Week 4 Fundamentals Success Questions

A nurse educator is evaluating whether a new staff understands the relationship between a fever and an infection. Which statement by the new staff nurse indicates an understanding of this relationship? 1. "Phagocytic cells release pyrogens that stimulate the hypothalamus." 2. "Leukocyte migration precipitates the inflammatory response." 3. "Erythema increases the flow of blood throughout the body." 4. "Pain activates the sympathetic nervous system."

1. "Phagocytic cells release pyrogens that stimulate the hypothalamus."

Which of the following independent and dependent nursing interventions help prevent thrombophlebitis during the postoperative period? Select all that apply. 1. Applying lower extremity sequential compression devices when in bed 2. Wearing antiembolism stockings when out of bed 3. Walking in the hall several times a day 4. Using an incentive spirometer 5. Coughing and deep breathing 6. Keeping the legs uncrossed

1. Applying lower extremity sequential compression devices when in bed 2. Wearing antiembolism stockings when out of bed 3. Walking in the hall several times a day 6. Keeping the legs uncrossed

A school nurse is teaching a class of adolescents about the function of the integumentary system. Which fact about how the skin protects the body against infection is important to include in this discussion? 1. Cells of the skin are constantly being replaced, thereby eliminating external pathogens. 2. Epithelial cells are loosely compacted on skin, providing a barrier against pathogens. 3. Moisture on the skin surface prevents colonization of pathogens. 4. Alkalinity of the skin limits the growth of pathogens.

1. Cells of the skin are constantly being replaced, thereby eliminating external pathogens.

Which is the most common dietary prescription the nurse can anticipate after a client who had abdominal surgery exhibits a return of intestinal peristalsis? 1. Clear liquids 2. Full liquids 3. Low fiber 4. Regular

1. Clear liquids

A nurse is caring for clients with a variety of wounds. Which would will likely heal by primary intention? Select all that apply. 1. Cut in the skin from a kitchen knife 2. Excoriated perianal area 3. Abrasion of the skin 4. Surgical incision 5. Pressure ulcer

1. Cut in the skin from a kitchen knife 4. Surgical incision

A nurse plans to remove a client's wound dressing. The nurse identifies the client, explains the procedure, washes the hands, collects equipment, provides for client privacy, and places the client in an appropriate and comfortable position. Place the following steps in the order in which they should be implemented when removing the soiled dressing. 1. Don clean gloves 2. Pull the tape away from the skin gently 3. Assess the volume, color, and odor of exudate 4. Place the soiled dressing and gloves in a biohazardous waste receptacle 5. Remove the dressing by lifting the edge of the dressing upward and toward the center of the wound 6. Loosen the edges of the tape around the dressing, starting from the outside and moving toward the center of the dressing

1. Don clean gloves 6. Loosen the edges of the tape around the dressing, starting from the outside and moving toward the center of the dressing 2. Pull the tape away from the skin gently 5. Remove the dressing by lifting the edge of the dressing upward and toward the center of the wound 3. Assess the volume, color, and odor of exudate 4. Place the soiled dressing and gloves in a biohazardous waste receptacle

A nurse is caring for a client with a Jackson- Pratt portable wound drainage device. Which should the nurse do when caring for a client with this type of drainage system? Select all that apply. 1. Empty the container and then compress the collection container, close the port, and release hand compression. 2. Wear sterile gloves when emptying the collection container. 3. Keep the collection container below the insertion site. 4. Shorten the length of the tubing by 1 inch daily. 5. Empty the collection container when full. 6. Attach tubing to clothing.

1. Empty the container and then compress the collection container, close the port, and release hand compression. 3. Keep the collection container below the insertion site. 6. Attach tubing to clothing.

A nurse is caring for a client recovering from abdominal surgery. Which nursing action is effective in facilitating ventilation? Select all that apply. 1. Encouraging fluid intake 2. Preventing abdominal distention 3. Positioning in the side-lying position 4. Implementing passive range of motion exercises 5. Ensuring that an incentive spirometer is used every hour when awake

1. Encouraging fluid intake 2. Preventing abdominal distention 5. Ensuring that an incentive spirometer is used every hour when awake

A client is admitted to the ambulatory surgery unit for an elective procedure. When performing a physical assessment, the nurse identifies that the client has Pediculus capitis (head lice). Place the nurse's interventions in the order in which they should be implemented. 1. Establish contact isolation. 2. Comb the hair with a fine-toothed comb. 3. Notify the provider of the client's condition. 4. Obtain a prescription for a pediculicidal shampoo. 5. Wash the client's hair with a pediculicidal shampoo.

1. Establish contact isolation. 3. Notify the provider of the client's condition. 4. Obtain a prescription for a pediculicidal shampoo. 5. Wash the client's hair with a pediculicidal shampoo. 2. Comb the hair with a fine-toothed comb.

A client has a right abdominal incision. What should the nurse teach the client to do when getting out of bed? Select all that apply. 1. Exit from the left side of the bed 2. Ask the nurse to apply an abdominal binder 3. Hold a pillow against the abdomen with both hands 4. Use the left arm to push up to a sitting position on the side of the bed 5. Sit on the side of the bed for a few minutes before moving to a standing position

1. Exit from the left side of the bed 4. Use the left arm to push up to a sitting position on the side of the bed 5. Sit on the side of the bed for a few minutes before moving to a standing position

A nurse is caring for a postoperative client. The client asks the nurse why vitamin C was prescribed by the primary healthcare provider. Which information should be included in response to this question? Select all that apply. 1. Facilitate healing 2. Improves digestive processes 3. Increases transport of oxygen to cells 4. Encourages growth of red blood cells 5. Minimizes formation of deep vein thrombosis

1. Facilitate healing

A nurse is assessing a client who had spinal anesthesia. For which common response should the nurse assess the client? 1. Headache 2. Neuropathy 3. Lower back discomfort 4. Increased blood pressure

1. Headache

Which client information collected by the nurse reflects a systemic response to a wound infection? Select all that apply. 1. Increased body temperature 2. Increased heart rate 3. Leukocytosis 4. Fatigue 5. Chills

1. Increased body temperature 2. Increased heart rate 3. Leukocytosis 4. Fatigue 5. Chills

Which client having emergency surgery should the nurse anticipate to be at the highest risk for postoperative mortality? 1. Individual who has alcoholism 2. Person who has epilepsy 3. Middle-age adult 4. Infant

1. Individual who has alcoholism

A nurse is caring for a postoperative client who had abdominal surgery. The client states, "the incision just felt like it gave way." The nurse identifies that the client had a dehiscence with slight evisceration. Which of the following should the nurse implement? Select all that apply. 1. Instruct the client to avoid coughing or bearing down 2. Notify the primary healthcare provider immediately 3. Position the client on the low Fowler position 4. Cover the incision with a sterile dressing 5. Prepare the client for surgery

1. Instruct the client to avoid coughing or bearing down 2. Notify the primary healthcare provider immediately 3. Position the client on the low Fowler position 4. Cover the incision with a sterile dressing 5. Prepare the client for surgery

Which factor places a client at the highest risk for postoperative nausea and vomiting after receiving general anesthesia? 1. Obesity 2. Inactivity 3. Hypervolemia 4. Unconsciousness

1. Obesity

A nurse is assessing a postoperative client. Which client response identified by the nurse indicates altered renal perfusion? 1. Oliguria 2. Cachexia 3. Yellow sclera 4. Suprapubic distention

1. Oliguria

When brushing a client's hair, the nurse identifies white oval particles attached to the hair behind the ears. Which condition with additional clinical manifestations that support it should lead the nurse to assess the client further? 1. Pediculosis 2. Hirsutism 3. Dandruff 4. Scabies

1. Pediculosis

Which nursing action protects clients from infection at the portal of entry portion of the chain of infection? Select all that apply. 1. Positioning an indwelling urine collection bag below the level of the client's pelvis 2. Using sterile technique when administering an intramuscular injection 3. Enclosing a urine specimen in a biohazardous transport bag 4. Wearing clean gloves when handling a client's excretions 5. Washing the hands after removal of soiled gloves 6. Maintaining a dressing over a surgical incision

1. Positioning an indwelling urine collection bag below the level of the client's pelvis 2. Using sterile technique when administering an intramuscular injection

A postoperative client experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude the client most likely experienced? 1. Pulmonary embolus 2. Hemorrhage 3. Heart attack 4. Pneumonia

1. Pulmonary embolus

A nurse in the postanesthesia care unit at 3 PM receives report from the nurse who is completing the dayshift. The following information about a 65-year-old man who was admitted at 1:30 PM after repair of a double inguinal hernia is reported. Which information does not meet the standard criteria for discharge from the unit? Temperature: 90°F Pulse: 98 bpm Respirations: 30 breaths per minute Blood pressure: 170/90 Abdominal dressing dry and intact, free of complications Urinary catheter draining more than 50 mL per hour Bowel sounds absent 1. Stability of vital signs 2. Level of consciousness 3. Absence of bowel sounds 4. Presence of urinary catheter

1. Stability of vital signs

The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique? Select all that apply. 1. Stool for occult blood 2. Stool for ova and parasites 3. Oropharyngeal mucus for a culture 4. Urine from a retention catheter 5. Exudate from a wound for culture and sensitivity

1. Stool for occult blood 2. Stool for ova and parasites

Which primary defense protects the body from infection? Select all that apply. 1. Tears in the eyes 2. Healthy, intact skin 3. Cilia of respiratory passages 4. Acidity of gastric secretions 5. Dry environment of the epidermis

1. Tears in the eyes 2. Healthy, intact skin 3. Cilia of respiratory passages 4. Acidity of gastric secretions 5. Dry environment of the epidermis

A nurse is caring for two clients. One of the clients has a Jackson-Pratt drain and the other client has a Hemovac drain. Which does the nurse understand is the difference between the two drains? 1. The size of the collection container 2. How the pressure within the collection container is reestablished 3. The type of pressure that promotes drainage to the collection container 4. Where the collection container should be placed in relation to the insertion site

1. The size of the collection container

A nurse is caring for a client who has a prescription for a vacuum-assisted closure device using black foam to facilitate wound healing. The nurse verifies the prescription, explains the procedure, gathers equipment, washes hands, sets a sterile field, and dons sterile gloves. Place the following steps in the order in which they should be implemented. 1. Trim the black foam to the size of the wound cavity 2. Pinch and cut a 2-cm round hole in the center of the transparent film 3. Connect the suction device tubing to the collection canister tubing and pump 4. Place the foam in the wound cavity without overlapping onto the surrounding skin 5. Place the suction device pad over the hole in the film and apply gentle pressure to the suction device pad 6. Apply the transparent film 1 to 2 inches beyond wound edges without stretching or wrinkling the transparent film

1. Trim the black foam to the size of the wound cavity 4. Place the foam in the wound cavity without overlapping onto the surrounding skin 6. Apply the transparent film 1 to 2 inches beyond wound edges without stretching or wrinkling the transparent film 2. Pinch and cut a 2-cm round hole in the center of the transparent film 5. Place the suction device pad over the hole in the film and apply gentle pressure to the suction device pad 3. Connect the suction device tubing to the collection canister tubing and pump

Which should the nurse do to interrupt the transmission link in the chain of infection? 1. Wash the hands before providing care to a client. 2. Position a commode next to a client's bed. 3. Provide education about a balanced diet. 4. Change a dressing when it is soiled.

1. Wash the hands before providing care to a client.

On the second postoperative day after an above-the-knee amputation, the client's elastic dressing accidentally comes off. Which should the nurse do first? 1. Wrap the residual limb with an elastic compression bandage 2. Apply a saline dressing to the residual limb 3. Notify the primary healthcare provider 4. Place two pillows under the limb

1. Wrap the residual limb with an elastic compression bandage

A nurse is teaching a postoperative client about the nutrients that are the best for supporting collagen production that promotes wound healing. Which food selected by the client indicates that the teaching was effective? Select all that apply. 1. Yellow bell peppers 2. Whole-grain bread 3. Cantaloupe 4. Oranges 5. Kiwi

1. Yellow bell peppers 3. Cantaloupe 4. Oranges 5. Kiwi

Which client responses best support the decision to discharge the client from the postanesthesia care unit? 1. saO2 of 95%, vital signs stable for 30 minutes, active gag reflex 2. Tolerable pain, ability to move extremities, dry intact dressing 3. Urinary output of 30 mL/hr, awake, turning from side to side 4.Afebrile, adventitious breath sounds, ability to cough

1. saO2 of 95%, vital signs stable for 30 minutes, active gag reflex

Which client statement indicates that further teaching by the nurse is necessary regarding how to ensure protection from food contamination? Select all that apply. 1. "I should stuff a turkey immediately before putting it in the oven." 2. "I love juicy, rare hamburgers with onion and tomato." 3. "I prefer chicken salad sandwiches with mayonnaise." 4. "I know to spit out food that does not taste good." 5. "I should defrost frozen food in the refrigerator."

2. "I love juicy, rare hamburgers with onion and tomato."

Which nursing action protects clients as susceptible hosts in the chain of infection? Select all that apply. 1. Wearing personal protective equipment 2. Administering childhood immunizations 3. Recapping a used needle before discarding 4. Instituting prescribed immunoglobin therapy 5. Disposing of soiled gloves in a waste container

2. Administering childhood immunizations 4. Instituting prescribed immunoglobin therapy

From which type of isolation precaution is this mask designed to protect the nurse? 1. Contact 2. Airborne 3. Standard 4. Protective

2. Airborne

A nurse compares the advantages and disadvantages of the central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following does the nurse concluded the reason why a peripheral catheter is more desirable? 1. Because it will not be in the superior vena cava 2. Because it will not cause a tension pneumothorax 3. Because it will not prevent the development of infection 4. Because it will not allow large volumes of fluid to be administered

2. Because it will not cause a tension pneumothorax

Which condition places a client at the highest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20 percent of the body 3. Presence of an indwelling urinary catheter 4. More than two puncture sites from laparoscopic surgery

2. Burns over more than 20 percent of the body

A postoperative client is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for a client with the Penrose drain? 1. Removing the excess external portion until drainage stops 2. Changing the soiled dressing carefully 3. Maintaining the negative pressure 4. Pinning the drain to dressing

2. Changing the soiled dressing carefully

A nurse is to apply a transparent wound barrier over a client's incision. Which nursing action is appropriate? 1. Stretch the transparent dressing snugly over the entire wound. 2. Clean the skin with normal saline before applying the dressing. 3. Cover the transparent wound barrier with a gauze dressing and secure with paper tape. 4. Ensure the reinforcing tape extends several inches beyond the edges of the transparent wound barrier.

2. Clean the skin with normal saline before applying the dressing.

A client's stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this client? 1. Droplet 2. Contact 3. Reverse 4. Airborne

2. Contact

A nurse is evaluating the effectiveness of nursing interventions for meeting the nutrition needs of clients during the first two days after abdominal surgery. Which outcome is most important? 1. Nausea and vomiting have not occurred 2. Fluids and electrolytes are balanced 3. Wound healing is progressing 4. Oral intake is reestablished

2. Fluids and electrolytes are balanced

Which is an example of a primary defense that protects the body from infection? Select all that apply. 1. Antibiotic therapy 2. Lysozymes in saliva 3. The low pH of the skin 4. The acidic environment of the vagina 5. Production of mucus by cells in the genitourinary tract

2. Lysozymes in saliva 3. The low pH of the skin 4. The acidic environment of the vagina 5. Production of mucus by cells in the genitourinary tract

There are discharge criteria for clients in the postanesthesisa care unit (PACU) regardless of the type of anesthesia used and additional criteria for specific types of anesthesia. Which is the criterion specific for the client who has received spinal anesthesia? 1. Oxygen saturation reaches the presurgical baseline 2. Motor and sensory function returns 3. Nausea and vomiting are minimal 4. Headache is reported as tolerable

2. Motor and sensory function returns

A client has a wound that is healing by secondary intention. Which solution to cleanse the wound and dressing should the nurse expect will be prescribed to support wound healing? 1. Normal saline and gauze dressing 2. Normal saline and a wet-to-damp gauze dressing 3. Povidone-iodine and a dry sterile dressing 4. Half peroxide and half normal saline and a wet-to-dry dressing

2. Normal saline and a wet-to-damp gauze dressing

A nurse working in a clinic is assessing clients of a variety of ages. Which age group should the nurse particularly assess for subtle clinical manifestations of subclinical infections? 1. Children of school age 2. Older adults 3. Adolescents 4. Infants

2. Older adults

A client tells the nurse, "I think I have an ear infection." For which objective human response to an ear infection should the nurse assess this client? Select all that apply. 1. Throbbing pain 2. Purulent drainage 3. Feeling of pressure 4. Dizziness when moving 5. Hearing a buzzing sound

2. Purulent drainage

A nurse is performing preoperative teaching a week before surgery. The client is taking 650 mg of aspirin twice a day for arthritis. Which instruction should the nurse expect the surgeon to have the nurse include in the preoperative teaching? 1. Continue to take the aspirin indefinitely 2. Stop taking the aspirin five days before surgery 3. Withhold the of aspirin on the morning of surgery 4. Reduce the dose of aspirin 81 mg a day until after surgery

2. Stop taking the aspirin five days before surgery

A nurse identifies that a client has an inflammatory response. Which localized client response supports this conclusion? Select all that apply. 1. Fever 2. Swelling 3. Erythema 4. Bradypnea 5. Tachycardia

2. Swelling 3. Erythema

How many days after surgery should the nurse anticipate that a postoperative client will begin to exhibit signs and symptoms of a wound infection if it should occur? 1. Fifth day 2. Third day 3. Ninth day 4. Seventh day

2. Third day

The client arrives in the postansethesia care unit. Which is the most important information that the nurse to know? 1. Anxiety level before surgery 2. Type and extent of the surgery 3. Type of intravenous fluids administered 4. Special requests that were expressed by the client

2. Type and extent of the surgery

When should the nurse initiate planned interventions regarding a client's perioperative management? 1. When the consent form is signed 2. When the decision for surgery is made 3. When the client is admitted for surgery 4. When the client is transfer to the operating room

2. When the decision for surgery is made

A primary health-care provider prescribes azithromycin for a client with a diagnosis of chronic bronchitis. Which should the nurse teach the client that is important to know about taking azithromycin? Select all that apply. 1. "Take this medication with food." 2. "You can discontinue the medication as soon as you feel better." 3. "Take 500mg on the first day and then 250mg for 4 more days, for a total of 1.5g." 4. The first dose should be taken after we notify you of the results of the culture and sensitivity." 5. "Avoid taking an antacid containing aluminum or magnesium within 2 hours of taking this medication."

3. "Take 500mg on the first day and then 250mg for 4 more days, for a total of 1.5g." 5. "Avoid taking an antacid containing aluminum or magnesium within 2 hours of taking this medication."

A client had a tonsillectomy and is on a soft diet. Which of the following should the nurse encourage this client to have during the first 24 hours after surgery? Select all that apply. 1. Warm pudding 2. Milk shakes 3. Apple juice 4. Ice pops 5. Gelatin

3. Apple juice 4. Ice pops 5. Gelatin

A client received conscious sedation during a colonoscopy. Which should the nurse expect regarding the client's experience with this procedure? 1. Client will be unresponsive and pain-free 2. Client will be at risk for malignant hyperthermia 3. Client will be sleepy but able to follow verbal commands 4. Client will be positioned in the supine position to prevent headache

3. Client will be sleepy but able to follow verbal commands

A nurse is caring for a client with a high fever secondary to septicemia. The primary health-care provider prescribes a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

3. Conduction

A nurse is caring for a postoperative client. Which action is effective in preventing postoperative urinary tract infections? 1. Eating foods within roughage 2. Taking six baths twice per day 3. Drinking an adequate amount of fluid 4. Increasing the intake of citrus fruit juices

3. Drinking an adequate amount of fluid

A client has a wound infection. Which local human response should the nurse expect to identify? Select all that apply. 1. Leukocytosis 2. Malaise 3. Edema 4. Fever 5. Pain

3. Edema 5. Pain

A nurse is caring for a client who has a prescription for shortening a Penrose drain 1 inch daily. The nurse washes the hands, removes the soiled dressing, sets a sterile field, done sterile gloves, and cleans around the drain with sterile saline solution as prescribed. Place the following steps in the order in which they should be implemented by the nurse. 1. Complete dressing the wound 2. Pull the drain out 1 inch, gently and steadily 3. Grip the Penrose drain with a pair of sterile forceps 4. Remove the pin and reattach it to the drain closer to the surface of the wound 5. Cut off the excess drain using sterile scissors, ensuring that 2 inches remain outside the wound

3. Grip the Penrose drain with a pair of sterile forceps 2. Pull the drain out 1 inch, gently and steadily 4. Remove the pin and reattach it to the drain closer to the surface of the wound 5. Cut off the excess drain using sterile scissors, ensuring that 2 inches remain outside the wound 1. Complete dressing the wound

A nurse is caring for a client to have an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? 1. Utilization of compression stockings at night 2. Deep breathing and coughing exercises daily 3. Leg exercises 10 times per hour when awake 4. Elevation of the legs on two pillows

3. Leg exercises 10 times per hour when awake

The clients perineal area must be examined by the primary healthcare provider prior to surgery. In which position should the nurse place the client for the physical assessment? 1. Sims 2. Supine 3. Lithotomy 4. Trendelenburg

3. Lithotomy

A nurse is concerned about a client's ability to withstand exposure to pathogens. Which blood component should the nurse monitor? 1.Platelets 2. Hemoglobin 3. Neutrophils 4. Erythrocytes

3. Neutrophils

Four days after abdominal surgery, while being transferred from her bed to a chair, a client says to a nurse, "my incision feels funny all of a sudden." Which should the nurse do first? 1. Take the vital signs 2. Apply an abdominal binder immediately 3. Place the client in the low Fowler position 4. Encourage slow deep breathing by the client

3. Place the client in the low Fowler position

A nurse is considering the commonalities and differences of equipment used for gastric decompression. Which is the major advantage to using a double lumen tube? 1. Minimizes the risk of bowel obstruction 2. Ensure drainage of the intestines 3. Prevents gastric mucosal damage 4. Promotes gastric rest

3. Prevents gastric mucosal damage

A nurse is to position a client in the postanesthesia care unit. Which factor is most important for the nurse to consider? 1. Allow for skeletal deformites. 2. Prevent pressure on bony prominences. 3. Provide for adequate thoracic expansion. 4. Avoid stretching of neuromuscular tissue.

3. Provide for adequate thoracic expansion.

A nurse is caring for a group of clients experiencing various medical conditions. Which condition places the client at the highest risk for a wound infection? 1. Surgical creation of a colostomy 2. First-degree burn on the back 3. Puncture of the foot by a nail 4. Paper cut on the finger

3. Puncture of the foot by a nail

An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the client? 1. Constipation 2. Urinary retention 3. Shallow breathing 4. Inability to provide self-care

3. Shallow breathing

Which is the most important assessment made by the nurse after ensuring a postoperative client has a patent airway? 1. Condition of the drains 2. Level of consciousness 3. Stability of the vital signs 4. Location of the surgical dressing

3. Stability of the vital signs

Which is the primary reason why the nurse should avoid glued-on artificial nails? 1. They interfere with dexterity of the fingers. 2. They could fall off in a client's bed. 3. They harbor microorganisms. 4. They can scratch a client.

3. They harbor microorganisms.

The nurse is reviewing the clinical record of a newly admitted older adult male client. Which piece of information should cause the most concern? 1. Temperature 103 F 2. Abdominal cramping 3. WBC 30,000 cells/mcL 4. Blood pressure 110/86 mm Hg

3. WBC 30,000 cells/mcL

A client has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative ileus in this client after surgery? 1. Identify the time of the first bowel movement 2. Monitor the tolerance of a clear liquid diet 3. Palpate for abdominal distention 4. Ausculate for bowel sounds

4. Ausculate for bowel sounds

One hour after the reduction of a compound fracture of the ulna and radius and application of the cast, the nurse observes a centimeter of drainage on the client's cast. Which should the nurse do first? 1. Inform the surgeon immediately 2. Reinforce the cast with a gauze dressing 3. Monitor the area frequently for no expansion 4. Circle the spot with a pen and date, time, and initial the area

4. Circle the spot with a pen and date, time, and initial the area

A client has negative pressure wound therapy after the amputation of a toe. The tubing is connected to intermittent negative pressure. What should the nurse do when the film over the wound collapses when negative pressure is exerted? 1. Notify the primary healthcare provider 2. Decrease the extent of negative pressure 3. Apply a new transparent film over the wound 4. Continue to observe the functioning of the device

4. Continue to observe the functioning of the device

Which client condition identified by a nurse is unrelated to infection? 1. Catabolism 2. Hyperglycemia 3. Ketones in urine 4. Decreased metabolic activity

4. Decreased metabolic activity

A nurse is caring for several clients who received general anesthesia. The client with which concurrent health problem poses the highest risk for the development of postoperative complications? 1. Gastroesophageal reflux disease 2. Reduced reflexes 3. Hypothyroidism 4. Emphysema

4. Emphysema

A primary healthcare provider prescribes antiembolism stockings for a client. Place the following steps in order in which they should be implemented when applied. 1. Assess the client for contraindications to use antiembolism stockings 2. Apply the antiembolism stockings before getting the client out of bed in the morning 3. Ensure that the applied stockings are 1 to 2 inches below the popliteal fold in the back of the knee 4. Explain that antiembolism stockings are prescribed by the primary healthcare provider and what is to be done and why 5. Measure the smallest circumference of the ankle, the largest circumference of the calf, and the length from the heal to 1 to 2 inches below the politeal fold in the back of the knee 6. Turn the stocking inside out so that the foot portion is inside the stocking leg, stretch each side of the stocking and ease it over the toes, Center the heel, and pull the stocking over the heal and up the leg

4. Explain that antiembolism stockings are prescribed by the primary healthcare provider and what is to be done and why 1. Assess the client for contraindications to use antiembolism stockings 5. Measure the smallest circumference of the ankle, the largest circumference of the calf, and the length from the heal to 1 to 2 inches below the politeal fold in the back of the knee 2. Apply the antiembolism stockings before getting the client out of bed in the morning 6. Turn the stocking inside out so that the foot portion is inside the stocking leg, stretch each side of the stocking and ease it over the toes, Center the heel, and pull the stocking over the heal and up the leg 3. Ensure that the applied stockings are 1 to 2 inches below the popliteal fold in the back of the knee

A nurse is caring for a group of hospitalized patients. Which should the nurse do first to prevent client infections? 1. Provide small bedside bags to dispose of used tissues. 2. Encourage staff to avoid coughing near clients. 3. Administer antibiotics prescribed. 4. Identify clients at risk.

4. Identify clients at risk.

Which does the nurse determine is a specific line of defense against infection? 1. Mucous membrane of the respiratory tract 2. Urinary tract environment 3. Integumentary response 4. Immune response

4. Immune response

A client spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection? 1. Intestines 2. Bladder 3. Wound 4. Lungs

4. Lungs

A hospitalized client who has been receiving medications via a variety of routes for several days is scheduled for surgery at 10 a.m. What should the nurse plan to do on the day of the surgery? 1. Use an alternative route for the oral medications 2. Withhold all the previously prescribed medications 3. Withhold the oral medications and administer the other drugs 4. Obtain directions from the primary healthcare provider regarding the medications

4. Obtain directions from the primary healthcare provider regarding the medications

A nurse is caring for a client who had abdominal surgery. Which type of incisional drainage should the nurse expect four hours after surgery? 1. Serous wound drainage 2. Purulent wound drainage 3. Sanguineous wound drainage 4. Serosanguineous wound drainage

4. Serosanguineous wound drainage

A nurse is caring for a client with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? 1. Using sterile technique when irrigating the tube 2. Recording intake and output every 2 hours 3. Providing oral hygiene every 4 hours 4. Setting suction at the prescribed level

4. Setting suction at the prescribed level

A client is admitted to the postanesthesia care unit. Which nursing action is most important during the client's stay in this unit? 1. Monitoring urinary output 2. Assessing level of consciousness 3. Ensuring patency of drainage tubes 4. Suctioning mucus from respiratory passages

4. Suctioning mucus from respiratory passages

A nurse is caring for a group of clients with infections. Which infection is classified as a health-care associated infection? 1. Respiratory infection contracted from a visitor 2. Vaginal infection in a postmenopausal woman 3. Urinary tract infection in a client who is sedentary 4. Wound infection caused by unwashed hands of a caregiver

4. Wound infection caused by unwashed hands of a caregiver

A nurse must initiate placement of a continuous passive motion machine after the client had a total knee replacement. Place the following steps in the order in which they should be implemented. 1. Position the extremity on the platform so the knee is centered over the break in the platform 2. Set the degree of flexion, speed, and time on and off the machine as prescribed 3. Ensure the extremity is aligned with the client's hips and torso 4. Assess the client's skin and provide skincare after the procedure 5. Position sheepskin on the platform, especially at the gluteal fold 6. Position the controller within easy reach of the client

5. Position sheepskin on the platform, especially at the gluteal fold 1. Position the extremity on the platform so the knee is centered over the break in the platform 3. Ensure the extremity is aligned with the client's hips and torso 2. Set the degree of flexion, speed, and time on and off the machine as prescribed 6. Position the controller within easy reach of the client 4. Assess the client's skin and provide skincare after the procedure