Asepsis
Which hospitalized patient is most at risk for developing a healthcare-associated infection?
a. Mr. Y, a 60-year-old patient who smokes two packs of cigarettes daily
b. Mrs. J, a 40-year-old patient who has a white blood cell count of 6,000/mm3
c. Mr. L, a 65-year-old patient who has an indwelling urinary catheter in place
d. Mrs. M, a 60-year-old patient who is a vegetarian and slightly underweight
C. Mr. L, a 65-year-old patient who has an indwelling
urinary catheter in place
The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?
A. Leave the thermometer in and notify the physician.
B. Remove the thermometer and assess the blood pressure and heart rate.
C. Remove the thermometer and assess the temperature via another method.
D. Call for assistance and anticipate the need for CPR.
B. Remove the thermometer and assess the blood pressure and heart rate.
What does the Braden Scale evaluate?
A) Skin integrity at bony prominences, including any wounds
B) Risk factors that place the patient at risk for skin breakdown
C) The amount of repositioning that the patient can tolerate
D) The factors that place the patient at risk for poor healing
B) Risk factors that place the patient at risk for skin breakdown
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
A) Stage I
A student nurse is demonstrating the proper procedure for maintaining a sterile field. Which of the following guidelines should be followed? (Select all that apply.)
A. Never reach across a sterile field.
B. Objects below the waist are considered unsterile.
C. A sterile object is still sterile if touched by a nonsterile object.
D. One inch around the edges is considered contaminated.
A. Never reach across a sterile field.
B. Objects below the waist are considered unsterile.
D. One inch around the edges is considered contaminated.
Which of the following lists the recommended sequence for removing soiled personal protective equipment when the nurse prepares to leave the patient's room?
a. Gown, goggles, mask, gloves, and exit the room
b. Gloves, wash hands, remove gown, mask, and goggles
c. Gloves, goggles, gown, mask, and wash hands
d. Goggles, mask, gloves, gown, and wash hands
c. Gloves, goggles, gown, mask, and wash hands
Which of the following vlues for vital signs would the nurse address first?
A) Heart rate = 72 beats per minute
B) Respiration rate = 28 breaths per minute
C) Blood pressure = 160/86
D) Oxygen saturation by pulse oximetry = 89%
E) Temperature = 37.2° C (99°
D) Oxygen saturation by pulse oximetry = 89%
A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
1. turn him frequently.
2. perform passive range-of-motion (ROM) exercises.
3. reduce the client's fluid intake.
4. encourage the client to use a footboard.
1. turn him frequently.
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
A) Necrotic tissue
B) Wound drainage
C) Drainage on the dressing
D) Wound after it has first been cleaned with normal saline
D) Wound after it has first been cleaned with normal saline
A student nurse recalls that the body has nonspecific defense systems to protect against infection. Which of the following is an example of this system?
A. Saliva
B. Antigens
C. B-lymphocytes
D. T-cells
A. Saliva
The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must:
A. Keep splashes on the sterile field to a minimum.
B. Cover the nose and mouth with gloved hands if a sneeze is imminent.
C. Use forceps soaked in a disinfectant.
D. Consider the outer 1 inch of the sterile field as contaminated.
D. Consider the outer 1 inch of the sterile field as contaminated.
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take?
A) Give him some slippers and tell him where the bathroom is located.
B) Ask the nursing assistant to assist him to the bathroom.
C) Obtain orthostatic blood pressure measurements.
D) Tell him it is not a good idea and provide a urinal.
C) Obtain orthostatic blood pressure measurements.
Which of the following includes all sites that are at high-risk and likelihood for external pressure related bedsores?
A. Patella, sacrum, scapula, ribs, illiac crest
B. Sacrum, scapula, trochanter, tibia
C. Coccyx, sacrum, patella, calcaneus (heel)
D. Trochanter, coccyx, sacrum, calcaneus (heel)
D. Trochanter, coccyx, sacrum, calcaneus (heel)
A client's wound is draining thick yellow material. The nurse correctly describes the drainage as:
1. Sanguineous
2. Serous-sanguineous
3. Serous
4. Purulent
4. Purulent; Drainage is described as purulent. Sanguineous and Serous-sanguineous contain blood. Serous is clear and watery.
The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following?
A) Eliminate the reservoir.
B) Block the portal of exit from the reservoir.
C) Block the portal of entry into the host.
D) Decrease the susceptibility of the host.
Block the portal of exit from the reservoir.
Rationale: Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other persons. Since the carrier person is the reservoir and the condition is chronic,
In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply.
A. A patient diagnosed with rubella
B. A patient diagnosed with varicella
C. A patient diagnosed with tuberculosis
D. A patient diagnosed with MRSA
A. A patient diagnosed with rubella
The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions?
A) Check other vital signs.
B) Recheck the blood pressure and give the client orange juice.
C) Recheck the blood pressure after ambulating the client safely.
D) Recheck the blood pressure, make sure the client is safe, and report the findings.
D) Recheck the blood pressure, make sure the client is safe, and report the findings.
The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment?
1. Lips
2. Sacrum
3. Earlobes
4. Back of the hands
1. Lips
Explanation:
In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge.
Heat causes _______, which increases blood flow to the area where heat was applied.
vasodilation
The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately?
a. a sterile tongue blade lubricated with water soluble gel
b. an otic curette
c. a small plastic ruler
d. a sterile, flexible applicator moistened with saline
d. a sterile, flexible applicator moistened with saline
A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient?
A. Imbalanced Nutrition: More Than Body Requirements related to immobility
B. Impaired Physical Mobility related to pain and discomfort
C. Chronic Pain related to immobility
D. Risk for Infection related to altered skin integrity
D. Risk for Infection related to altered skin integrity
Place the vital signs in order of priority for your nursing interventions:
1) SpO2= 89%
2) BP= 160/86 mmHG
3) Temperature= 37.3 (99.4)
4) HR= 72 BPM
5) RR= 28 BrPM
1, 5, 2, 4, 3
A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate?
a. Pain
b. Impaired Skin Integrity
c. Disturbed Body Image
d. Disturbed Thought Processes
c. Disturbed Body Image
A home health nurse visits a client who twisted an ankle in the morning. The client has an ice bag on the ankle. Which one of the client's chronic conditions contraindicates the use of ice?
1. Gastritis
2. Diabetes
3. Glaucoma
4. Osteoporosis
2. Diabetes; Diabetes contradicts the use for ice. Clients with neurological or circulatory impairment are at risk for injury with ice use.
Name the 16th President of the United States
Abraham Lincoln