NURSE 105

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225 terms · final prep

1. The nurse knows that the primary reason for appropriate hand washing is to:

1. Remove all microorganisms from the "care giver's" hands.

2. Control the transmission of infectious microorganisms.

3. Provide a protective antimicrobial skin barrier on the "care giver's" hands.

4. Minimize the possible transfer of microorganisms from patient to care giver.

2. control the transmission of infections microorganisms

2. An antiseptic hand rub may be effectively used when the hands:

1. Exhibit dry, cracked skin.

2. Are not visibly contaminated.

3. Are sensitive to antimicrobial soap.

4. Have been exposed to a protein-based contaminate.

2. Are not visibly contaminated

3. The nurse is discussing the guidelines for proper hand washing with assistive personnel.

Which of the following statements made by the assistive personnel requires follow-up by the nurse?

1. "I always wash my hands when entering a patient's room."

2. "To prevent dry skin I apply lotion each time I wash my hands."

3. "It takes at least 15 seconds of scrubbing to wash hands properly."

4. "Like I tell the new personnel, when in doubt—wash your hands."

2. To prevent dry skin i apply lotion each time i wash my hands

4. The nurse is discussing the need for proper hand washing with assistive personnel. Which of the following patients is at greatest susceptibility to infection?

1. A patient receiving chemotherapy for lung cancer

2. A patient who experienced a myocardial infarction 3 days ago

3. A patient who fractured his ankle from a fall caused when he became dizzy

4. A patient who is scheduled for exploratory abdominal surgery in the morningction 3 days ago

1. A patient receiving chemotherapy for lung cancer

5. When using an alcohol-based, waterless, antiseptic hand rub, it is necessary to:

1. Rinse hands with warm, running water.

2. Continue to rub hands together until completely dry.

3. Apply moisturizing lotion to prevent skin dryness.

4. Keep fingernails closely trimmed to prevent bacteria growth.

2. Continue to rub hands together until completely dry

1. The nurse is caring for a patient with vancomycin-resistant enterococcus (VRE). The nurse should realize that the primary reason that equipment used in delivering nursing care remains in the patient's room is to:

1. Improve personnel safety in the health care environment.

2. Conform with institutional policies and procedures related to infection control.

3. Prevent exposure to and transmission of infectious organisms based on the type of contact expected.

4. Comply with OSHA and CDC regulations and recommendations regarding personal protective equipment (PPE).

3. Prevent exposure to and transmission of infectious organisms based on the type of contact.

2. To ensure the effective application of the PPE being used in patient care requiring contact precautions, the nurse should:

1. Perform hand hygiene before donning gloves.

2. Tie the top strings first when applying a mask.

3. Apply eyewear and goggles snugly around the eyes.

4. Clean the diaphragm of a stethoscope with 70% alcohol.

1. Perform hand hygiene before donning gloves.

3. The nurse is discussing the guidelines for proper use of PPE by assistive personnel. Which of the following statements made by the assistive personnel requires follow-up by the nurse?

1. "Like I tell the new personnel, when in doubt, wear gloves."

2. "I really dislike wearing a mask, so it's the first thing I take off."

3. "I always wash my hands when entering and leaving a patient's room."

4. "I wear a mask whenever I am caring for a patient who is coughing."

2. I really dislike wearing a mas, so it's the first thing i take off.`

4. The nurse should prepare to wear a fit-tested respirator or mask under which circumstances?

1. If exposure to bodily fluids is likely

2. Anytime a gown and cap are called for

3. When there is a risk of exposure to an airborne infectious agent

4. If you need to assess areas of the patient's body that show signs of edema

3. When there is a risk of exposure to an airborne infectious agent

5. When delegating patient care that requires the use of PPE by assistive personnel, it is necessary to:

1. Review the type of isolation precautions required.

2. Document that the care was delegated to assistive personnel.

3. Assess the patient's need for a specific type of isolation precaution.

4. Observe the assistive personnel appropriately donning the required PPE.

1. Review the type of isolation precautions required.

1. During the admissions process, the nurse initially assesses the patient's temperature primarily for the purpose of:

1. Clarifying the patient's need for a private room.

2. Determining the presence of generalized infection.

3. Providing a baseline as part of the patient's vital signs.

4. Assessing the patient for the risk of infection transmission.

3. Providing a baseline as part of the patient's vital signs.

2. Which of the following statements provides essential information when instructing assistive personnel in the appropriate use of an electronic thermometer to monitor the patient's rectal temperature?

1. "Place the patient in the side-lying Sims' position."

2. "Be sure to wear treatment gloves during the process."

3. "Flexing the upper leg makes insertion of the probe easier."

4. "The red-tip probe should be stored with the thermometer."

1. Place the patient in the side-lying Sims' position.

3. Which of the following statements made by the nurse will be most effective in instructing

ancillary staff regarding the appropriate manner in which to monitor the patient's oral temperature using an electronic thermometer?

1. "Be sure the patient is not a mouth breather."

2. "Place the probe properly in the posterior sublingual pocket."

3. "Instruct the patient to close his or her lips tightly around the probe."

4. "The blue-tip probe should be already attached to the thermometer."

2. Place the probe properly in the posterior sublingual pocket.

4. Which of the following statements made by ancillary staff assigned to measure the rectal temperature of an elderly patient with an electronic thermometer shows the best understanding of the importance of communicating the patient's reactions to the intervention with the nurse?

1. "She needs help getting into a side-lying position."

2. "The patient's hemorrhoids are painful and swollen."

3. "She has been incontinent of both urine and feces."

4. "Her temperature was 0.2F higher than it was the last time."

2. The patient's hemorrhoids are painful and swollen

5. The nurse can best determine the effect of an oral antipyretic provided for an oral temperature of 101.6F by assessing the:

1. Patient for reports of physical aching.

2. Patient's skin temperature by physical touch.

3. Patient's oral temperature again in 30 minutes.

4. Patient's skin color for signs of fever-related flushing.

3. Patients oral temperature again in 30 minutes

1. During the admissions process, the nurse initially assesses the patient's temperature primarily for the purpose of:

1. Clarifying the patient's need for a private room.

2. Determining the presence of generalized infection.

3. Providing a baseline as part of the patient's vital signs.

4. Assessing the patient for the risk of infection transmission.

3. Providing a baseline as part of the patient's vital signs.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff regarding the appropriate technique for monitoring the adult patient's tympanic temperature using an electronic thermometer?

1. "Make sure to leave the probe in place until the reading is complete."

2. "Don't forget to put a new disposable probe cover on for each patient."

3. "Gently tug the pinna back, up, and out before inserting the probe."

4. "Look and see if you can see any impacted cerumen in the ear."

3. Gently tug the pinna back, up and out before inserting the probe.

3. Which of the following actions will have the greatest effect on minimizing the patient's risk of infection during the measurement of her temperature tympanically?

1. Replacing the disposable probe cover between each patient

2. Being careful to snugly fit the probe into the outer ear canal

3. Wearing treatment gloves when measuring the temperature tympanically

4. Cleansing the ear pinna with warm soapy water before inserting the probe

1. Replacing the disposable probe cover between each patient

4. Which of the following statements made by ancillary staff assigned to measure the tympanic temperature of an elderly patient with an electronic thermometer shows the best understanding of the importance of communicating the patient's reactions to the intervention with the nurse?

1. "She told me that her left ear is sore when I touched it."

2. "I recorded the patient's temperature on the flow sheet as you asked."

3. "Her temperature was 1.2F higher than it was the last time I took it."

4. "Her temperature is usually higher at dinner time than it is at breakfast."

Her temperature was 1.2 F higher than it was the last time i took it.

5. The nurse can best determine the effect of an oral antipyretic provided for a tympanic

temperature of 101.6F by assessing the:

1. Patient for reports of physical aching.

2. Patient's skin temperature by physical touch.

3. Patient's oral temperature again in 30 minutes.

4. Patient's skin color for signs of fever-related flushing.

3, Patient's oral temperature again in 30 minutes

1. During the admissions process, the nurse initially assesses the patient's radial pulse primarily for the purpose of:

1. Assessing peripheral blood perfusion.

2. Providing a baseline as part of the patient's vital signs.

3. Assessing the patient for the risk of cardiovascular disease.

4. Determining the rate, rhythm, and strength of cardiac contractions.

2. Providing a baseline as part of the patient's vital signs.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff regarding the appropriate technique for monitoring the adult patient's radial pulse?

1. "Make sure the patient is comfortable before measuring the pulse."

2. "Bend the patient's elbow 90 degrees, and then support her forearm well."

3. "Remember to document whether the patient's pulse is bounding or thready."

4. "Palpate the patient's inner wrist on the thumb side with your two middle fingers."

4. "Palpate the patient's inner wrist on the thumb side with your two middle fingers."

3. Which of the following actions would have priority when determining that the radial pulse has an irregular rhythm?

1. Reassess the pulse for a full minute.

2. Assess the patient for a pulse deficit.

3. Wait 5 minutes and reassess the radial pulse.

4. Review documentation regarding an irregular rhythm.

2. Assess the patient for a pulse deficit..

4. Which of the following statements made by ancillary staff assigned to measure the radial pulse of an elderly patient shows the best understanding of the importance of communicating the patient's reactions to the intervention with the nurse?

1. "She told me that her right pulse is always weaker than her left."

2. "I recorded the patient's radial pulse on the flow sheet as you asked."

3. "Her radial pulse was four beats faster than it was the last time I took it."

4. "Her radial pulse is usually slower in the morning than it is in the afternoon."

1. "She told me that her right pulse is always weaker than her left

5. The nurse can best determine the effect of exercise on a patient's radial pulse by:

1. Measuring the patient's radial pulse before and after exercise.

2. Assessing the patient's radial pulse 30 minutes after exercise.

3. Comparing the patient's radial and apical pulses after exercise.

4. Comparing the patient's pre-exercise radial and post-exercise apical pulses.

1. Measuring the patient's radial pulse before and after exercise.

1. During the admissions process, the nurse initially assesses the patient's apical pulse primarily for the purpose of:

1. Assessing the patient's cardiac function.

2. Providing a baseline as part of the patient's vital signs.

3. Assessing the patient for the risk of cardiovascular disease.

4. Determining the rate, rhythm, and strength of cardiac contractions.

2. Providing a baseline as part of the patient's vital signs

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff regarding the appropriate technique for monitoring the adult patient's apical pulse?

1. "Remember to document the patient's pulse rate and rhythm."

2. "Make sure the patient is comfortable before measuring the pulse."

3. "Please review the patient's previous apical pulse measurements."

4. "Place your stethoscope at the fifth intercostal space over midclavicle."

4. Place your stethescope at the fifth intercostal space over midclavicle

3. Which of the following actions would have priority when determining that the apical pulse has an irregular rhythm?

1. Reassess the pulse for a full minute.

2. Assess the patient for a pulse deficit.

3. Wait 5 minutes and reassess the apical pulse.

4. Review documentation regarding an irregular rhythm.

2. Assess the patient for a pulse deficit

4. Which of the following statements made by ancillary staff assigned to measure the apical pulse of an elderly patient shows the best understanding of the importance of communicating the patient's reactions to the intervention with the nurse?

1. "I recorded the patient's apical pulse on the flow sheet as you asked."

2. "Her apical pulse was four beats faster than it was the last time I took it."

3. "Her apical pulse is usually slower in the morning than it is in the afternoon."

4. "Her apical pulse was a little faster, but she had just returned from the bathroom."

4. Her apical pulse was a little faster, but she had just returned from the bathroom

5. The nurse can best determine the effect of emotions, such as crying, on a patient's apical pulse by:

1. Measuring the patient's apical pulse before and after crying.

2. Assessing the patient's apical pulse 30 minutes after crying.

3. Comparing the patient's radial and apical pulses after crying.

4. Comparing the patient's post-crying apical rate with her baseline.

4. Comparing the patient's post-crying apical rate with her baseline

1. During the admissions process, the nurse initially assesses the patient's respirations primarily for the purpose of:

1. Assessing respiratory function.

2. Providing a baseline as part of the patient's vital signs.

3. Assessing the patient for the risk of respiratory disease.

4. Determining the rate, rhythm, and depth of respiratory movement.

2. Providing a baseline as part of the patient's vital signs.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff regarding the appropriate technique for measuring the adult patient's respiratory rate?

1. "Please review the patient's previous documented respiratory rates."

2. "Remember to document the patient's respiratory rate, depth, and rhythm."

3. "Make sure the patient isn't aware that you are measuring her respirations."

4. "Inform me immediately if the rate is less than 12 or more than 20 per minute."

3. Make sure the patient isn't aware that you are measuring her respirations.

3. Which of the following actions should the nurse instruct the ancillary staff to initiate first when it is determined that the patient's respiratory rate is not within normal limits?

1. Reassess the respirations for a full minute.

2. Provide 2 liters of oxygen via nasal cannula.

3. Promptly report the assessment data to the nurse.

4. Encourage the patient to attempt to breathe at a normal rate.

3. Promptly report the assessment data to the nurse.

4. Which of the following statements made by ancillary staff assigned to measure the respiratory rate of an elderly patient shows the best understanding of the importance of communicating the patient's reactions to the intervention with the nurse?

1. "I recorded the patient's respiratory rate on the flow sheet as you asked."

2. "Her respiratory rate was 24 breaths per minute, regular and shallow."

3. "Her respiratory rate was two breaths faster than it was the last time I took it."

4. "Her respiratory rate is usually slower in the morning than it is in the afternoon."

2. "Her respiratory rate was 24 breaths per minute, regular and shallow

5. The nurse can best minimize the effect of exercise, such as ambulation, on a patient's respiratory assessment by:

1. Assessing the pulse for a full minute before assessing respirations.

2. Encouraging 10 minutes of rest before assessing respirations.

3. Comparing the post-exercise respirations with his baseline findings.

4. Comparing the post-exercise findings with the previous at-rest findings.

2. Encouraging 10 minutes of rest before assessing respirations.

1. During the admissions process, the nurse initially assesses the patient's blood pressure primarily for the purpose of:

1. Assessing cardiovascular function.

2. Providing a baseline as part of the patient's vital signs.

3. Assessing the patient for the risk of cardiovascular disease.

4. Determining the patient's systolic and diastolic blood pressures.

2. Providing a baseline as part of the patient's vital signs.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff regarding the appropriate technique for measuring the adult patient's blood pressure? "In addition to making sure you use the appropriate size blood pressure cuff:

1. Please review the patient's previous documented blood pressure."

2. Remember to document the patient's blood pressure on the flow sheet."

3. Please be sure to wrap the cuff evenly and snugly around the upper arm."

4. Inform me immediately if the measurement is not within normal limits for this patient."

3. Please be sure to wrap the cuff evenly and snugly around the upper arm."

3. Which of the following actions should the nurse instruct the ancillary staff to initiate first when it is determined that the patient's blood pressure is not within normal limits?

1. Ask the patient what his normal blood pressure is.

2. Assess the cuff for proper size and arm positioning.

3. Promptly report the assessment data to the patient's nurse.

4. Encourage the patient to rest quietly in bed for 30 minutes.

3. Promptly report the assessment data to the patient's nurse.

4. Which of the following statements made by ancillary staff assigned to measure the blood pressure of an elderly patient shows the best understanding of the importance that the proper use of the blood pressure equipment has on the accuracy of the measurement?

1. "I always have the patient resting comfortably when I take the blood pressure."

2. "It isn't always easy to position the blood pressure gauge to keep it at eye level."

3. "If the stethoscope touches the patient's clothing, the noise is really a problem."

4. "Her blood pressure is usually lower in the morning than it is in the afternoon."

2. "It isn't always easy to position the blood pressure gauge to keep it at eye level."

5. Which of the following statements to ancillary staff made by the nurse reflects the best instructions regarding the appropriate site selection for blood pressure assessment for a patient who has experienced a left mastectomy?

1. "Please be aware of the need to avoid the arm on the affected side."

2. "You will find a cuff large enough for that patient in the clean utility room."

3. "If you have trouble finding the popliteal artery, let me know and I'll help you."

4. "She has an intravenous line in her right arm to provide her with pain medication."

3. "If you have trouble finding the popliteal artery, let me know and I'll help you."

1. The primary purpose of measuring the oxygen saturation of a patient whose respiratory rate is above normal limits it to:

1. Assess the effectiveness of his respiratory function.

2. Confirm the need for a diagnostic arterial blood gas.

3. Determine the number of liters of oxygen the patient requires.

4. Measure the percentage of hemoglobin that is binding to oxygen.

4. Measure the percentage of hemoglobin that is binding to oxygen.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff regarding the appropriate site for the measurement of a patient's oxygen saturation?

1. "If her nails are polished, check to see if you can use another acceptable site."

2. "I've checked her capillary refill and it's acceptable in both hands and feet."

3. "Please review the patient's previous documented pulse oximetry reading for the site used."

4. "Ask the patient to keep her finger motionless when you are monitoring her oxygen saturation."

2. "I've checked her capillary refill and it's acceptable in both hands and feet."

3. Which of the following actions should the nurse instruct the ancillary staff to initiate first when it is determined that the patient's oxygen saturation is not within normal limits?

1. Reassess the oxygen saturation in a different location.

2. Promptly report the assessment data to the patient's nurse.

3. Encourage the patient to rest quietly in bed for 30 minutes.

4. Ask the patient whether he or she is experiencing respiratory difficulties.

2. Promptly report the assessment data to the patient's nurse.

4. Which of the following statements made by ancillary staff assigned to measure the oxygen saturation of an elderly patient shows the best understanding of the importance of communicating abnormalities to the nurse?

1. "Her respirations are 22 per minute and shallow, and her pulse ox is 89%."

2. "She tells me she usually gets short of breath when climbing her stairs."

3. "The patient is not nearly as restless as she was before you put her oxygen on."

4. "The patient told me that she has taken medication for asthma for 5 years now."

1. "Her respirations are 22 per minute and shallow, and her pulse ox is 89%."

5. Which of the following statements made by ancillary staff reflects the best understanding of the importance of communicating abnormalities related to a patient's pulse oximetry measurement with the nurse?

1. "I documented her 97% oxygen saturation measurement on her flow sheet."

2. "Both hands were injured in the fall, so I used the great toe on her left foot."

3. "Her pulse ox was 90% on room air while sitting in a semi-Fowler's position."

4. "I waited to measure her oxygen saturation until she rested for a few minutes."

3. "Her pulse ox was 90% on room air while sitting in a semi-Fowler's position."

1. The primary purpose for assessing a patient for pain at the time of admission is to:

1. Evaluate the effect of pain on the patient's life.

2. Establish a baseline pain level as a baseline for comparison.

3. Identify an acceptable level of pain for individualized patient function.

4. Provide a basis for evaluating the effectiveness of pain-relief methods.

2. Establish a baseline pain level as a baseline for comparison.

2. Which statement made by the nurse will be most effective in instructing ancillary staff about the importance of appropriate communication of information that will affect the management of pain?

1. "Let me know at least 30 minutes before you transport her so I can give her pain medication."

2. "Be sure to provide enough rest between bathing her and transferring her to the chair."

3. "Be sure to tell me if she reports to you that she is in pain greater than 3 out of 10."

4. "I've given her some pain medication; please notify me when she falls asleep."

1. "Let me know at least 30 minutes before you transport her so I can give her pain medication."

3. Which of the following patient outcomes obtained 45 minutes after receiving oral pain medication is the most reflective of adequate management for pain originally rated as 7 out of 10 on the pain scale?

1. The patient is seen quietly reading a magazine.

2. The patient rates current pain as 4 out of 10 on the pain scale.

3. The patient is overheard telling family that she is, "feeling better today."

4. The patient is observed sleeping with respirations assessed at 18/minute.

2. The patient rates current pain as 4 out of 10 on the pain scale.

4. The nurse is conducting an admission interview when the patient states, "I've had this knee pain for a long time." Which of the following questions will be most informative regarding the management of the patient's pain?

1. "What does the pain actually feel like?"

2. "When did you actually start having this pain?"

3. "What have you done that seems to lessen the pain?"

4. "Does the pain keep you from being independent?"

3. "What have you done that seems to lessen the pain?"

5. Which of the following statements made by the nurse reflects the best understanding of the importance of communicating the effectiveness of the prescribed pain medication?

1. "She is able to help with her AM care if she is medicated right before breakfast."

2. "The patient is resting quietly 30 minutes after receiving her IV pain medication."

3. "The patient is still rating the pain at 7 out of 10 after being medicated."

4. "She told me that she is a little nauseated but the pain has lessened."

3. "The patient is still rating the pain at 7 out of 10 after being medicated."

1. The primary purpose for measuring a patient's height and weight at the time of admission for abdominal pain and a history of congestive heart failure is to:

1. Evaluate the effect of obesity on the patient's life.

2. Establish a height and weight baseline level for future comparison.

3. Help evaluate the patient's nutritional status and general health.

4. Track the treatment of such disorders as fluid overload and renal failure.

2. Establish a height and weight baseline level for future comparison.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of measuring a patient's height and weight regarding the importance of appropriate communication of information that reflects the patient's tolerance of the intervention?

1. "He is a large man, so let me know how many people you needed to weigh him."

2. "He gets uncooperative, so let me know if he helped you with his weighing."

3. "Be sure to provide enough rest between bathing him and weighing him."

4. "Report back to me if he reported being dizzy or lightheaded."

4. "Report back to me if he reported being dizzy or lightheaded."

3. Which of the following preparations are necessary to insure an accurate measurement of weight?

1. Always weigh the patient at the same time of day.

2. Make sure pouches or drainage devices are emptied before weighing the patient.

3. Request that the patient list all food and drink consumed since the last time you weighed him/her.

4. Ask the patient if there have been any changes in his/her exercise program.

4. The nurse is conducting an admission interview when the patient states, "I've lost 30 pounds over the

2. Make sure pouches or drainage devices are emptied before weighing the patient.

4. The nurse is conducting an admission interview when the patient states, "I've lost 30 pounds over the last 4 months." Which of the following questions will be most informative regarding the nature of the alteration in the patient's weight?

1. "Is your health care provider aware of this weight loss?"

2. "Has your weight fluctuated like this before?"

3. "Have you been following a specific diet?"

4. "Is it easy for you to lose weight?"

3. "Have you been following a specific diet?"

5. Which of the following statements made by the nurse to ancillary staff assigned the responsibility of measuring the height and weight of a newly admitted elderly patient provides the most guidance regarding the patient's risk for injury?

1. "She is unable to bear weight on her left leg, so her balance is unstable."

2. "If you need assistance with weighing her, just let me know and I'll help."

3. "She is a large lady, so be careful of both her and yourself."

4. "If you need to, bring a chair scale into her room."

1. "She is unable to bear weight on her left leg, so her balance is unstable."

1. When preparing to provide a comatose patient with oral care, the nurse best ensures patient safety by first:

1. Assessing the patient's gag reflex.

2. Inspecting the patient's oral cavity.

3. Placing the bed into a flat position.

4. Providing appropriate suction equipment.

1. Assessing the patient's gag reflex.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of providing oral care for an unconscious patient in order to maximize the staff's ability to safely provide the care?

1. "What are you prepared to do if the patient starts gagging?"

2. "Remember to use a gloved hand when assessing for a gag reflex."

3. "Do you understand the importance of evaluating the ability to swallow?"

4. "Be sure to check that your suction equipment is working effectively."

4. "Be sure to check that your suction equipment is working effectively."

3. Which of the following actions should have priority in order to best ensure that the unconscious patient has the benefits of proper oral care?

1. Assessing the patient's lips and oral cavity for ulcerations, bleeding, dryness, or crusting

2. Documenting the patient's mucous membranes as moist and pink with no signs of inflammation

3. Arranging for an in-service of ancillary staff to ensure that effective care is being provided

4. Interviewing the patient's family to assess their ability to provide appropriate oral hygiene upon discharge

1. Assessing the patient's lips and oral cavity for ulcerations, bleeding, dryness, or crusting

4. Which of the following statements made by ancillary staff assigned with the responsibility of providing a comatose patient with oral hygiene reflects the best understanding of the importance of appropriately communicating with the nurse regarding this current intervention?

1. "The state of her oral health has really improved since we started using the sponges."

2. "He did require some oral suctioning; I don't believe he has much of a gag reflex left."

3. "The family is concerned about being able to perform oral hygiene well once he is discharged."

4. "The patient did not have any signs of inflammation or even dryness of his mucous membranes."

2. "He did require some oral suctioning; I don't believe he has much of a gag reflex left."

5. Which of the following patients should be scheduled for oral care at least every 2 hours in order to best minimize the risk of dried oral mucous membranes?

1. 66-year-old patient with a history of petit mal seizures

2. 76-year-old hospice patient currently experiencing dyspnea

3. 85-year-old patient diagnosed with advanced Alzheimer disease

4. 47-year-old patient recently diagnosed with an oral cancerous lesion

2. 76-year-old hospice patient currently experiencing dyspnea

1. When preparing to assist a patient who requires assistance with caring for dentures, the nurse best ensures the safety of the appliance by first:

1. Padding the sink basin with a washcloth or paper towels.

2. Providing the patient with a complete explanation of the procedure.

3. Determining the patient's preference of cleansing products to be used.

4. Grasping the dentures with a gauze pad when removing them from the patient's mouth.

1. Padding the sink basin with a washcloth or paper towels.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of cleaning a patient's dentures in order to maximize the staff's ability to minimize the risk of damage to the dentures?

1. "What do you plan to use to clean the dentures?"

2. "Remember to rinse the dentures well after brushing in tepid water."

3. "Do you understand the importance of protecting the dentures from cracking?"

4. "If your patient doesn't use denture adhesive, remember to moisten the dentures."

2. "Remember to rinse the dentures well after brushing in tepid water."

3. Which of the following actions should have priority in order to best ensure that the patient's dentures are cleansed in a manner that minimizes the introduction of harmful pathogens into the oral cavity?

1. Assessing the patient's mouth regularly for signs of damage

2. Providing denture care each time oral mouth care is provided

3. Keeping the dentures moist when not actually in the patient's mouth

4. Brushing all surfaces of the dentures with a soft bristled toothbrush and cleanser

4. Brushing all surfaces of the dentures with a soft bristled toothbrush and cleanser

4. Which of the following statements made by ancillary staff assigned with the responsibility of providing denture care for a patient diagnosed with Alzheimer disease reflects the best understanding of the importance of appropriately communicating with the nurse regarding this current intervention?

1. "The patient really doesn't like having me remove his lower dentures to clean them."

2. "I asked the patient if he was experiencing any tenderness or soreness of the mouth."

3. "The patient appears to have two small, reddened areas on his lower gum on the left side."

4. "I am just about out of cleansing toothpaste, and a new toothbrush would also be helpful."

3. "The patient appears to have two small, reddened areas on his lower gum on the left side."

5. Which of the following statements made by ancillary staff assigned with the responsibility of providing denture care for a patient reflects the best understanding of the importance of safe storage of the dentures between use?

1. "The patient prefers keeping his dentures under his pillow where he can easily reach them."

2. "I asked the patient if he had a special way he preferred to store his dentures at night."

3. "I got the patient a denture cup that will hold his soaking liquid while storing his dentures."

4. "I suggested that the patient's family might bring in some soaking solution and a denture cup."

3. "I got the patient a denture cup that will hold his soaking liquid while storing his dentures."

1. When preparing to assist a patient with hair care, the nurse best ensures patient safety by first:

1. Assembling all the equipment that the intervention requires.

2. Determining the patient's ability to assist with the intervention.

3. Applying a hair detangling agent at the roots and combing downward.

4. Assessing the patient's scalp for signs of inflammation or skin breakdown.

4. Assessing the patient's scalp for signs of inflammation or skin breakdown.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of providing a patient with hair care to maximize the staff's ability to minimize the risk of cross-contamination?

1. "What are you prepared to do if the patient's hair contains dried blood?"

2. "Do you understand the importance of preventing cross-contamination?"

3. "If you notice any small white specks, realize that they could be head lice."

4. "Remember to dispose of the used toweling appropriately in the linen hamper."

3. "If you notice any small white specks, realize that they could be head lice."

3. Which of the following actions should have priority in order to best ensure that the patient's hair care is provided in a manner that minimizes the risk of pain for the patient?

1. Complete the intervention in an efficient, time-effective manner.

2. Assess the patient's willingness to cooperate with the intervention.

3. Loosen large tangles of hair manually before attempting to comb the hair.

4. When combing through tangled hair, start at the ends and work toward the scalp.

4. When combing through tangled hair, start at the ends and work toward the scalp.

4. Which of the following statements made by ancillary staff assigned with hair care for an elderly, confused patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding the current intervention?

1. "Do you think I could postpone the care until after her family visits?"

2. "Do you think we could ask the family about having the patient's hair cut?"

3. "The patient became agitated and a bit combative while I was washing her hair."

4. "The patient did seem so much more relaxed after her shampoo was done and her hair combed."

3. "The patient became agitated and a bit combative while I was washing her hair."

5. Which of the following actions should be especially avoided when providing hair care for a bed-bound patient with a history of dizziness?

1. Raising the patient quickly into a sitting position after completing a bed shampoo

2. Getting water into the patient's ears during the rinsing phase of the shampoo

3. Placing the neck in a hyperextended position during the shampoo process

4. Having the entire shampooing process last longer than 15 minutes

3. Placing the neck in a hyperextended position during the shampoo process

1. When preparing to assist a male patient with the task of shaving facial hair, the nurse best ensures patient safety by first:

1. Reviewing the patient's medical history for the risk of bleeding.

2. Securing the patient's cooperation with the shaving of his facial hair.

3. Inspecting his face for signs of skin damage or inflammation.

4. Wearing treatment gloves if there is any possibility of cross-contamination.

1. Reviewing the patient's medical history for the risk of bleeding.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of shaving a dependent patient in order to maximize the staff's ability to perform the intervention safely?

1. "Does this patient have good skin integrity on his face?"

2. "Remember to carefully shave him; please avoid nicks or cuts."

3. "Do you understand the importance of being careful not to cut the patient?"

4. "If there are any nicks or cuts, be sure to apply pressure and then cover them."

2. "Remember to carefully shave him; please avoid nicks or cuts."

3. Which of the following actions should have priority when preparing to shave a patient with a history of bleeding in order to best ensure that the patient has a minimal risk of injury during the intervention?

1. Fully explain the process to the patient in order to secure his cooperation.

2. Pay particular attention to technique in order to avoid nicks and/or cuts.

3. Use an electric razor instead of a disposable razor to perform the intervention.

4. Review current prothrombin time (PT) and/or partial thromboplastin time (PTT).

4. Review current prothrombin time (PT) and/or partial thromboplastin time (PTT).

4. Which of the following statements made by ancillary staff assigned with the responsibility of shaving an elderly, confused patient with a history of bleeding reflects the best understanding of the importance of appropriately communicating with the nurse regarding this current intervention?

1. "He likes being shaved while sitting up in the chair."

2. "He does better when shaved right after he has eaten."

3. "The patient's family said that they believe that he would not want his beard shaved."

4. "The patient seemed to enjoy the attention and smiled when he looked in the mirror."

3. "The patient's family said that they believe that he would not want his beard shaved."

5. Which of the following actions by the nurse shaving a patient is most likely to ensure minimal patient discomfort during the intervention?

1. Fully explain the process to the patient in order to secure his cooperation.

2. Pay particular attention to technique in order to avoid nicks and/or cuts.

3. During the intervention, ask the patient often if he is experiencing discomfort.

4. Encourage the patient to participate in the shaving as much as he is capable.

3. During the intervention, ask the patient often if he is experiencing discomfort.

1. When preparing to provide foot care for a patient diagnosed with type 2 diabetes mellitus, the nurse best ensures patient safety by first:

1. Inspecting the feet for signs of impaired peripheral circulation.

2. Reviewing the patient's medical history for the risk of infection.

3. Wearing treatment gloves to minimize the risk of cross-contamination.

4. Securing the patient's consent for and cooperation with the act of nail care.

1. Inspecting the feet for signs of impaired peripheral circulation.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of foot care for a dependent patient in order to maximize the staff's ability to perform the intervention safely?

1. "Does this patient have any problems with foot neuropathy?"

2. "If you have any doubts about the status of the patient's feet, just let me know."

3. "If his feet are reddened or dry and cracked, postpone the care until I see them."

4. "Do you understand the importance of filing the patient's toe nails, not cutting them?"

3. "If his feet are reddened or dry and cracked, postpone the care until I see them."

3. Which of the following actions should have priority when preparing to provide foot care for a patient with a history of type 2 diabetes mellitus in order to best ensure that the patient has a minimal risk of injury during the intervention?

1. Assessing the patient's ability to feel light touch to the surfaces of his feet

2. Fully explaining the process to the patient in order to secure his cooperation

3. Testing the temperature of the water before using it to wash the patient's feet

4. Shaping the toe nails with a file rather than trimming with scissors or clippers

1. Assessing the patient's ability to feel light touch to the surfaces of his feet

4. Which of the following statements made by ancillary staff assigned with providing foot care for an elderly, confused patient with a history of peripheral vascular disease reflects the best understanding of the importance of appropriately communicating with the nurse regarding this current intervention?

1. "His feet look so much better because I soak and clean them twice a week."

2. "His family brought in some foot lotion that they would like applied routinely."

3. "His feet appear to be swollen and red between the toes, but he said they don't hurt."

4. "The sore on his left great toe is smaller and less red than when I washed his feet on Monday."

3. "His feet appear to be swollen and red between the toes, but he said they don't hurt."

5. Which of the following actions by the nurse providing nail care for a patient is most likely to ensure maximum patient comfort during the intervention?

1. Fully explain the process to the patient in order to secure his cooperation.

2. Position the patient in a comfortable physical position before beginning.

3. Rewarm the water in the soaking basin every 10 minutes or as needed.

4. Keep the entire process to under 20 minutes to minimize the effect of chilling.

3. Rewarm the water in the soaking basin every 10 minutes or as needed.

1. When preparing to assist a patient with a gown change, the nurse best addresses infection control by first:

1. Placing the dirty gown in the appropriate linen hamper.

2. Performing hand hygiene and donning treatment gloves.

3. Determining whether the patient's current gown is wet or soiled.

4. Measuring the patient's temperature to determine if it's elevated.

3. Determining whether the patient's current gown is wet or soiled.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of changing a patient's gown to maximize the staff's ability to minimize the patient's risk of injury during the intervention?

1. "Do you understand the importance of safeguarding the patient's intravenous lines?"

2. "Are you prepared to change the gown when intravenous lines are involved?"

3. "Be sure to provide the patient with all the assistance he or she needs to safely change the gown."

4. "This patient is reporting severe shoulder pain, so please be aware of that physical limitation."

4. "This patient is reporting severe shoulder pain, so please be aware of that physical limitation."

3. Which of the following actions should have the greatest effect on properly maintaining the patient's intravenous (IV) fluids when it is necessary to take the IV fluid container off the pole to facilitate the changing of the patient's gown?

1. Completing the intervention in an efficient, time-effective manner.

2. Assessing the patient's willingness to cooperate with the intervention.

3. Manually keeping the fluid container above the level of the patient's heart.

4. Checking the fluid flow rate and adjusting it if necessary after completing the task.

3. Manually keeping the fluid container above the level of the patient's heart.

4. Which of the following statements made by ancillary staff assigned to change the gown of an elderly patient with left-sided weakness reflects the best understanding of the importance of appropriately encouraging the patient to participate in the clothing change?

1. "She is quite capable of letting me know when she wants her gown changed."

2. "She uses her strong arm to remove the gown from her weak arm really well."

3. "She uses her strong arm to position herself in the bed when we change her gown."

4. "She helps with changing her gown because she's been going to physical therapy."

2. "She uses her strong arm to remove the gown from her weak arm really well."

5. Which of the following actions would be most effective in facilitating gown changes for a patient receiving IV fluids?

1. Completing the intervention in an efficient, time-effective manner

2. Using gowns with ties, snaps, or Velcro fasteners along the sleeves

3. Manually keeping the fluid container above the level of the patient's heart

4. Changing the gown to coincide with hanging new IV fluid containers

2. Using gowns with ties, snaps, or Velcro fasteners along the sleeves

1. The nurse is delegating a bed bath on a bed-ridden, totally dependent patient to assistive personnel. Which of the following statements made by the assistive personnel requires follow-up by the nurse?

1. "This bed bath is a good time to talk with the patient."

2. "I'll see if the patient's daughter wants to bathe her mom. She likes doing things for her."

3. "I'll be sure to take a good look at her perineum since she has been incontinent."

4. "The patient enjoys her bath just before bedtime. I'll arrange my schedule to do it then."

2. "I'll see if the patient's daughter wants to bathe her mom. She likes doing things for her."

2. Which of the following information should the nurse share with the assistive personnel assigned to give a patient a bed bath?

a. The patient has a reddened area on her left elbow.

b. The patient has threatened to harm herself in the past.

c. The patient has been treated for type 2 diabetes for 5 years.

d. The patient has expressed a disliking for her roommate's family.

e. The patient suffered a deep vein thrombosis (clot) in her left leg last month.

f. The patient will be transferred to an extended care facility tomorrow at noon.

1. b, c, f

2. a, c, e

3. d, e, f

4. b, d, e

2. a, c, e

3. A dependent patient is being given a bed bath. The nurse realizes that she will need another washcloth to complete the bath. To ensure patient safety the nurse should:

1. Use the call bell to ask someone to bring another washcloth.

2. Raise all the side rails on the patient's bed before leaving the room.

3. Explain to the patient that she will need to go and get another washcloth.

4. Position the patient on her side to face toward the door of her room.

2. Raise all the side rails on the patient's bed before leaving the room.

4. The nurse is preparing to provide a bed bath for a patient on strict bedrest. The nurse will minimize the chance of cross-contamination by doing which of the following?

a. Cleansing the patient's face first

b. Patting, not rubbing, the skin dry

c. Changing bath water when it loses its warmth

d. Changing treatment gloves when they become soiled

e. Cleansing the patient's eyelids from inner to outer canthus

f. Soaking the patient's hands and nails in soapy water for 5 to 10 minutes

1. b, c, d

2. a, d, e

3. c, d, f

4. b, c, e

2. a, d, e

5. The nurse is preparing to delegate a patient's bed bath to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I will be sure to tell you if I see any cracks or redness on her heels or elbows."

2. "I will ask her if she needs to use the bedpan before I get her undressed for her bath."

3. "I will close the door to the patient's room during her bath to provide the necessary privacy."

4. "I will encourage the patient to wash her face, arms, and chest since she was able to wash them yesterday."

3. "I will close the door to the patient's room during her bath to provide the necessary privacy."

1. An intervention directly related to safety that must to be considered when providing an elderly patient with a tub bath or shower is to:

1. Provide the patient with a mild soap to minimize dry skin.

2. Assess the patient's skin for signs of impaired skin integrity.

3. Encourage the patient to be actively involved in the bathing process.

4. Monitor the water temperature closely before the patient enters the tub or shower.

4. Monitor the water temperature closely before the patient enters the tub or shower.

2. The nurse is delegating a patient's shower to assistive personnel. The patient has mild leftsided muscle weakness resulting from a cerebralvascular accident (CVA) 2 years ago. Which of the following statements made by the assistive personnel requires follow-up by the nurse?

1. "I'll check to see that we have a rubber bath mat to place in the tub."

2. "I will make sure the patient is positioned with the grab bar on her right side."

3. "She really likes the smell of lilac bath oil, so I'll be sure to put some in the bath water."

4. "The patient enjoys her bath just before bedtime. I'll arrange my schedule to do it then."

3. "She really likes the smell of lilac bath oil, so I'll be sure to put some in the bath water."

3. Which of the following should the nurse share with the assistive personnel assigned to give a patient a tub bath?

a. The patient is sometimes confused.

b. The patient has a bruised area on her left buttock.

c. The patient will be discharged tomorrow morning.

d. The patient has expressed a disliking for her roommate's family.

e. The patient is currently taking an oral anticoagulation medication.

f. The patient has been on long-term antidepressant medication therapy.

1. a, d, f

2. b, e, f

3. a, b, e

4. c, d, f

3. a, b, e

4. The nurse is assisting a patient with a tub bath. After the patient is safely positioned in the tub, he tells the nurse, "I'll call you when I'm done." The nurse's best response is:

1. "Alright, just call out and I'll come help you out of the tub when you're ready."

2. "Well, I'll check back with you in about 5 minutes to see if you need anything."

3. "That's not safe. I'd rather sit just outside the door and wait for you to be done."

4. "I'll be back in 15 minutes. That should be enough time for you to finish up with the bath."

2. "Well, I'll check back with you in about 5 minutes to see if you need anything."

5. The nurse is preparing to delegate a patient's tub bath to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I will be sure to stay nearby so I can hear if she calls."

2. "I will certainly tell you if I see any cracks or redness on her skin."

3. "I will encourage her to soak for 20 to 30 minutes since that will relax her."

4. "I will drain the tub completely before helping her out to get dressed."

3. "I will encourage her to soak for 20 to 30 minutes since that will relax her."

1. The nurse is delegating female perineal care on a bed-ridden, totally dependent patient to assistive personnel. Which of the following statements made by the assistive personnel requires follow-up by the nurse?

1. "I'll ask if I need help positioning her."

2. "I'll see if she's up to the care right now."

3. "I'll let you know if there are any signs of redness or discharge."

4. "I'll be sure to use hot, soapy water since she has been incontinent.

4. "I'll be sure to use hot, soapy water since she has been incontinent.

2. How much of the following information should the nurse share with the assistive personnel assigned to provide a female patient with perineal care?

a. The patient has complained of perineal itching.

b. The patient has a history of chronic depression.

c. The patient has had a urinary catheter inserted.

d. The patient has expressed an intense dislike for her physician.

e. The patient has a confirmed allergy to products containing latex.

f. The patient will be transferred to a private room tomorrow morning.

1. a, b, f

2. b, c, e

3. a, d, f

4. a, c, e

4. a, c, e

3. The nurse is preparing to provide a female patient with perineal care when the patient tells the nurse, "I can do that myself." Which of the following actions should be given priority?

1. Provide all the necessary equipment and linen for this task.

2. Assess the patient's understanding of proper perineal care.

3. Ensure that the patient has privacy while performing perineal care.

4. Document any complaints of irritation or pain in the perineal area.

2. Assess the patient's understanding of proper perineal care.

4. The nurse is preparing to provide a catheterized female patient with perineal care. The nurse will promote infection control by:

1. Avoiding the application of any tension on the catheter.

2. Patting, not rubbing, the skin dry after a thorough rinsing.

3. Cleaning the patient's labia from the pubis bone toward the rectum.

4. Using warm water to cleanse the patient's entire perineal area.

3. Cleaning the patient's labia from the pubis bone toward the rectum.

5. The nurse is preparing to delegate a female patient's perineal care to assistive personnel.

Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I will encourage her to wash herself if she can."

2. "I know how much she dislikes this, so I'll get it done quickly."

3. "I'm sure you want to know if I notice any redness or discharge."

4. "I will ask the patient when she wants this care and arrange to do it then."

2. "I know how much she dislikes this, so I'll get it done quickly."

1. An intervention directly related to patient safety that must to be considered when providing an elderly male catheterized patient with perineal care is to:

1. Use treatment gloves during care.

2. Assess the patient's ability to provide self-care.

3. Encourage the patient to report any pain originating from the catheter.

4. Monitor the amount of urine in the drainage bag to prevent overflow.

1. Use treatment gloves during care.

2. The nurse has delegated perineal care of a male patient to assistive personnel. Which of the following observations of the care being provided requires follow-up by the nurse?

1. Assisting the patient into the supine position within the bed

2. Cleansing the tip of the penis with a circular motion starting at the meatus

3. Reserving the cleansing of the tip of the penis as the final step in perineal care

4. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin

3. Reserving the cleansing of the tip of the penis as the final step in perineal care

3. The nurse is assisting a male patient with perineal care. The patient tells the nurse that, "It has started to hurt a little down there." The nurse's best response is:

1. "When did you start experiencing the pain?"

2. "Rate the pain on a scale of 1 to 10."

3. "I'll assess your perineal area for the possible cause of the pain."

4. "Would you like some pain medication before I continue with your care?"

3. "I'll assess your perineal area for the possible cause of the pain."

4. The nurse is preparing to delegate a male patient's perineal care to assistive personnel.

Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I will check to see if he cleans himself well."

2. "I will let you know if I see any redness or drainage."

3. "I will ask him if he is experiencing any pain in that area."

4. "I will be sure to use hot, soapy water to be sure he's clean."

4. "I will be sure to use hot, soapy water to be sure he's clean."

5. The nurse knows that the primary reason for performing perineal care on an incontinent male patient is to:

1. Provide comfort and a relaxed, refreshed feeling.

2. Promote personal hygiene while minimizing perineal odor.

3. Remove all microorganisms from the patient's perineal area.

4. Reduce the risk of skin breakdown on the patient's genitals and perineum.

4. Reduce the risk of skin breakdown on the patient's genitals and perineum.

1. The nurse is preparing to make an unoccupied bed for a patient admitted with abdominal pain. The primary purpose of this intervention is to:

1. Encourage the patient to ambulate.

2. Facilitate the changing of bed linen.

3. Provide clear, wrinkle-free bed linen.

4. Assess the patient's ability to ambulate.

3. Provide clear, wrinkle-free bed linen.

2. The nurse is preparing to change the soiled linen on a patient's unoccupied bed. The nurse realizes that which of the following precaution should be taken to best minimize the risk of transmitting microorganisms?

1. Perform hand hygiene and wear clean gloves.

2. Place fresh linen on a clean bedside table or chair.

3. Put soiled linen in a pillow case before placing in a hamper.

4. Roll soiled linen together with the dirty sides toward the center.

1. Perform hand hygiene and wear clean gloves.

3. The assistive personnel has been delegated the task of making an unoccupied bed. To use time and energy effectively, the assistive personnel should:

1. Place all linen on a clear, flat surface.

2. Stack bed linens in order of use with the bottom sheet on top.

3. Lay linens on the bed with the seams facing away from the patient.

4. After removing all the bed linen, roll the soiled sides inward to form one unit.

2. Stack bed linens in order of use with the bottom sheet on top.

4. The nurse is preparing to delegate the changing of the linen on an unoccupied bed to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I'll use gloves if I see that the sheets have been soiled with urine or feces."

2. "She said her daughter was bringing in her special pillow. I'll see if it's here yet."

3. "I noticed some red areas on her back, so I'll be extra careful to remove all the wrinkles."

4. "The family usually walks her out to the lounge after breakfast. I'll change the linen then."

1. "I'll use gloves if I see that the sheets have been soiled with urine or feces."

5. When preparing to delegate the making of an unoccupied bed to assistive personnel, the nurse must first:

1. Observe the assistive personnel while assisting in the making of an unoccupied bed.

2. Determine the most appropriate time for the assistive personnel to change the linen.

3. Assess the assistive personnel's understanding of the proper technique for this task.

4. Inform the assistive personnel of any restrictions the patient may have regarding ambulation.

3. Assess the assistive personnel's understanding of the proper technique for this task.

1. With time and energy conservation in mind, when preparing to make an occupied bed, the nurse should first:

1. Assemble the linen stacked in order of use from top to bottom.

2. Inquire as to whether the patient agrees to the intervention.

3. Arrange for a mutually acceptable time for the intervention.

4. Determine the patient's ability to assist with the intervention.

1. Assemble the linen stacked in order of use from top to bottom.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of making an occupied bed on how to best minimize the risk of injury to staff or patient through compliance with standard precautions?

1. "Do you understand the application of standard precautions during this task?"

2. "What are you prepared to do if you see that the bed is contaminated with blood?"

3. "There are gloves in both the bathroom and on the wall at the head of the patient's bed."

4. "Be sure to have a linen hamper available so that the soiled linen is not placed on a chair or the floor."

3. "There are gloves in both the bathroom and on the wall at the head of the patient's bed."

3. Which of the following actions should have priority in order to best ensure that the patient will not experience unnecessary pain during the linen change on an occupied bed?

1. Stop the intervention if the patient expresses or displays physical signs of pain.

2. Explain the intervention to the patient before beginning the linen change.

3. Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed.

4. Postpone the intervention if the patient reports the presence of physical pain before the linen change.

3. Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed.

4. Which of the following statements made by ancillary staff assigned to change the linen on the occupied bed of an elderly confused patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding this current intervention?

1. "Do you think I could postpone the linen change until after her family leaves?"

2. "I wanted to let you know that she was really tired after I finished making her bed."

3. "Do you think that I could get some help with changing the linen on her bed?"

4. "Keeping track of all those tubes and IV lines makes changing her linen a challenge."

2. "I wanted to let you know that she was really tired after I finished making her bed."

5. Which of the following patient's requiring an occupied bed linen change should not be assigned to ancillary staff without the supervision of a registered nurse?

1. 47-year-old patient in the terminal stage of renal failure

2. 66-year-old comatose patient with a history of seizures

3. 85-year-old patient diagnosed with Alzheimer disease

4. 76-year-old hospice patient currently experiencing dyspnea

4. 76-year-old hospice patient currently experiencing dyspnea

1. When preparing to move or position a patient, the nurse should first:

1. Assemble adequate help to facilitate the change.

2. Assess the patient's ability to assist with the change.

3. Determine the effect of the patient's weight on the change.

4. Decide upon the most effective method to facilitate the change.

2. Assess the patient's ability to assist with the change.

2. It has been determined that a patient is capable of assisting with her own repositioning toward the head of the bed. Which of the following statements made by the nurse will be most effective in instructing the patient on how to best facilitate the move?

1. "When I count to 3, please push off with your feet."

2. "Please help by folding your arms across your chest."

3. "Please bend your knees so your feet are flat on the bed."

4. "Please let me know how I can best help you with this move."

3. "Please bend your knees so your feet are flat on the bed."

3. A comatose patient who weighs 201 pounds requires repositioning in the bed. Which of the following actions is most likely to ensure that the client and staff will be safe during the move?

1. Accomplish the move in two or three small moves instead of one big move.

2. Place a repositioning aid (such as a lift sheet) from his shoulders to his thighs.

3. Enlist the help of two assistants since the patient weighs more than 200 pounds.

4. Assume a wide stance with the foot closest to the head of the bed behind the other.

2. Place a repositioning aid (such as a lift sheet) from his shoulders to his thighs.

4. Which of the following statements made by ancillary staff assigned to position an immobile patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding this intervention?

1. "I'll let you know if I need your help with her positioning."

2. "Do you think she will be ready to be positioned before lunch?"

3. "I noticed a small reddened area on her left hip when I turned her."

4. "Do you think I should use the mechanical lift when moving her?"

3. "I noticed a small reddened area on her left hip when I turned her."

5. Which of the following patients should not be assigned to ancillary staff for repositioning in bed?

1. A 66-year-old patient who is 2 days postcholecystectomy.

2. A 47-year-old patient in the terminal stage of lung cancer.

3. A 16-year-old patient with a concussion resulting from a bicycle accident.

4. A 76-year-old patient who has a Foley catheter and an intravenous fluid line.

3. A 16-year-old patient with a concussion resulting from a bicycle accident.

1. When preparing to safely transfer a patient from a bed to a wheelchair, the nurse should first:

1. Determine the patient's arm strength.

2. Assess the patient's weight-bearing ability.

3. Assess the patient's willingness to cooperate.

4. Decide upon the most appropriate transfer method.

3. Assess the patient's willingness to cooperate.

2. It has been determined that a patient is capable and willing to assist with her own transfer from the bed to the chair. Which of the following statements made by the nurse will be most effective in instructing the patient on how to best facilitate the move?

1. "When I count to three, please rock yourself into a standing position."

2. "Please help me by holding onto my waist while I help you stand."

3. "Please let me know how I can best help you get up off the bed and stand up."

4. "Please push down onto the mattress with both hands and stand when I count to three."

4. "Please push down onto the mattress with both hands and stand when I count to three."

3. Which of the following actions should have priority to best ensure that the patient will not fall while being transferred to the chair using a transfer belt?

1. Place skid-resistant shoes or slippers on the patient's feet.

2. Have the patient sit on the side of the bed with legs dangling for several minutes.

3. Apply the transfer belt snugly over outer clothing while not impairing breathing.

4. Position the chair so that the move will be toward the patient's stronger side.

2. Have the patient sit on the side of the bed with legs dangling for several minutes.

4. Which of the following statements made by ancillary staff assigned with the transfer of a mobility-impaired patient reflects the best understanding of the importance of appropriately communicating with the nurse regarding this intervention?

1. "I'll let you know if I need your help with her transfer."

2. "Do you think she will enjoy eating lunch in her chair?"

3. "Has she been complaining of pain or dizziness today?"

4. "She is less able to help with the transfer than she was yesterday."

4. "She is less able to help with the transfer than she was yesterday."

5. Which of the following patient transfers should not be assigned to ancillary staff without supervision by a registered nurse?

1. 66-year-old patient receiving cancer radiation treatments

2. 47-year-old patient in the terminal stage of renal failure

3. 26-year-old patient who is 8 hours post- cesarean section

4. 76-year-old patient who has an intravenous fluid line in place

3. 26-year-old patient who is 8 hours post- cesarean section

1. The nurse is preparing to transfer a patient from her bed to a stretcher for transport to radiology for testing. The nurse realizes that a primary concern regarding patient safety is to:

1. Assess the patient's ability to actively participate in the actual transfer.

2. Minimize the risk of falls or other injury during the transfer procedure.

3. Assure the patient that the transfer will cause her as little pain as possible.

4. Reassure the patient that she will be safely transported to the radiology department.

2. Minimize the risk of falls or other injury during the transfer procedure.

2. The nurse realizes that precautions should be taken in order to minimize the risk of injury to those involved in the transfer. Which of the following apply?

1. Medicate the uncooperative patient before attempting the transfer.

2. Encourage the patient to help with the transfer as such as possible.

3. Have enough available staff members to assist with the patient transfer.

4. Transfer the patient when he or she is most willing to cooperate with staff.

3. Have enough available staff members to assist with the patient transfer.

3. The assistive personnel may be delegated the task of transferring a patient from bed to a stretcher. Which of the following patient's transfers should the nurse delegate to assistive personnel?

1. 92-year-old hospice patient who is being transferred to a skill nursing unit

2. 35-year-old patient who has been on bedrest for 15 days as a result of a neck injury

3. 26-year-old patient who experienced a closed-head injury resulting from a fall 3 days ago

4. 63-year-old patient who will be transferred for the first time since knee replacement surgery

1. 92-year-old hospice patient who is being transferred to a skill nursing unit

4. The nurse is preparing to delegate the transfer of a client from bed to a stretcher for transport to the physical therapy (PT) department to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I'll use gloves for the transfer if the bed sheets have been soiled."

2. "She said her daughter was going to PT with her. I'll see if she's here."

3. "I noticed some red areas on her back, so I'll be extra careful to position her on her side."

4. "The PT department is chilly, I'll be sure to send an extra blanket with the client."

1. "I'll use gloves for the transfer if the bed sheets have been soiled."

5. When preparing to delegate the transfer of a client from bed to stretcher to assistive personnel, the nurse must first:

1. Observe the assistive personnel while making the transfer.

2. Determine the most appropriate time for the assistive personnel to transfer the client.

3. Assess the assistive personnel's understanding of the proper technique for this task.

4. Inform the assistive personnel of any restrictions the patient may have regarding the transfer.

3. Assess the assistive personnel's understanding of the proper technique for this task.

1. When preparing to safely transfer a patient using a hydraulic lift, the nurse should first:

1. Assess the patient for IV or catheter tubing.

2. Arrange for the appropriate number of staff to assist.

3. Inquire as to whether the patient agrees to the intervention.

4. Arrange for the equipment to be available at the agreed upon time.

1. Assess the patient for IV or catheter tubing.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the transfer of a patient using a hydraulic lift on how to best perform this intervention?

1. "Let me know if you need my help with the transfer."

2. "This patient can become agitated when she's anxious"

3. "Remember to position the horseshoe under the bed with its legs wide open."

4. "Be sure to put the wheelchair near the bed, but leave space to maneuver the lift."

3. "Remember to position the horseshoe under the bed with its legs wide open."

3. Which of the following actions should have priority in order to best ensure that the patient will not experience unnecessary pain during a transfer facilitated with a hydraulic lift?

1. Stop the intervention if the patient expresses or displays physical signs of pain.

2. Explain the intervention to the patient before starting the transfer process.

3. Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed.

4. Postpone the intervention if the patient reports the presence of physical pain or anxiety at the time of the

3. Provide the patient with a dose of prescribed analgesic 30 minutes before the intervention if needed.

4. Which of the following statements made by ancillary staff assigned with the responsibility of transferring an elderly patient using a hydraulic lift reflects the best understanding of the importance of appropriately communicating with the nurse regarding this intervention?

1. "Do you think I really need the hydraulic lift to transfer her?"

2. "I'll let you know if I need your help with working the hydraulic lift."

3. "Do you think that she will be as anxious about the transfer as she was the first time?"

4. "The patient was really much stronger today than she was last time I transferred her."

4. "The patient was really much stronger today than she was last time I transferred her."

5. Which of the following patient transfers using a hydraulic lift should not be assigned to ancillary staff without supervision by a nurse?

1. 47-year-old patient in the terminal stage of renal failure

2. 66-year-old comatose patient with a history of seizures

3. 26-year-old patient on the first day post-op for reduction of a fractured femur

4. 76-year-old hospice patient diagnosed with lung cancer and dementia

3. 26-year-old patient on the first day post-op for reduction of a fractured femur

1. The nurse knows that the primary objective for the application of a gait belt on a patient who is unstable when ambulating is to:

1. Minimize the risk of falls.

2. Reduce the weight-bearing load.

3. Provide a sense of physical security.

4. Aid in the support of lower extremities.

1. Minimize the risk of falls.

2. The nurse is preparing to initiate ambulation for a patient who has been on bedrest for several weeks. To minimize the risk of the patient experiencing dizziness, the nurse first:

1. Raises the head of the patient's bed to 90 degrees.

2. Assists the patient into a sitting position on the side of the bed.

3. Ask the patient if he has felt dizzy when moving in the bed.

4. Assesses the patient's blood pressure before attempting to ambulate.

1. Raises the head of the patient's bed to 90 degrees.

3. The nurse has applied a gait belt to a post-operative patient to facilitate ambulation. Within a few feet of his bed the patient begins to complain of dizziness and leans heavily on the nurse. The nurse's initial response is to:

1. Use the gait belt to help slowly lower the patient to the floor.

2. Attempt to sit the patient down on a chair just a few steps away.

3. Ask the patient's roommate to use her call bell to alert additional staff.

4. Inform the staff that help is needed by calling out in a loud but calm voice.

1. Use the gait belt to help slowly lower the patient to the floor.

4. The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to assistive personnel. Which of the following statements by the assistive personnel requires follow-up by the nurse?

1. "I will be sure to put non-skid slippers on the patient before getting him up to ambulate."

2. "I use the under-axilla technique to get him up and then use the gait belt to walk him."

3. "Rocking the heavier patient into a standing position seems to work really well for me."

4. "The patient has a weak left side from a stroke. I'll position myself on that side for more support."

2. "I use the under-axilla technique to get him up and then use the gait belt to walk him."

5. The nurse is ambulating a patient with a gait belt. Which of the following events warrants returning the patient to bed immediately?

1. She complains of "feeling nauseous."

2. Her son arrives for a much awaited visit.

3. She states, "I don't want to get too tired."

4. The hospital chaplain responds to a referral.

1. She complains of "feeling nauseous."

1. When initially preparing to apply elastic stockings, the nurse must first:

1. Measure the patient's legs.

2. Select the appropriate size stockings.

3. Determining the patient's sensitivity to talcum powder.

4. Place the patient in a comfortable sitting position in the bed.

1. Measure the patient's legs.

2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff in the most effective means of minimizing patient discomfort when applying elastic stockings?

1. "Please be sure that you smooth out any wrinkles in the stockings."

2. "It's easier to put them on if you turn them inside out up to the heels."

3. "She isn't allergic, so apply a little powder to the legs and feet before you start."

4. "There is a clean pair of stockings in her bedside stand; her family brought them."

3. "She isn't allergic, so apply a little powder to the legs and feet before you start."

3. Which of the following instructions provided by the nurse to ancillary staff assigned the responsibility of bathing a patient who has been prescribed elastic stockings is most likely to ensure the continued skin integrity of the patient's legs?

1. "Please let me know when the stockings are off so I can look at her legs."

2. "Be sure to tell me if you see any redness, dryness, or cracking on her legs."

3. "Turning the foot of the stockings inside out will make putting them on easier."

4. "Remember to apply a little powder to her legs before reapplying the stockings."

1. "Please let me know when the stockings are off so I can look at her legs."

4. Which of the following statements made by ancillary staff assigned to apply the elastic stockings of an elderly patient shows the best understanding of the importance of communicating the patient's reactions to the intervention with the nurse?

1. "She doesn't like the fact that she has to wear the stockings."

2. "She tells me that her legs are itching and there is a slight red rash."

3. "I asked her family to bring in a clean pair of stocking she has at home."

4. "Please explain to the patient why I can't remove the stockings all the time."

2. "She tells me that her legs are itching and there is a slight red rash."

5. The nurse can best determine the effect of elastic stockings on the patient's peripheral vascular circulation by assessing:

1. For pain or numbness in the legs when the stockings are on.

2. Pedal pulses before, during, and after application of the stockings.

3. The skin color of the legs immediately after removing the stockings.

4. The skin temperature of the legs frequently while the stockings are on.

2. Pedal pulses before, during, and after application of the stockings.

1. An intervention that is directly related to patient safety that must be considered when providing an elderly patient with a urinal is to:

1. Determine the patient's risk for orthostatic hypotension.

2. Assess the patient's genitals for signs of impaired skin integrity.

3. Monitor the patient's demonstration of the proper use of a urinal.

4. Encourage the patient to notify staff when the urinal requires emptying.

1. Determine the patient's risk for orthostatic hypotension.

2. The nurse is discussing a patient's need for a urinal with assistive personnel. The patient has mild left-sided muscle weakness resulting from a cerebrovascular accident (CVA) 2 years ago and is mildly confused, especially in the evenings. Which of the following statements made by the assistive personnel indicates a need for follow-up by the nurse?

1. "Does he have a clean urinal in his bedside stand?"

2. "Is the patient allowed to stand beside the bed to urinate?"

3. "I'll make sure the patient can reach his urinal with his right hand"

4. "I'll have him recap the urinal and let me know when it needs to be emptied."

4. "I'll have him recap the urinal and let me know when it needs to be emptied."

3. For which of the following patients should the nurse personally assume responsibility when assisting with the use of a urinal?

a. Patient with a history of urinary infections

b. Patient who is being prepped for outpatient surgery

c. 76-year-old patient who is 2 days post-op for a knee replacement

d. 90-year-old patient who is confused and sometimes uncooperative

e. New admission complaining of abdominal pain and dizziness

f. 54-year-old patient who had a urinary catheter removed this morning

1. a, c

2. e, f

3. d, e

4. b, c

2. e, f

4. The nurse is assisting a patient with placement of a urinal. The patient tells the nurse, "I'll call you when I'm done." The nurse's best response is:

1. "Alright, just call out and I'll come to help you when you are finished."

2. "Fine. Recap the urinal, hang it on your side rail, and use your call bell."

3. "I'll check on you when I'm finished with your roommate's bed bath."

4. "I'll be back in 15 minutes. That should be enough time for you to finish up."

2. "Fine. Recap the urinal, hang it on your side rail, and use your call bell."

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