test 4
The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?
"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."
You are caring for a patient who has an infection spread by respiratory droplets and is in Droplet Precautions. The patient asks, "Can my spouse visit me?" Which of the following responses is correct?
"Yes, as long as your spouse wears a mask and stays at least 3 feet away from you."
Types of drainage
* Purulent - pus * Serous - clear * Serosanguineous - yellowish with small amounts of blood * Sanguineous - red
A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
A commercially packaged surgical item is not considered sterile if past expiration date.
A nurse is preparing an operation theater for a surgical procedure. Which of the following points regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
A commercially packaged surgical item is not considered sterile if past expiry date.
For which of the following patients is foot care likely the highest priority?
A patient who is obese and has a diagnosis of type 1 diabetes
You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately?
A sterile, flexible applicator moistened with saline
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
AIRBORNE
A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development?
Albumin 2.8 mg/dL
A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development?
Braden scale
When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?
Discard the bottle and get a new one because the saline has expired.
To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?
Do you experience incontinence
The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take?
Drop the item from 6 in (15 cm) above the sterile field.
To eliminate needlesticks as potential hazards to nurses, the nurse should
Immediately deposit uncapped needles into puncture-proof plastic container
During range-of-motion exercises, the nurse turns the sole of a patient's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions?
Inversion and eversion of the ankle
A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?
Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.
When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?
Off-load pressure from the heel.
A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of which of the following?
Pediculosis
A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task?
Pour the solution from a height of 4 to 6 in (10 to 15 cm)
Which of the following is an indication for the use of negative pressure wound therapy?
Pressure ulcers
A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action?
Removing dead or infected tissue to promote wound healing
The nurse is performing range-of-motion exercises on a patient's arm. The nurse starts by lifting the arm forward to above the head of the patient. Which action would the nurse perform next?
Return the arm to the starting position at the side of the body.
The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents?
Teaching nurses how to prevent falls
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?
The hospital must bear any costs incurred for treating the client's injury.
A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?
The nurse is caring for a client with a C. difficile infection.
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should
Understand that his culture may influence his hygiene and ask him his preference
Which of the following modifications to bathing should be implemented for a patient who is incontinent?
Use special perineal skin cleaners and moisture barriers.
Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?
adolescents
The nurse would recognize which of the following patients as being particularly susceptible to impaired wound healing?
an obese woman with type 1 diabetes
An 18-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following?
automobile accidents
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?
backrub before bed
The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?
biohazards
A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be which of the following?
client will participate in self care measures by the end of week
A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?
glossitis
Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?
gown and gloves
When educating families on fire safety in the home, which information is important for the nurse to emphasize?
have a meeting place outside in case of fire
A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?
hold sterile items above waist
The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select?
hydrocolloid
A nurse is taking stock of the equipment in the room of an elderly client with pneumonia who has been on parenteral nutrition for a long time. Which of the following equipment can transmit infection to elderly clients?
indwelling catheter
A nurse working in a long-term care facility institutes interventions to prevent falls in the elderly population. Which intervention would be an appropriate alternative to the use of restraints for ensuring patient safety and preventing falls?
involve a family member
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?
noncommunicable disease
A patient has been recently admitted to the hospital unit following a suspected stroke and a family member states that the patient's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the patient's lenses after removal?
normal saline
During morning care, the nurse notices a glasslike appearance to the patient's eyes and prepares to perform eye care. What solution should the nurse use to perform basic eye care to remove the excessive secretions related to illness?
normal saline solution
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?
nurse keeps fingernails less than 1/4 inch
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?
nurse should question the client about source of bruises
Any microorganism capable of disrupting normal physiologic body processes is a:
pathogen
The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces?
patient in a chair who slides down
The nurse would recognize which of these devices as an open drainage system?
penrose drain
Which of the following health problems is most clearly suggestive of a history of inadequate dental care?
periodontitis
The nurse is caring for a client with a latex sensitivity. Which of the following resources would be the most appropriate for the nurse to access when developing the client's plan of care?
policy for clients with latex sensitivity
An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following?
recapping a. needle
The nurse on a medical surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. Which of the following should be the nurse's first action?
remove client from room
The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?
review current infection rate protocols
After changing the bed linens for a client, the nurse uses an alcohol-based handrub to perform hand antisepsis. What is the proper way to use an alcohol-based handrub?
rub product between hands until they dry
A client has sexual intercourse with someone infected with HIV. The vehicle of transmission is
semen
A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?
stage II
Which action should the nurse perform first after an exposure to a client's body fluids?
wash exposed area with soap and water
When is hand hygiene with an alcohol-based rub appropriate as opposed to using handwashing?
when hands are not visibly soiled
