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31 Cards in this Set
- Front
- Back
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A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? |
Select one: a. Change tracheostomy ties when soiled. b. Remove soiled dressing with sterile gloves. c. Suction the tracheostomy before beginning care. d. Clean disposable inner cannula with hydrogen peroxide. Answer
a. Change tracheostomy ties when soiled.
CORRECT. Tracheostomy ties should be changed once a day or when soiled. Secure new ties in place before removing old soiled ones to prevent accidental decannulation. One or two fingers should be able to be placed between the tie tape and the neck. |
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A client has fallen in the bathroom. Which of the following is the priority nursing action? |
Select one: a. Notify the healthcare provider
b. Assist the client back to bed
c. Assess the client’s level of consciousness
d. Obtain the client’s vital signs
Answer
d. Obtain the client’s vital signs CORRECT. Safety first. Before proceeding with the assessment or taking vital signs assess the level of consciousness. Complaints of pain, any joint or bone deformity may provide evidence of fractures or dislocations. Inspection of the skin will determine lacerations, contusions, or hematomas that may need to be treated. After a report to the provider, additional x-rays or exams may be ordered.
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A nurse is providing discharge education for a female client diagnosed with Chlamydia. Which statement made by the client would indicate the need for further instruction? |
Select one: a. “Symptoms of reinfection may include yellow vaginal discharge.” b. “I will return to the clinic in one month for re-screening.” c. “Possible complications to monitor for include pelvic inflammatory disease.” d. “I will refrain from sexual intercourse until completion of antibiotics.”
Answer
b. “I will return to the clinic in one month for re-screening.”
CORRECT. No test for cure is required, but all women should be rescreened for re-infections 3 to 12 months after treatment because of high risk for pelvic inflammatory disease (PID). There is less evidence of the need for re-screening of treated men, but it should be considered.
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A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C (105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an Unlicensed Assistive Personnel (UAP)?
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Select one: a. Assess the client’s skin for any reddened b. Bathe the client to keep the skin damp c. Obtain a fan for the client’s used. Report shivering by the client
Answer
d. Report shivering by the client. CORRECT. The unlicensed assistive personnel should be taught to observe for and report shivering during any form of external cooling. Shivering may indicate that the client is being cooled too quickly.
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A nurse is triaging clients following a mass casualty event. The nurse should place a client who has sustained fatal injuries in which of the following triage categories? |
Select one: a. Emergent Category (Class I)
b. Urgent Category (Class II)
c. Nonurgent Category (Class III)
d. Expectant Category (Class IV)
Answer
d. Expectant Category (Class IV) CORRECT. Class IV (Expectant Category) is reserved for clients who are not expected to live and will be allowed to die naturally. Comfort measures may be provided, but restorative care will not. These clients are the lowest priority when a mass casualty has occurred.
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A nurse is positioning a client for a urinary catheterization. Which of the following nursing actions would be best in preventing musculoskeletal injuries during the procedure? |
Select one: a. Raising the bed to a comfortable height.
b. Narrowing the base of support.
c. Using the non-dominant hand to insert the catheter.
d. Positioning the client using a draw sheet.
Answer
a. Raising the bed to a comfortable height. CORRECT. Working with the bed at a comfortable height is more ergonomically appropriate to prevent back strain and possible injury, to prevent bending and/or twisting from the waist.
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A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client’s risk for falls? |
Select one: a. Hourly rounding by the nurse.
b. Use of a night-light.
c. Place bedside table in close proximity.
d. Demonstrate how to use the call light.
Answer
a. Hourly rounding by the nurse. CORRECT. In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction.
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A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another building. Which of the following clients would have the highest priority for the charge nurse to evacuate? |
Select one: a. A client post left hip replacement of two days ago whose daughter is visiting.
b. A client receiving IV antibiotics every six hours for a leg ulcer.
c. A client semi-comatose after a cerebrovascular accident with an indwelling urinary catheter.
d. A client admitted with pancreatitis with nasogastric tube and PCA pump in place.
Answer
b. A client receiving IV antibiotics every six hours for a leg ulcer. CORRECT. The client with a leg ulcer can walk unassisted without an IV pole. In a hospital evacuation, unlike triage and evacuation outside of the hospital, the most stable, ambulatory clients will be evacuated first, followed by those who need assistance with mobility (wheelchairs) or equipment (tubes, catheters), and finally those who need to be moved by stretcher or in their hospital beds. The prevailing concept is to move as many clients as quickly and safely as possible from the area.
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A nurse is providing the family of a client with acquired immunodeficiency syndrome (AIDS) education in preparation for discharge. A family member asks about appropriate clean up of blood or body fluids. Which of the following is the correct response by the nurse? |
Select one: a. Disinfect the area with 70% isopropyl alcohol after initial cleaning. b. Clean the area with soap and water and rinse thoroughly with ammonia. c. Use soap and water to clean, rinse thoroughly, and allow the area to air dry. d. Disinfect the area with a 10% bleach solution after initial cleaning.
Answer
d. Disinfect the area with a 10% bleach solution after initial cleaning. CORRECT. A solution of 1 part bleach to 10 parts water (10% solution) is the disinfecting agent of choice after blood or body fluids are initially cleaned up and disposed of (at home in a sealed plastic bag and placed in the regular trash), and the area is initially cleansed with soap and water.
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A nurse is providing the family of a client with acquired immunodeficiency syndrome (AIDS) education in preparation for discharge. A family member asks about appropriate clean up of blood or body fluids. Which of the following is the correct response by the nurse? |
Select one: a. Disinfect the area with 70% isopropyl alcohol after initial cleaning.
b. Clean the area with soap and water and rinse thoroughly with ammonia.
c. Use soap and water to clean, rinse thoroughly, and allow the area to air dry.
d. Disinfect the area with a 10% bleach solution after initial cleaning.
Answer
d. Disinfect the area with a 10% bleach solution after initial cleaning. CORRECT. A solution of 1 part bleach to 10 parts water (10% solution) is the disinfecting agent of choice after blood or body fluids are initially cleaned up and disposed of (at home in a sealed plastic bag and placed in the regular trash), and the area is initially cleansed with soap and water.
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A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2 hours. Which intervention is the priority? |
Select one: a. Monitor urine output.
b. Fill out an incident report.
c. Report the defective equipment.
d. Document the amount of fluid infused.
Answer b. Fill out an incident report. CORRECT. A malfunctioning device or product should be documented using an incident report. The report is confidential and separate from the medical record. It should never be documented in the client’s medical record that an incident report was completed.
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A graduate nurse is caring for a client who is on neutropenic precautions. Which of the following actions by the nurse would require further teaching by the charge nurse? |
Select one: a. Discarding an empty blood bag and blood tubing in the client’s beside trash can. b. Taking a blood pressure cuff to the bedside of a client on neutropenic precautions. c. Taking an infusion pump from the bedside of a client to the dirty utility room. d. Disposing of a used needle and syringe in the biohazard box in the client’s room. Answer
a. Discarding an empty blood bag and blood tubing in the client’s beside trash can.
CORRECT. The empty blood bag and tubing are considered to be biohazard waste and should be disposed of in a red bag or bin that will be incinerated rather than taken to a landfill.
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A newly-licensed nurse is preparing the surgical suite for a client who has a latex allergy. Which action demonstrates a need for further education? |
Select one: a. Using glass syringes. b. Scheduling the case late in the day. c. Covering IV tubing ports with tape. d. Placing monitoring devices in stockinet.
Answer
b. Scheduling the case late in the day. CORRECT. This action indicates a need for further education. Clients with latex allergy should be scheduled as the first case in the morning. This will allow latex dust (from the previous day) to be removed overnight.
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A nurse is orienting a newly licensed nurse to the operating room. Which of the following actions by the new nurse indicates a need for further education about surgical aseptic hand hygiene? |
Select one: a. Drying with a sterile towel moving from the hands to the elbows. b. Rinsing hands and arms while keeping them lower than elbows. c. Cleaning under nails of both hands with a nail pick while under running water. d. Lathering hand and arms with soap to 5 cm (2 inches) above the elbows Answer
b. Rinsing hands and arms while keeping them lower than elbows. CORRECT. While rinsing removes transient bacteria from fingers, hands and forearms, keeping hands elevated above the elbows allows water to flow from least to most |
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A client has just returned to the surgical unit after an open cholestectomy. A nurse notes the abdominal dressing is saturated with sanguineous drainage. Which of the following is the most appropriate intervention? |
Select one: a. Reinforce the dressing with additional gauze. b. Outline the drainage size with a marker. c. Remove the dressing to assess the incision. d. Document the assessment findings.
Answer
a. Reinforce the dressing with additional gauze. CORRECT. The appropriate intervention for a dressing that becomes wet from drainage is to reinforce the dressing by adding more dressing material to the existing dressing. The first dressing change is performed by the surgeon. |
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The parents of an adolescent client ask the nurse why the meningiococcal conjugate vaccine is recommended before attending college. Which of the following statements best explains the reason why college-aged students should receive this vaccine? |
Select one: a. Upper respiratory infections are more common on college campuses. b. Adults who contract meningitis rarely have complications from it. c. Receiving the vaccine provides guaranteed immunity to the disease. d. Living in a dormitory increases the risk of exposure to the disease.
Answer
d. Living in a dormitory increases the risk of exposure to the disease. CORRECT. Living in close quarters, like dormitories or barracks, greatly increases the risk of being exposed to meningococcal pneumonia. Other risk factors include travel to a country where the disease is endemic, biologists who work with the organism and clients who have no spleen function (and consequently are immunosuppressed).
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A nurse is instructing a client with a right fractured tibia on the correct technique for using a three-point gait with crutches. Which of the following should be included in teaching? |
Select one: a. Weight is placed on both legs, and crutches are placed one stride in front and then legs swing to the crutches. b. Partial weight is placed on the right foot moving the crutch at the same time as the right leg. c. Weight is evenly distributed, with each leg being moved alternately with the opposing crutch. d. Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated.
Answer
d. Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated. CORRECT. Three point gait requires the client to bear all of the weight on one foot. The affected leg does not touch the ground.
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A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? |
Select one: a. “I should always support my baby’s head when I pick him up.” b. “Once my baby begins to roll over it is okay to use a small pillow in the crib.” c. “I should never leave my baby unattended with pets or other children.” d. “My baby’s car seat should be in the back seat facing backwards.”
Answer
b. “Once my baby begins to roll over it is okay to use a small pillow in the crib.” CORRECT. It is never safe to have a pillow or a soft surface in the crib because of the danger of suffocation.
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A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? |
Select one: a. “We will need to remove the baby’s ankle identification band during diaper changes.” b. "When the baby is born, my thumb print will be taken along with the baby’s footprint.” c. “When the baby is returned to us from the nursery, we should check the baby’s identification band.” d. “We will request to see picture identification badges for all facility staff who care for our baby.”
Answer
a. “We will need to remove the baby’s ankle identification band during diaper changes.” CORRECT. This statement indicates a need for further education. The mother, newborn, and significant other are identified by plastic identification bands with permanent locks that must be cut to be removed. Per most hospitals’ policies, newborns will be provided with both ankle and armband identification. These identification bands should not be removed for any reason until the newborn is discharged from the hospital.
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A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and blood pressure of 132/88. Which of the following is the priority nursing intervention? |
Select one: a. Place the client on 2 Liters oxygen b. Immediately notify the provider c. Administer albuterol inhalerd. Reassess pulse oximetry
Answer
d. Reassess pulse oximetry CORRECT. When the other vital signs are within normal range, the immediate intervention would be to reassess the low oxygen saturation using another site before any other interventions are completed. Causes of low readings include client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish.
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A nurse is caring for a client diagnosed with an acute anxiety disorder. Which of the following is the priority nursing intervention? |
Select one: a. Administer prescribed selective serotonin inhibitor (SSRI). b. Encourage to attend a behavioral therapy group. c. Remain with the client during the crisis period. d. Evaluate coping mechanisms for controlling anxiety. Answer
c. Remain with the client during the crisis period. CORRECT. This action is priority. It is imperative that the nurse remain with the client and provide safety and comfort measures during the crisis period of the anxiety disorder. This will increase the likelihood of anxiety relief and ensure client safety during the acute period.
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When the nurse takes morning medications to a client, the client states “I’ve never seen that one before.” Which of the following is the most appropriate action for the nurse to take? |
Select one: a. Administer the rest of the medications and recheck the one that was questioned. b. Return to the nurse’s station and check all medications against provider orders c. Tell the client that the medication must be new and to go ahead and take it. d. Recheck the medication with the medication administration record (MAR).
Answer
b. Return to the nurse’s station and check all medications against provider orders CORRECT. The best action would be to hold off on administering any of the medications until they are all verified against provider orders in the client record. Once that is complete, the nurse can tell the client with certainty that the medications have all been verified with the provider order, and then answer any questions about the medications the client or family asks. These actions prevent errors and build trust.
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A nurse is providing staff development. The nurse understands that which of the following may impede learning? |
Select one: a. Proven learner. b. Self-directed. c. Intrinsic motivation. d. Self-confidence. Answer
d. Self-confidence. CORRECT. Self-confidence is not an asset for learning. Self-confidence is considered an obstacle to learning.
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A client is receiving chemotherapy and reports that the tubing has pulled apart and notices a puddle on the floor. Which of the following is the priority nursing action to take after ensuring the client is stable and appropriate tubing disposal? |
Select one: a. Soak up the spill with a towel and dispose of it in a biohazard bag. b. Obtain the spill kit specifically designated for this type of spill and use it. c. Complete an incident report about the spill. d. Notify housekeeping of the spill.
Answer
b. Obtain the spill kit specifically designated for this type of spill and use it. CORRECT. The first thing the nurse needs to do after determining that the client is stable, is to arrange for the spill to be cleaned up with a specially designed clean up kit which should be on the unit where any chemotherapy is being given. Whether the nurse does it or someone else does is not important – the spill is an environmental hazard, and chemotherapy is a carcinogen and teratogen to anyone who handles it in an unprotected manner.
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A client being admitted to a nursing unit asks the nurse, “My friend has carpal tunnel syndrome and said I would probably get it too because of my work. What can I do to prevent it?” Which of the following statements would be the nurse’s best response? |
Select one: a. “Keep your wrists in a neutral position or wear wrist braces for support.” b. “Find out if other family members have it because it is hereditary.” c. “Begin a supervised exercise program to strengthen both of your wrists.” d. “Consider asking for a different job if your wrists start to bother you.”
Answer
a. “Keep your wrists in a neutral position or wear wrist braces for support.” CORRECT. Repetitive motions that stress the wrist due to bending or twisting are most frequently associated with carpal tunnel syndrome. For example assembly line workers have a very high incidence of carpal tunnel syndrome. There may be a hereditary predisposition as well due to an inborn narrowing of the carpel tunnel where the median nerve passes through the wrist. The key to prevention is to avoid the twisting, bending motions of the wrist and minimize repetitive motions. Take breaks, stretch and exercise the wrists as well as back and shoulders. A wrist brace will help to maintain neutral position.
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A nurse is caring for multiple clients on the acute care unit. Which action demonstrates effective time management? |
Select one: a. Document all client care activities at the conclusion of the shift. b. Avoid delegation of tasks to other members of the health care team. c. Cluster activities that are to be performed on the same client. d. Complete difficult tasks after simpler tasks have been completed.
Answer c. Cluster activities that are to be performed on the same client. CORRECT. Clustering activities that are to be performed on the same client or are in close physical proximity is a time-saving strategy that helps prevent unnecessary walking.
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A nurse is preparing to transfer a client from the bed to a stretcher. Which action increases the nurse’s risk for injury? |
Select one: a. Manually lifting the client’s full weight. b. Encouraging the client to assist. c. Keeping knees slightly flexed. d. Standing with feet wide apart. Answer
a. Manually lifting the client’s full weight. CORRECT. Lifting is a high-risk activity that causes significant biochemical and postural stressors. Manual lifting should only be performed as a last resort and only if it does not involve lifting most or all of a client’s weight. Use of client-handling equipment (i.e., friction reducing slide sheets) helps reduce the caregiver muscle strain during client handling. |
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A hospital has been notified that possible bioterrorist activity has taken place at a large sporting event nearby. A nurse has been put in charge of preparing a holding area to meet the needs of victims who report headache, dizziness, anxiety and shortness of breath, and are noted to have a bitter almond odor to their breath. What medication should the nurse be prepared to administer? |
Select one: a. Cyanide vaccine b. Amyl Nitrate c. Vitamin K d. Acetylcysteine Answer
b. Amyl Nitrate CORRECT. The victims’ symptoms are consistent with cyanide poisoning. Amyl Nitrate is given for cyanide poisoning. |
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A nurse is reinforcing teaching with an older adult about food safety in the home. Which of the following instructions should the nurse include in teaching? |
Select one: a. When preparing a meal raw and fresh foods should be handled separately. b. Food poisoning is usually caused by a fungus. c. The older adult recovers from food poisoning in a few days. d. Clients at risk for food poisoning should follow a low cholesterol diet.
Answer
a. When preparing a meal raw and fresh foods should be handled separately. Correct: Raw and fresh foods should be handled separately to prevent cross contamination. |
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A nurse applies restraints to a mental health client who is refusing to take his antipsychotic medication. The nurse may be charged with which of the following intentional torts? |
Select one: a. False Imprisonment b. Malpractice c. Assault d. Negligence
Answer
a. False Imprisonment Correct: False imprisonment is confining a client against his/her will.
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A nurse is caring for a client following a right below the knee amputation. Which of the following should the nurse include in the plan of care to prevent infection? |
Select one: a. Position the affected limb elevated on a pillow. b. Encourage the client to lie prone for 20-30 minutes several times a day. c. Encourage the client to lie supine for 20-30 minutes several times a day. d. Position the affected limb in a dependent position.
Answer
d. Position the affected limb in a dependent position. Correct: Positioning the extremity in a dependent position will promote blood flow and oxygenation which will decrease the risk of infection.
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