HYGIENE
When assessing the hygiene needs of a patient, what question would be most appropriate?
A. When was the last time you bathed?B. Would you prefer a sponge bath or sit in a chair to shower?
C. How often do you bathe?
D. You don't need a bath while in the hospital.
B. Would you prefer a sponge bath or sit in a chair to shower?
When caring for a patient on bedrest with a fracted LE (lower extremity), what is the least appropriate intervention to prevent DVT?
A. Immobilizing the affected limb.
B. Sequential compression devises (SCD's)
C. TED Hose (compression stockings)
D. Early Ambulation
D. Early Ambulation
Which pain scale is most appropriate for a patient that is alert and oriented x 4?
A. The Wong-Baker FACES Pain Rating Scale
B. Visual Analog scale
C. CPOT (critical care observation tool)
D. Numeric rating scale (NRS) from 0-10
D. Numeric rating scale (NRS) from 0-10
Which lab value would be elevated in the presence of infection?
A. Hemoglobin
B. Platelets
C. White Blood Cell Count
B. Reticulocyte Count
C. White Blood Cell Count
Why would the nurse instruct the UAP to shave a patient with an electric razor and not a razor blade?
A. Because the razor causes skin irritation
B. Because this is what the client prefers
C. Because this is what the family requested
D. Because the patient has a low platelet count
D. Because the patient has a low platelet count
Which statement made by the patient indicates understanding about denture care?
A. I wear my dentures at night while sleeping
B. I don't need to visit the dentist because I have dentures.
C. I should clean my dentures in hot water.
D. I clean my dentures by brushing them and using denture tablets.
D. I clean my dentures by brushing them and using denture tablets.
When attempting to transfer a patient that requires 1:1 assist from the chair to the bed, what is the appropriate assistive device to use?
A. Walker
B. Crutches
C. Gait Belt
D. Nothing, just see what the patient can do on their own.
C. Gait Belt
What assessment finding on a nonverbal patient would be indicative of acute pain?
A. Restlessness
B. HR 68 RR 18 BP 128/64
C. Resting soundly
D. Bradycardia
A. Restlessness
What PPE (personal protective equipment) should be used when preparing to perform wound care on a patient?
A. Goggles
B. Gown
C. Disposable clean gloves
D. Shoe covers
C. Disposable clean gloves
What statement made by the client indicates understanding as it relates to application of cold packs?
A. I can expect the cold packs to make my skin very red.
B. I can apply the cold packs directly to my skin
C. If I get a blister from the cold packs, I will notify my provider.
D. I can keep the cold pack on my skin for at least 30 min and as long as I can tolerate it
C. If I get a blister from the cold packs, I will notify my provider.
How should the nurse perform oral care on an unconscious patient?
A. Brush the teeth with a tooth brush and mouthwash.
B. Use a moistened mouth swab for oral care.
C. Brush teeth with hard bristled toothbrush because they are unconscious.
D. Use a moistened swab that is attached to suctioning for oral care.
D. Use a moistened swab that is attached to suctioning for oral care.
When instructing a patient on how to ambulate with a cane, the nurse tells the patient to hold the cane on which side?
A. The affected side to support the weaker leg
B. The unaffected side to support the weaker leg
C. There's no need for a cane
D. Place the cane approximately 24 in in front of the foot before advancing.
A. The affected side to support the weaker leg
What type of pain would a patient that is experiencing an MI (myocardial infarction) be experiencing if they complain of jaw pain?
A. Cutaneous
B. Referred
C. Phantom
D. Fake pain
B. Referred
As it relates to hand hygiene, nurses should do all of the following except...
A. Apply lotion
B. Wash hands promptly
C. Wear acrylic/artificial nails so long as they are short
D. Inspect their hands for breaks in the skin
C. Wear acrylic/artificial nails so long as they are short.
What type of activity orders should the nurse question for a patient with generalized weakness and unsteady gait?
A. Ambulate with 1:1 assist
B. Up ad lib
C. Transfer with 2 person assist
D. Ambulate with W/C (wheel chair)
B. Up ad lib
When planning hygiene for a patient that has suffered a CVA with hemiparalysis, which is the most appropriate for washing hair?
A. Make the patient perform the task by themselves in order to promote independence.
B. Wait for PT/OT
C. Wash hair using rinse-free shampoo or using a basin in the bed
D. Don't wash the patient's hair because of the paralysis.
C. Wash hair using rinse-free shampoo or using a basin in the bed
When preparing to ambulate a patient with a walker, what should the nurse do in order to maintain client safety?
A. Hold the walker in the middle and pull it while the patient is walking.
B. Walk behind the patient and push them gently at the small of their back.
C. Adjust the height of the walker until the elbows are bent 30 degrees.
D. Walk ahead of the patient with the gait belt around the patient's waist.
C. Adjust the height of the walker until the elbows are bent 30 degrees.
What observation would the nurse have for a patient that has dementia that would lead her to believe that the patient is experiencing pain?
A. The patient is grimacing and clenching their fist.
B. Patient is easily redirectable.
C. Patient HR is 72.
D. Patient's BP is normotensive.
A. The patient is grimacing and clenching their fist.
Patients with varicella should be on what type of isolation precautions?
A. Airborne
B. Standard
C. Protective
D. Tactile
A. Airborne
The patient experiencing dysphagia after suffering a CVA must be evaluated for which of the following before feeding?
A. The ability to swallow
B. Last bowel movement
C. Food preferences
D. Incontinence
A. The ability to swallow
The Nurse is assisting the patient with their hygiene. What is the most appropriate question regarding hair care?
A. Since you are in the hospital why do you want your hair washed?
B. How do you usually care for your hair at home?
C. Do you need assistance with your hair?
D. Do you have shampoo from home?
B. How do you usually care for your hair at home?
What is the most appropriate way to teach a patient partial weight bearing for a client using crutches>
A. Two point Gait
B. Alternating Gait
C. Swinging gait
D. Four point Gait
A. Two point Gait
What duty can be delegated to UAP (unlicensed assistive personal) to assist with pain relief?
A. Administer Dilaudid IV push.
B. Administer Morphine IV push.
C. Administer Tylenol 650 mg by mouth.
D. Reposition the patient using pillows.
D. Reposition the patient using pillows.
When a client has positive blood cultures, fever and chills, they are experiencing what type of infection?
A. Localized
B. Systemic
C. Latent
D. Secondary
B. Systemic
The patient is found on the floor, what is the initial action of the nurse?
A. Assist the patient to the bed.
B. Call the provider.
C. Ask the UAP for help
D. Inspect for injury
D. Inspect for injury