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. -Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. -Don a second pair of sterile gloves over the first pair.

-Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply. -Kidney stones -Contractures -Pressure injuries -Falls -Delirium

-Contractures -Pressure injuries -Falls -Delirium

A nurse is assessing a client's respirations and notes that the client's rate is irregular. Which action by the nurse would be most appropriate? -Note the number of times the chest rises and falls in 15 seconds -Have the client cough and then attempt to count the rate -Auscultate the lungs sounds to obtain the respiratory rate -Count the respirations over a period of 1 minute

-Count the respirations over a period of 1 minute

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority? -Preventing deterioration of the oral cavity -Preventing dental caries -Decreasing the incidence of hospital-acquired pneumonia -Promoting the client's sense of well-being

-Decreasing the incidence of hospital-acquired pneumonia

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed? -Fold two bottom linens in half and place one at the top of the bed and one at the bottom. -Pull the clean linens under the client from the bottom to the top of the bed. -Apply the bottom sheet, securing it at the bottom of the bed. -Ease the clean linens under the client, from the top to the bottom of the bed.

-Ease the clean linens under the client, from the top to the bottom of the bed.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply. -Ensure the parent to take naps frequently. -Ensure the parent engages in regular exercise. -Increase the parent's social interaction. -Provide frequent reorientation. -Ensure that the parent's routine changes frequently.

-Ensure the parent engages in regular exercise. -Increase the parent's social interaction. -Provide frequent reorientation.

When providing oral care to an unconscious client, the nurse takes which action? -Have endotracheal suction supplies at the bedside. -Brush the tongue and each tooth surface multiple times -Ensure there is a towel and basin positioned for drainage. -Place the head of the client's bed in high-Fowler's position.

-Ensure there is a towel and basin positioned for drainage.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency? -Every 45 minutes to 1 hour -Every 3 to 4 hours -Every 1 to 2 hours -Every 20 to 30 minutes

-Every 3 to 4 hours

How should the nurse open the bottom sheet when making an unoccupied bed? -Fold in half in the center -Fanfold to the center -Fanfold to the side -Fold in thirds to the side

-Fanfold to the center

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens? -Fold the linens in fourths on the bed and then hang them over a clean chair. -Fold the bedding in half on the bed and then place them at the bottom of the bed -Fold the bedding in fourths on the bed and place them on the overbed table. -With the assistance of another nurse, fold the linens in fourths on the bed and then place them on a clean chair.

-Fold the linens in fourths on the bed and then hang them over a clean chair.

The nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply. -Basin -Gown -Bath blanket -Protective pads -Towels -Linen

-Gown -Bath blanket -Protective pads -Towels -Linen

The nursery nurse is placing a newborn under the radiant warmer. Where should the nurse apply the temperature probe to the baby? -Lower left quadrant of abdomen -Halfway between xiphoid and umbilicus -Lower right quadrant of abdomen -On abdomen below the umbilicus

-Halfway between xiphoid and umbilicus

How would the nurse remove the top linens when making an occupied bed? -Have the client hold onto the bath blanket and reach under it to remove the linens. -Arrange the client's gown for privacy and roll the linens to the bottom of the bed. -Fanfold the linens at the bottom of the bed and remove them to the chair. -Have the client hold onto the bath blanket and reach under it to remove all linens except the top sheet.

-Have the client hold onto the bath blanket and reach under it to remove the linens.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? -Respiratory infection -Health care-associated infection -Sexually transmitted infection -Droplet infection

-Health care-associated infection

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct? -Heat the entire package in the microwave, following the manufacturer's recommendation. -Place the washcloths in warm water, one at a time, in the order they will be used. -Fill the sink with hot water, place the unopened package in the water, and let it soak for at least 10 minutes. -Twenty minutes before beginning the bath, place the unopened package underneath the small of the client's back.

-Heat the entire package in the microwave, following the manufacturer's recommendation.

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply. -Grasp the mattress and shift it down to the foot of the bed. -Place soiled linen on the floor. -Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible. -Place a bath blanket over the client. -Put on gloves before removing soiled linens. -Secure clean top linens under the head of the mattress.

-Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible. -Place a bath blanket over the client. -Put on gloves before removing soiled linens.

What is the best way for the nurse to promote comfort for the client when assessing an apical pulse? -Holding the stethoscope's diaphragm against the palm of the hand for a few seconds -Exposing the chest area at the apical site -Wiping the stethoscope's bell and diaphragm with an alcohol swab -Assisting the client to a sitting or reclining position

-Holding the stethoscope's diaphragm against the palm of the hand for a few seconds

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure? -Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant. -If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. -An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection. -If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

-If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

An overhead radiant warmer has which direct and indirect effects on infants? Select all that apply. -Decreases respiratory rate -Increases blood flow -Minimizes the oxygen and calories that the infant expends -Maintains normal body temperature -Increases heart rate -Increases metabolic activity

-Increases blood flow -Minimizes the oxygen and calories that the infant expends -Maintains normal body temperature

The nurse places the client on a hypothermia blanket to manage the client's temperature. Which action does the nurse take? -Insert a rectal thermometer probe and secure it in place. -Document the client's vital signs once every hour. -Turn the client every 2 hours and as needed. -Ensure all body surface areas are in contact with the cooled surface.

-Insert a rectal thermometer probe and secure it in place

Where should the nurse roll soiled linens when removing them from an unoccupied bed? -Inside the bottom sheet -On the floor -Inside the top sheet -On the bedside table

-Inside the bottom sheet

What action does the nurse perform to remove gloves after performing a sterile procedure? -Place the first removed glove in the waste. -Pull the glove off starting at the fingers. -Lay the first removed glove in the sterile field. -Invert the glove as it is removed.

-Invert the glove as it is removed.

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens? -Keep the blanket in place over the client to provide privacy and remove the top sheet. -Raise the client's legs and roll the linens from the bottom of the bed to the client's buttocks. -Help the client to a supine position in the bed and pull the sheets from the top to the bottom of the bed. -Sit the client up and roll the soiled linens from the top of the bed until they meet the client's backside.

-Keep the blanket in place over the client to provide privacy and remove the top sheet.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? -Compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns. -Grasp the client's inner wrist with the nondominant thumb positioned over the radial artery. -Lightly compress the client's radial artery using the first, second, and third fingers. -Encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands.

-Lightly compress the client's radial artery using the first, second, and third fingers.

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens? -Lying flat -Lying prone -Lying on one side -Sitting up

-Lying on one side

While under the radiant warmer, the infant becomes febrile. What interventions are important for the nurse to provide to keep the infant safe? Select all that apply. -Bundle the baby and place in open crib.- -Maintain the automatic setting on the warmer. -Remove the baby from the warmer and expose to cooler air. -Keep the baby naked. -Administer an antipyretic.

-Maintain the automatic setting on the warmer. -Keep the baby naked.

Which action does the nurse include when measuring the client's pulse deficit? -Count the apical and radial pulse rate simultaneously. -Use the pulse oximetry monitor to measure the radial pulse. -Measure the apical and radial pulse separately. -Palpate the carotid pulse and compare to the radial pulse.

-Measure the apical and radial pulse separately.

The nurse making an occupied bed. Under which body part of the client would the nurse place the drawsheet? -Midsection -Buttocks -Head -Feet

-Midsection

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that wearing contact lenses. What is the priority action by the nurse? -Irrigate the eyes with 0.9% normal saline to aid in removal of the contact lenses. -Remove the contact lenses and place in a storage case marked L and R. -Ask the client to remove the contact lens from the unaffected eye and place in a storage case marked L and R. -Notify the emergency department health care provider the client is wearing contact lenses.

-Notify the emergency department health care provider the client is wearing contact lenses.

While donning sterile gloves for a client's dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action? -Place a new sterile glove over the ripped glove. -Continue with the dressing change. -Obtain a new pair of sterile gloves. -Use the ripped glove for nonsterile actions.

-Obtain a new pair of sterile gloves.

A nurse is preparing a sterile field using a pre-packaged kit. The nurse opens the outside cover and removes the kit, placing it in the center of the work surface. The nurse places the kit so that the topmost flap is positioned in which direction? -Toward the nurse's body -To the left of the nurse -To the right of the client -On the far side of the package

-On the far side of the package

Which are basic principles of surgical asepsis? Select all that apply. -Only a sterile object can touch another sterile object. -Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. -Hold sterile objects at hip level or above. -Forceps soaked in disinfectant can be used to add items to a sterile field. -Avoid talking, coughing, sneezing, or reaching over a sterile field. -Never turn the back on a sterile field

-Only a sterile object can touch another sterile object. -Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. -Avoid talking, coughing, sneezing, or reaching over a sterile field. -Never turn the back on a sterile field

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take? -Obtain a new pair of sterile gloves. -Slide the gloves out of the package. -Reach under the package folds to open. -Open the top and bottom folds completely.

-Open the top and bottom folds completely.

When putting on the second sterile glove, the nurse places the gloved thumb at which location? -Under the fingers, as in a fist -Outward away from the gloved hand -Close to the palm of the gloved hand -Adjacent to the fifth finger

-Outward away from the gloved hand

A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment? -Over the radial artery on the anterior wrist -Over the space between the fifth and sixth ribs on the left midclavicular line -In the center of the upper back -Over the carotid artery in the anterior neck

-Over the space between the fifth and sixth ribs on the left midclavicular line

The nurse would use which part of the hand when assessing the radial pulse? -Tips of the second and third fingers -Palm of the hand -Pads of first, second, and third fingers -Thumb

-Pads of first, second, and third fingers

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? -Palpate both arteries at the same time. -Measure the rate for 1 full minute -Measure the rate for 30 seconds and multiply by 2. -Palpate one artery at a time.

-Palpate one artery at a time.

The nurse has gathered several individually packaged dressings for a sterile dressing change. When adding these dressings to the sterile field, which action would the nurse take? -Tear open the package across the top. -Cut the package open with sterile scissors. -Peel the edges apart with both hands. -Pull the top cover off at an angle.

-Peel the edges apart with both hands.

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best? -Powder in the genital area can create a medium for bacterial growth." -"Evidence states that powder in the genital area causes female cancers." -"It is no longer an acceptable part of perineal care to apply powder to the groin." -"Powder can crumble together and irritate the genital folds causing redness."

-Powder in the genital area can create a medium for bacterial growth."

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action? -Tidy up the client's room -Provide client comfort -Prepare the client to receive visitors -Remove soiled linens

-Provide client comfort

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply. -Provide privacy while the client removes dentures from the mouth. -After cleaning, insert the lower denture followed by the upper denture. -Rinse the dentures with normal saline if the client is dehydrated. -Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. -Use a toothbrush and paste to gently brush all surfaces. -Use a sterile 4 × 4 gauze to remove debris from the gums and mucous membranes.

-Provide privacy while the client removes dentures from the mouth. -Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. -Use a toothbrush and paste to gently brush all surfaces.

A nurse is shaving a male client's face. Which should the nurse do? -Shave against the direction of hair growth, using short strokes. -Pull the skin taut and shave in the direction of hair growth using short strokes. -Pull the skin taut and use short, upward strokes. -Let the skin hang loose and shave in long downward strokes.

-Pull the skin taut and shave in the direction of hair growth using short strokes.

A nurse is having difficulty observing the rise and fall of a client's chest when assessing respirations. Which action would be most appropriate? -Document the rate as unattainable at this time. -Put the stethoscope at the apical site and watch its movement. -Have the client breathe deeply in and out of the mouth. -Ask the client if he or she is having trouble breathing at this time.

-Put the stethoscope at the apical site and watch its movement.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure? -Close curtains around the bed and close the door to the room, if possible. -Place a drain container underneath the drain of the shampoo board. -Raise the bed to elbow height. -Place a protective pad under the client's head and shoulders.

-Raise the bed to elbow height.

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action? -Raise the side rail. -Push the client to the other side of the bed. -Remove the old linens out from under the client. -Move to other side of bed.

-Raise the side rail.

The nurse is preparing the client to use the hypothermia blanket. How does the nurse measure the client's temperature while the blanket is in use? -Rectal temperature every 2 hours -Oral temperature every 2 hours -Rectal probe continuously -Tympanic temperature every hour

-Rectal probe continuously

The nurse notes that a health care provider failed to observe transmission precautions in a client's room and is entering another client's room. What is the nurse's next action? -Ask the charge nurse to speak with the health care provider. -Insist the health care provider observe additional hand hygiene. -Remind the health care provider about the transmission precautions. -Report the health care provider to the unit supervisor or manager.

-Remind the health care provider about the transmission precautions.

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply. -Remove clutter from walkways. -Use a night light. -Avoid climbing on a chair or table to reach items that are too high to reach. -Keep electrical and telephone cords against the wall and out of walkways. -Consider the use of an electronic personal alarm.

-Remove clutter from walkways. -Use a night light. -Avoid climbing on a chair or table to reach items that are too high to reach. -Keep electrical and telephone cords against the wall and out of walkways.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action? -Place the clean bottom sheet in center of bed. -Replace soiled gloves with new ones. -Scrub the mattress with antimicrobial cleaner. -Remove gloves, unless indicated for transmission precautions.

-Remove gloves, unless indicated for transmission precautions.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct? -Fold the antiembolism stockings halfway down to allow assessment of the popliteal pulse. -Leave the antiembolism stockings in place but be sure to remove all wrinkles. -Remove the antiembolism stockings before the bath. -Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings.

-Remove the antiembolism stockings before the bath.

While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse would be most appropriate? -Apply a new pair of sterile gloves over the current ones. -Continue the procedure using only the left gloved hand. -Cover the contaminated glove with a non-sterile disposable glove -Replace the current gloves with a new set of sterile gloves.

-Replace the current gloves with a new set of sterile gloves.

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action? -Retract the foreskin when washing the prepuce of adolescents and older. -Retract the foreskin, wash the area, and allow the foreskin to dry 5 minutes before pulling it back. -Retract the foreskin when washing the prepuce. -Do not retract the foreskin as this may cause edema and tissue injury.

-Retract the foreskin when washing the prepuce of adolescents and older.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct? -Soak the end of the penis in warm water before cleaning the shaft of the penis. -Avoid retraction of the foreskin because injury and scarring could occur. -Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. -Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry, and then replace the foreskin in its original position.

-Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

A nurse is providing nail care for an older adult client. Which actions should the nurse take? Select all that apply. -Leave hangnails alone -Round the tips of the nails in a gentle curve using a file -Cut the nail straight across -Trim the nail far down on the sides -Gently clean under the nails using an orangewood stick -File the nail straight across

-Round the tips of the nails in a gentle curve using a file -Cut the nail straight across -Gently clean under the nails using an orangewood stick -File the nail straight across

The nurse is teaching a client with peripheral vascular disease about foot care. What will be included in the teaching plan? Select all that apply. -Dry feet thoroughly and apply lotion between the toes. -See a podiatrist for treatment for bunions. -Schedule foot exams with podiatrist at least once per year. -Wear appropriate footwear. -Inspect feet once a week and report any problems to the podiatrist for early intervention.

-Schedule foot exams with podiatrist at least once per year.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area? -Scrotum -Shaft -Meatus -Glans penis

-Scrotum

During the time a client is on a hypothermia blanket, the nurse turns and positions the client every 30 to 60 minutes. What assessments will the nurse complete on each turn? Select all that apply. -Neurological assessment -Sensory impairment -Lip and nail bed changes -Facial muscle twitching -Skin color change

-Sensory impairment -Lip and nail bed changes -Skin color change

The nurse has created a sterile field with sterile dressings in preparation for a client's wound care. While getting ready to apply a dressing, the client moves his arm and touches the sterile field. Which action by the nurse would be most appropriate? -Set up an entirely new sterile field. -Ask the client if he touched anything. -Replace any items that moved with new ones. -Add new sterile dressings to the sterile field.

-Set up an entirely new sterile field.

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client? -Supine -Prone -Side-lying -Semi-Fowler's

-Side-lying

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client? -Head of the bed at 45 degrees -Head of the bed at 30 degrees -Head of the bed at 10 degrees -Sitting at the edge of the bed

-Sitting at the edge of the bed

The client has been experiencing very high temperatures that have not responded to antipyretics. Which assessments must the nurse make prior to initiating the use of a hypothermia blanket? Select all that apply. -Skin integrity -Range of motion -Peripheral circulation -Vital signs -Neurological status

-Skin integrity -Peripheral circulation -Vital signs -Neurological status

The nurse has put on one sterile glove and is preparing to put on the other. What is the next step in donning the second glove? -Use the thumb and index finger to grasp the cuff. -Slide the gloved fingers under the cuff of the second glove. -Hold the second glove in the palm of the gloved hand. -Use the fingers to grasp the edges of the cuff of the second glove.

-Slide the gloved fingers under the cuff of the second glove.

A nurse is preparing to give a bed bath to a client. What approach should the nurse take? -Start with the posterior aspect of the body and then move to the anterior aspect. -Start with cleanest areas and end with most soiled areas. -Start with the head and work down the body. -has Start with the most private areas and end with the least private areas.

-Start with cleanest areas and end with most soiled areas.

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? -Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field -Sterile drape positioned with the moisture-proof side facing up -Sterile drape hanging off the work surface -Sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field

-Sterile drape positioned with the moisture-proof side facing up

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client? -Towel -Emesis basin -Toothpaste -Suction toothbrush

-Suction toothbrush

Which includes practices used to render and keep objects and areas free from microorganisms? -Hand hygiene -Clean technique -Surgical asepsis -Medical asepsis

-Surgical asepsis

A nurse assesses a client's respiration and determines that the respiratory rate is 26 breaths per minute and shallow. Which term would the nurse use to document this finding? -Cheyne-Stokes -Hypoventilation -Biot's -Tachypnea

-Tachypnea

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take? -Reach toward the other end of the table and pick up the supplies. -Discard the current sterile field and supplies and begin again. -Prepare a second sterile field to cover the entire table surface. -Take a few steps around the table to pick up the additional supplies.

-Take a few steps around the table to pick up the additional supplies.

The unlicensed assistive personnel (UAP) reports to the nurse that the client's pulse is difficult to feel and is skipping beats. What action should the nurse take? -Take an apical pulse. -Document the findings. -Notify the health care provider. -Auscultate with a doppler.

-Take an apical pulse.

What would be most important to document after shaving a client? -That the chin was nicked with the razor -Type of shaving cream used -That aftershave lotion was applied -Time shaving was completed

-That the chin was nicked with the razor

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse? -The UAP begins cleansing from the pubic bone toward the anus. -The UAP begins cleansing from the anus toward the pubic bone. -The UAP uses a clean portion of the washcloth for each stroke. -The UAP uses a towel to dry the cleaned areas.

-The UAP begins cleansing from the anus toward the pubic bone.

The nurse has delegated contact lens removal to the unlicensed assistive personnel (UAP) for a client in the preoperative area. Which action by the UAP requires intervention by the nurse? -The UAP has placed the storage case on the overbed table. -The UAP has placed the client in a side-lying position. -The UAP is donning clean gloves. -The UAP is using the pads of the thumb and index finger to grasp the lens.

-The UAP has placed the client in a side-lying position.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? -The nurse should bathe the man herself, as he has dementia. -The nurse should call a family member and have him or her bathe the man. -The client should be allowed to complete as much of the bath as he can. -The nurse should have a male nurse bathe the client.

-The client should be allowed to complete as much of the bath as he can.

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client? -The client would like the spouse to assist with shaving. -The client should use an electric razor. -The client prefers shaving gel over shaving cream. -The client likes to shave while in the shower.

-The client should use an electric razor.

The nurse has prepared a sterile field using a pre-packaged kit. Which would be important for the nurse to keep in mind? -Sterile gloves are not needed to obtain any items from the field. -No other sterile items can be added to the sterile field at this point. -The items contained in the kit are considered clean. -The field is contaminated if it is out of the nurse's site.

-The field is contaminated if it is out of the nurse's site.

When opening a pre-packaged kit to prepare a sterile field, which would be important to keep in mind? -The outside surface of the outer wrapper becomes the sterile field. -The edges of the wrapper are positioned to hang below the edges of the work surface. -The inner surface of the outer wrapper is considered sterile. -The outer 2-in (5-cm) border of the wrapper is considered contaminated.

-The inner surface of the outer wrapper is considered sterile.

The nurse is opening a package containing a sterile drape to establish a sterile field. Which occurrence would indicate that the nurse had contaminated the sterile drape? -The nurse allows the drape to touch his or her body. -The nurse touches the sterile drape by its corners. -The nurse places the shiny side of the drape facing down. -The nurse allows the drape to unfold gently.

-The nurse allows the drape to touch his or her body.

The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves? -The nurse touches one glove to the other glove. -The nurse picks up a sterile dressing from the sterile field. -The nurse keeps both hands above waist level. -The nurse touches the client's skin with one hand.

-The nurse touches the client's skin with one hand.

The nurse determines that the sterile field has been contaminated when which action occurs? -The field is above waist level. -A sterile object falls within the 1-in (2.5-cm) border of the field. -The nurse turns his or her back to the field. -The nurse reaches around the sterile field.

-The nurse turns his or her back to the field.

The nurse is planning to use a pre-packaged kit to prepare a sterile field. Which would be of least importance in ensuring the sterility of the kit? -The outer wrapper is disposed in an appropriate receptacle. -The kit is dry. -The expiration date is not yet reached. -The kit is unopened.

-The outer wrapper is disposed in an appropriate receptacle.

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? -The student rolls gloves into each other during removal for disposal in the waste can. -The student uses one gloved hand to grab the outside surface of the other glove. -The student reaches under the glove on one hand to peel the glove off of the other hand. -The student pulls the gloves off starting with the fingertips prior to removal.

-The student pulls the gloves off starting with the fingertips prior to removal.

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client's large abdominal wound. The nurse uses the extra gloves for what purpose? -To be able to change gloves if the wound has copious draining -To remove the existing dressing from the abdominal wound -To use if the first pair of sterile gloves gets contaminated -To leave in the room with additional supplies for the next change

-To use if the first pair of sterile gloves gets contaminated

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct? -Slide one gloved hand under the other glove for removal. -Touch the inside of the gown and pull it away from the torso. -Remove the goggles before removing other equipment. -Remove respirator at the doorway of the client's room.

-Touch the inside of the gown and pull it away from the torso.

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply. -Towel -Emesis basin -Toothpaste -Lip lubricant -Toothbrush -Disposable gloves

-Towel -Emesis basin -Toothpaste -Toothbrush -Disposable gloves

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth? -Twice a day -Three times a day -Once a day -Four times a day

-Twice a day

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy? -Use a clean portion of the washcloth for each stroke. -Uncover only the area being cleaned. -Cleanse from pubic bone to anus. -Identify the client using two identifiers before beginning.

-Uncover only the area being cleaned.

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body? -Underneath the fingernails and toenails -The inner and outer canthus of each eye -Underneath the breasts and in between skin folds -The antecubital fossa and popliteal space

-Underneath the breasts and in between skin folds

When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which action would the nurse take first? -Unfold the top flap away from the body. -Pull the corners of the wrapper back toward the wrist. -Hold the package in the non-dominant hand. -Reach over the package to open the side flaps.

-Unfold the top flap away from the body.

Which modification to bathing should be implemented for a client who is incontinent? -Decrease the frequency of bathing to preserve skin integrity. -Use a topical antiseptic, such as povidone-iodine, in the perineal area. -Use special perineal skin cleansers and moisture barriers. -Perform a full bed bath each time the client has an episode of incontinence

-Use special perineal skin cleansers and moisture barriers.

A client with a history of diabetes is demonstrating nail care to the nurse. Which action by the client requires teaching by the nurse? -Filing the nail straight across and then rounding in a gentle curve -Using a towel to dry between toes -Using a nail clipper to cut the nail straight across -Using a cuticle stick to push cuticles back

-Using a nail clipper to cut the nail straight across

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing? -Drying the hands, then fingers -Using a rubbing, circular motion -Washing to 1 in (2.5 cm) below the elbows -Keeping the hands above the elbows

-Using a rubbing, circular motion

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first? -Warm the cap in the microwave. -Wet the client's hair with water. -Add water to the cap to create a lather. -Apply the cap to the client's head.

-Warm the cap in the microwave.

The health care provider tells the nurse that the desired body temperature for the client is 99.8°F (37.67°C). When does the nurse turn off the blanket? -When the client's temperature reaches 100.8°F (38.22°C). -When the client reports feeling cold and uncomfortable. -When the client reports feeling nauseated and dizzy. -When the client's temperature reaches 99.8°F (37.67°C).

-When the client's temperature reaches 100.8°F (38.22°C).

A nurse is assessing the respirations of a 9-month-old infant. The nurse would obtain the respiratory rate by counting movement of which area? -abdomen -Nostril flaring -Thorax -Shoulders

-abdomen

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client? -every 2 hours -every 4 hours -every 60 minutes -every 30 minutes

-every 60 minutes

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply. -polypharmacy -placing objects in familiar places -ambulation devices -extension cords -clutter

-polypharmacy -extension cords -clutter

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first? -base of the penis -scrotum -anal area -tip of the penis

-tip of the penis

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene? -applying an electronic personal alarm -waiting outside of the closed bathroom door while the client uses the toilet -transferring the client to a room that is in view of the nursing station -placing a "high fall risk" designation on the outside of the client's room

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

The nurse is preparing to measure an adult's radial pulse using a Doppler device. Place the following steps of the procedure in the correct order. Use all options. 1) Apply conducting gel to the site where the pulse will be auscultated. 2) Place the Doppler probe tip in the gel. 3) Maneuver the tip of the Doppler probe over the area until the pulse is heard. 4) Adjust the volume of the device, as needed. 5) Count the number of heartbeats for one full minute. 6) Wipe the gel off of the client's skin.

1) Apply conducting gel to the site where the pulse will be auscultated. 2) Place the Doppler probe tip in the gel. 3) Adjust the volume of the device, as needed. 4) Maneuver the tip of the Doppler probe over the area until the pulse is heard. 5) Count the number of heartbeats for one full minute. 6) Wipe the gel off of the client's skin.

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading? 130oF (54.4oC) 105oF (40.6oC) 98oF (36.7oC) 89oF (31.7oC)

105oF (40.6oC)

An overhead radiant warmer is typically adjusted to keep an infant's anterior abdominal skin at which temperature range? 36°C (96.8°F) to 36.5°C (97.7°F) 36.5°C (97.7°F) to 37°C (98.6°F) 37°C (98.6°F) to 37.5°C (99.5°F) 35.5°C (95.9°F) to 36°C (96.8°F)

36°C (96.8°F) to 36.5°C (97.7°F)

When adding sterile items to a sterile field, the nurse would drop the sterile items from which height? 14 in (35 cm) 10 in (25 cm) 6 in (15 cm) 2 in (5 cm)

6 in (15 cm)

Which item would the nurse remove first when removing personal protective equipment? Mask Gloves Face shield Gown

Gloves

The nurse is required to wear a gown, gloves, goggles, and mask as personal protective equipment (PPE) when caring for an assigned client. What should the nurse put on first? Gloves Mask Goggles Gown

Gown

The nurse prepares to wear personal protective equipment (PPE) when entering a client's room. What action does the nurse take first? Perform hand hygiene. Open the door to the room. Verify the type of precautions. Ensure the gown is closed.

Perform hand hygiene.