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Terms in this set (109)
After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately?The glovesA nurse is about to irrigate a client's open wound. Besides gloves, which of the following protective personal equipment should the nurse wear?A face shieldWhat should the nurse do to maintain standard precautions?disinfect hands immediately after removing glovesA nurse is washing their hands with soap and water prior to repositioning a client in bed. During the hand washing procedure, it is important to take which of the following actions?wash for at least 20 secondsWhich of the following is an advantage of using alcohol-based gel?it takes less time than washing with soap and waterA nurse is caring for a client who has Mycoplasma pneumoniae. the client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client?Protect their eyesA nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI?A salmonella infection that occurs after eating contaminated food from the cafeteriaWhich of the following products can affect the permeability of latex gloves?petroleum-based hand lotionContact precautions should be implemented for an adult client who has a been hospitalized and haas which of the following?Infectious diarrheaa nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?Hold the crutches on your unaffected side when preparing to sit in a chair.A nurse is caring for a client who has a prescription for knee-length anti embolic stockings. which of the following actions should the nurse take?Measure the client's calf circumference and leg length from heel to kneeA nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique?Aligning the nurse's knees with the client's knees just before the transferA nurse is caring for a client who has been hospitalized and is preforming active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?flexing the shoulder by raising the arm from a side position of a 180 degree angleA nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?extend one leg and allow the client to slide down the leg to the floorA nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?leaves the bed in the lowest position throughout the procedureA nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?move their leg behind their bodyWhen teaching the guardian of a toddler about feeding and eating, the nurse should include which of the following safety measures?Do not offer the child raw vegetablesA charge nurse is reviewing anthropometric values with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?the client should be weighed on the same scale at the same time each dayWhich of the following actions should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing?auscultate the client's lungsWhich of the following interventions should a nurse use at mealtimes for a client who has visual impairment?identify the food location was though the palate were a clockA nurse is caring for a client who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this client undergo which of the following?swallowing examinationa client has finished 16-oz container of orange juice. the intake and output sheet documents fluid in millimeters. What amount should the nurse document as the client's intake?480 mLA nurse is reviewing a client's laboratory values. Which of the following information is correct regarding albumin levels and nutritional status?albumin level is a poor short-term indicator of protein statuswhich of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent?making healthful food choices more convenient and available for the adolescentwhich of the following food choices are appropriate for a client who is prescribed a full liquid diet?plain yogurt, custard, ice cream, gelatinwhich of the following is the primary purpose for asking a client to keep a 3- to 7-day food diary?to assess the pattern of intake and compare with daily reference intakeswhich of the following dietary modifications should an adolescent who participates in sports implement?drink water before and after sports activitiesa nurse is caring for a client who has impaired swallowing due to cerebrovascular accident. Which of the following interventions should the nurse use to assist the client with feeding?elevate the head of the bed 45 degrees to 90 degreesa nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure?ileostomya nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence?press gently around the barrier for 30 seconds to 1 minA nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching?use irrigation to help establish a regular bowel patternA nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about the leakage. Which of the following should the nurse recommend?consume foods that are low in fiber contenta nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include?empty the pouch when it is less than half fulla nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary eliminations?Kock's pouchA nurse is reinforcing teaching with a client about replacing anatomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest?push the skin away from the barrier while removing ita nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first?cleanse the stoma and peristomal skinA nurse should recognize which of the following findings is an indication for oxygen therapy?Oxygen saturation (SaO2) 90%A nurse is caring for a critically ill client who has COPD and requires delivery of precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client.venturi maskadministering oxygen therapy with a nonrebreather mask has which of the following advantages?offers the highest oxygen concentration of the low-flow systemsa nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy?cracks in the oral mucosaa nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective?respiratory rate 14/mina home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client mustreposition the elastic band frequentlyA nurse is caring for a client who has a tracheostomy. which of the following pieces of equipment should the nurse use when administering oxygen to this client?A tracheostomy collarA nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange?diagnosisoxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings?elevated blood pressurea nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the rightstops the flow of oxygena nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. which of the following instructions should the nurse include?place the oxygen tank in a clutter-free environmentA nurse is planning morning hygiene for a postoperative client. Which of the following actions should the nurse take?Ask the client in what order they typically perform their morning care.A nurse is teaching a newly licensed nurse about proving oral hygiene for clients who are unconscious. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?I'll swab the client's mouth with chlorhexidineA nurse is preparing to assist a client with a tub bath. Identify the sequence of steps the nurse should take.1. Gather all necessary supplies
2. place a rubber mat on the tub floor
3. assist the client into the bathroom
4. instruct the client on using safety bars when getting in and out of the tub
5. instruct the client to remain in the tub for no longer than 20minA nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection?clean lease-soiled areas prior to cleaning the most-soiled areasa nurse is preforming a complete bed bath for a client. Which of the following actions should the nurse take?raise the room temperatureA nurse is preparing to provide oral care for a client who is NPO. The client tells the nurse, "I don't need oral care because I haven't eaten anything." Which of the following responses should the nurse make?Oral care is still important even though you are not eatingAa nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes?Moisture from excessive diaphoresis can cause skin breakdownA nurse is observing an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure?The AP reuses the client's clean blanket and spreadA nurse is caring for a client who has diabetes mellitus is having difficulty obtaining a capillary fingerstick blood sample for point-of-care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the client's finger?wrap the finger in a warm clothA nurse is caring for a group of clients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate?routine urinalysisA nurse obtains a capillary blood glucose result of 180 mg/dL from a client who has diabetes mellitus. Which of the following actions should the nurse take?Administer insulin according to the patient's sliding scale ordersA nurse is teaching a client about home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse include?obtain specimens from three different stoolsa nurse is collecting a blood specimen for culture from a client. Which of the following actions should the nurse take?rub the client's arm at the selected site prior to venipunctureA nurse is caring for a client who needs to collect a midstream urine specimen. Which of the following actions should the nurse take?Have a client urinate a small amount of urine before starting the collectionAn assistive personnel (AP) is collecting a 24-hour ursine specimen from client. Which of the following statements by the AP indicates that the specimen collection will have to be restarted?the client just told me that they forgot to put the urine in the containera nurse is caring for a client who has a stage III pressure injury on the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury?rotate a sterile swab in the area of drainageA nurse is caring for a client who has a suspected urinary tract infection (UTI). Which of the following urinalysis results should the nurse identify as manifestation of a UTI?Leukocyte esteraseA nurse is teaching a client about collecting stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period?PoultryWhile waiting for a sterile procedure to begin, how should the nurse position their hands and arms?With hands clasped together in front of the body above waist levelA nurse should identify the which of the following areas of the hands requires special attention during the prescribe wash?The area under each fingernailA nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows?to encourage water and soap to flow away from the clean handsA nurse is preparing to flush and change the dressing on client's central venous catheter. Which of the following should the nurse identify as the primary purpose for preforming this intervention using surgical asepsis.to control the introduction of micro-organisms at the catheter siteA nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse should perform the following steps.1. position the tray so that the top flap is farthest away from their body
2. open the flap furthest from their body
3. open the side flaps
4/ open the flap closest to their bodywhen donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand?the inner edge of the cuff will lie against the skin and thus will not be sterilewhen opening a sterile pack, which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack?holding the sterile pack below waist or table levela nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field?A cotton ball dampened with sterile normal saline is placed on the field
The nurse turns to address the client's question concerning the procedure
The procedure is postponed for 30 min to accommodate the client
The liquid is poured into a sterile container from a distance of 25 cm (10 in)Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items should a nurse don?Protective eyewear
hair cover
mask
shoe coversA nurse should identify that which of the following is the goal of surgical asepsis?To create and maintain a micro-organism-free environmentA nurse is providing teaching to an assistive personnel (AP) about the use of sterile gloves. Which of the following instructions regarding the open gloving method should the nurse give?Grasp only the inside of the glove with your ungloved handA nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?Over the fifth intercostal space at the left midclavicular lineA nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?respirations 30/minA nurse is obtaining a client's vital signs. The client has a a new onset of a temperature of 39 degrees C (102 degrees F) . Which of the following other vital signs should the nurse expect?An elevated pulse rateA nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take?Insert the probe about 2.5 cm (1 in) into the client's anusA nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?It might not follow with a fifth Korotkoff soundA nurse is assessing a client's respiration. Which of the following actions should the nurse take?Elevate the head of the client's bed 45 to 60 degreesA nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?Pulse pressureA nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?Place the probe in the posterior lingual pocket lateral to the midlineA nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respirations?Observe the degree of chest-wall movement during inspiration and expirationA nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading?Pull the pinna back and upward gentlyA nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?Use a cuff of the appropriate size for the clientAa nurse is auscultating a client's special pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?When the semilunar valves closeA nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?Observe the client's chest movements while appearing to assess their pulseA nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used?the client has a BMI of 35
The client is reporting a "stuffy" nose
The client is taking digoxin for an irregular heart rate
the client had a mastectomy 2 years agoA nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis?AlginateA nurse is caring for a client who has multiple sclerosis has a chronic non healing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?CorticosteroidsA nurse is documenting data about a deep necrotic wound on a client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document?sloughA nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?hydrogelThe nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?Apply oxygen at 2 L/min via nasal cannulaA nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?Pulsating lavageA nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage?SerosanguineousA nurse is caring for a client who has developed a stage one pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury?Barrier creamsA nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough an no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following?Stage 3
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