A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?
A. Explaining the roles of the RN, licensed practical nurse, and assistive personnel
B. Understanding the client's routine for his own care at home
C. Determining the client's mobility
D. Introducing health care team members to the client
C. Determining the client's mobility
A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take
A. Keep the clients’ rooms dark.
B. Instruct the clients to use the call light.
C. Move overbed tables away from the bed.
D. Place a fall risk wristband on each of the clients.
E. Perform client checks every 4 hr.
B,D
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion.
The nurse inspects the wound on the client's leg has and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
A. Laceration
B. Contusion
C. Abrasion
D. Puncture
A. Laceration
A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
A. Wear a mask when entering the client's room.
B. Remove potted plants from the room.
C. Allow the client to leave the room every 2 hr.
D. Dedicate equipment and supplies for use with the client.
D. Dedicate equipment and supplies for use with the client.
A charge nurse is observing a staff nurse caring for a client who has multiple skin lesions from a varicella zoster infection. Which of the following actions should the charge nurse identify as an indication that the nurse understands the precautions to take when caring for a client who has this infection?
A. The nurse wears a high-efficiency particulate air (HEPA) filter mask.
B. The nurse wears gloves when checking the drop rate of the client’s IV infusion.
C. The nurse wears a gown when administering oral medications.
D. The nurse wears a face shield when assisting the client with oral hygiene.
A. The nurse wears a high-efficiency particulate air (HEPA) filter mask.
.A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
A. Contractures of extremities
B. Hypertension
C. Diarrhea
D. Crackles in the lungs
E. Pressure ulcers
A,D,E
.A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?
A. One nurse lifting as the client pushes with his feet
B. Two nurses lifting the client under the shoulders
C. One nurse lifting the client’s legs as the client uses a trapeze bar
D. Two nurses using a friction-reducing device
D. Two nurses using a friction-reducing device
.A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client’s skin integrity?
A. Reposition the client every 3 hr.
B. Massage bony prominences to promote circulation.
C. Provide the client with a diet high in protein.
D. Apply cornstarch to keep the skin dry.
C. Provide the client with a diet high in protein.
A nurse is removing an isolation gown that has waist ties in the front after caring for a client who requires contact precautions. Which of the following steps should the nurse take?
A. Untie the neck ties, remove the gloves, and untie the front waist ties.
B. Untie the front waist ties, remove the gloves, and untie the neck ties.
C. Remove the gloves, perform hand hygiene, and untie the front waist ties.
D. Remove the gloves, untie the neck ties, and untie the front waist ties.
B. Untie the front waist ties, remove the gloves, and untie the neck ties.
22.A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?
A. Mask
B. Gown
C. Eyewear
D. Gloves
A. Mask
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take?
A. Apply ice to the ankle.
B. Encourage range-of-motion exercises of the foot.
C. Provide the client with a light snack.
D. Apply a compression bandage.
E. Elevate the foot.
A,D,E
A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A. "I will keep my walker at the end of my bed."
B. "I will keep the fluorescent ceiling light on in my room at night."
C. "I will place an area rug at the entry of my bathroom."
D. "I will place a bath seat in my shower to use when I bathe."
D. "I will place a bath seat in my shower to use when I bathe."
.A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
A. Apply a heat lamp twice a day.
B. Cleanse with 0.9% sodium chloride irrigation.
C. Cleanse with povidone-iodine solution.
B. Cleanse with 0.9% sodium chloride irrigation.
A nurse is caring for a group of clients. For which of the following tasks should the nurse wear gloves? (Select all that apply.)
A. Emptying urine from an indwelling urinary catheter collection bag
B. Providing oral care
C. Changing an ostomy pouch
D. Delivering a food tray to a client who has AIDS
E. Placing oral medication tablets into a client’s hand
A,B,C
A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?
A. Provide a positive pressure airflow room.
B. Wear an N95 respirator mask.
C. Encourage the client to ambulate in the hall.
D. Wear gloves when entering the client’s room.
B. Wear an N95 respirator mask.
A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take?
A. Place the chair parallel to the bed.
B. Place a transfer belt on the client.
C. Stand with the feet together.
D. Pull the client to a standing position.
B. Place a transfer belt on the client.
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?
A. The client’s ability to communicate
B. The client’s current weight-bearing status
C. The client’s activity tolerance
D. The type of equipment the staff used to transfer the client in the past
B. The client’s current weight-bearing status
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
A. Unbroken skin with un-blancheable erythema
B. Full-thickness tissue loss extending to underlying support structures
C. A shallow, ruptured or intact skin blister without slough
D. A deep crater without visible bone, tendon, or muscle
D. A deep crater without visible bone, tendon, or muscle
.A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment? (Select all that apply.)
A. Giving personal care to an infant who is HIV-positive
B. Providing a newborn’s first bath
C. Withdrawing cord blood from a neonate
D. Transporting a cerebral spinal fluid specimen to the laboratory
E. Suctioning secretions from a child’s newly placed tracheostomy tube
C,E
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client’s infection?
A. Changing the client’s bed linens each day
B. Encouraging the client to consume a diet high in protein
C. Performing hand hygiene before, during, and after direct contact with the client
D. Placing the client in a room with positive pressure airflow
C. Performing hand hygiene before, during, and after direct contact with the client
A nurse is planning care for a client who is immobile and requires continuous mitten restraints. Which of the following interventions should the nurse contribute to client’s care plan?
A. Document restraint checks every 2 hr.
B. Educate the client’s family about restraint use.
C. Obtain the provider’s prescription renewal every 72 hr.
D. Implement passive range-of-motion exercises.
E. Release the restraints every 4 hr.
A,B,D
10.An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move
independently since that time. The nurse caring for her should observe for which of the following findings that
indicates a complication of immobility?
A. A reddened area over the sacrum
B. Stiffness in the lower extremities
C. Difficulty moving the upper extremities
D. Difficulty hearing some types of sounds
A. A reddened area over the sacrum
A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
A. Chlorhexidine washes
B. Urinary catheterization
C. Malnutrition
D. Multiple caregivers
B. Urinary catheterization
A nurse is reinforcing teaching with an assistive personnel (AP) about using personal protective equipment while
caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?
A. "I will wear gloves whenever I am in contact with clients."
B. "I will wear gloves and a gown when bathing a client who has open skin lesions."
C. "I will wear gloves to reduce the number of times I have to wash my hands."
D. "I will wear gloves when measuring a client’s BP."
B. "I will wear gloves and a gown when bathing a client who has open skin lesions."
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an
elevation in which of the following laboratory values as an indication that the client has developed an infection?
A. BUN
B. Potassium
C. RBC count
D. WBC count
D. WBC count