A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe
... [Show More] care of this client?
A. Supine
B. Semi Fowler's
C. Semi-Prone
D. Trendelenburg - B
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?
A. Obtain a walker for the client to use to transfer back to bed.
B. Call for help with transfer
C. Use transfer belt to assist client back to bed
D. Determine clients ability to help with transfer - D
A nurse is completing discharge instrucitons for pt with COPD. What demonstrates pt understanding with difficulty breathing at night?
A. lie on back with head and shoulders on pillow
B. Lie flat on stomach with head to one side.
C. Sit on side of bed with arms over pillows on bedside table.
D. Lie on side with weight on hip and should with arms flexed in front of her - C
A nurse manager is reviewing guidelines for preventing injury with staff nurses. which of the following instructions should the nurse manager include. Select all that apply
A. Request assistance when re-positioning client
B. Avoid twisting spine or bending at waist
C. Keep knees slightly lower than hips when sitting for extended periods
D. Use smooth movements when lifting and moving clients
E. Take a break from repetitive movements every 2 to 3 hrs to flex and stretch joints and muscles - A B D
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements shoudl the nurse identify as an indication that an attendee understands the teaching. Select all that apply
A. My line of gravity should fall outside my base of support
B. The lower the center of gravity the more stable I am
C. To broaden my base of support, I should spread my feet apart
D. When I lift an object I should hold it as close to my body as possible
E. When pulling an object I should move my front foot forward - BCD
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority?
A.A client who received crush injuries to the chest and abdomen and is expected to die
B.A client who has a 4-inch laceration to the head
C.A client who has partial-thickness and full-thickness burns to his face, neck, and chest
D.A client who has a fractured fibula and tibia - c
A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (Select all that apply.)
A.A client who is dehydrated and receiving IV fluid and electrolytes
B.A client who has a nasogastric tube to treat a small bowel obstruction
C.A client who is scheduled for a transurethral resection of the prostate (TURP)D.A client who is 24 hr postoperative following a mastectomy
E.A client who is scheduled for an appendectom - cd
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply.)
A.Open doors to client rooms.
B.Place blankets over clients who are confined to beds
C.Move beds away from the windows.
D.Draw shades and close drapes.
E.Relocate ambulatory clients in the hallways back into their room - bcd
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
A.Irrigate the affected area with running water.
B.Wash the affected area with antibacterial soap.
C.Brush the chemical off the skin and clothing.
D.Apply a neutralizing agent. - c
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?A."I will get the caller off the phone as soon as possible so I can alert the staff."
B."I will use overhead paging to alert the entire facility."
C."I will not ask any questions and just let the caller talk."
D."I will listen for background noises. - d
A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply.)
A.Place a belt restraint on the client when he is sitting on the bedside commode.
B.Keep the bed in low position with full side rails up.
C.Ensure that the client's call light is within reach.
D.Provide the client with nonskid footwear.
E.Complete a fall-risk assessmen - c d e
A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction?
A."I will place the client on his side."
B."I will go to the nurses' station for assistance."
C."I will administer medications as prescribed."
D."I will be prepared to insert an airway. - b
A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse?
A.Extinguish the fire.
B.Pull the fire alarm.
C.Evacuate the clients.
D.Close all open doors on the unit - c
A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station?
A.A 43-year-old client who is postoperative following a laparoscopic cholecystectomy
B.A 61-year-old client being admitted for telemetry to rule out a myocardial infarction
C.A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle
D.A 79-year-old client who is postoperative following a below-the-knee amputatio - d
A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse?
A.Complete a fall-risk assessment.
B.Educate the client and family on fall risks.
C.Complete a physical assessment.
D.Survey the client's belonging - a
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse
A.keep the sterile field at least 6 ft away from the client's bedside.B.instruct the client to refrain from coughing and sneezing during the dressing change.
C.place a mask on the client to limit the spread of micro-organisms into the surgical wound.
D.keep a box of facial tissues nearby for the client to use during the dressing change - C
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.)
A.A bottle containing a sterile solutionB.The edge of the sterile drape at the base of the field
C.The inner wrapping of an item on the sterile field
D.An irrigation syringe on the sterile field
E.One gloved hand with the other gloved hand - C D E
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
A.The flap closest to the body
B.The right side flap
C.The left side flap
D.The flap farthest from the body - D
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.)
A.Apply 3 to 5 mL of liquid soap to dry hands.
B.Wash the hands with soap and water for at least 15 seconds.
C.Rinse the hands with hot water.
D.Use a clean paper towel to turn off hand faucets.
E.Allow the hands to air dry after washing - B D
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.)
A.The provider drops a sterile instrument onto the near side of the sterile field.
B.The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
C.The procedure is delayed 1 hr because the provider receives an emergency call.
D.The nurse turns to speak to someone who enters through the door behind the nurse.
E.The client's hand brushes against the outer edge of the sterile field - B C D
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)
A.Planning and evaluating control and prevention strategies
B.Determining public health priorities
C.Ensuring proper medical treatment
D.Identifying endemic disease
E.Monitoring for common-source outbre - A B C E
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.)
A.Place the client in a room that has negative air pressure of at least six exchanges per hour.
B.Wear a mask when providing care within 3 ft of the client.
C.Place a surgical mask on the client if transportation to another department is unavoidable.
D.Use sterile gloves when handling soiled linens.
E.Wear a gown when performing care that may result in contamination from secretions - B C E
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect?
A.Allergic reaction
B.Ringworm
C.Systemic lupus erythematosus
D.Herpes zoste - D
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?A.Prodromal
B.Incubation
C.Convalescence
D.Illnes - D
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.)
A.Fever
B.Malaise
C.Edema
D.Pain or tenderness
E.Increase in pulse and respiratory rate - A B E
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)
A. Capillary refill in 2 seconds
B. 1+ pitting edema in both feet
C. Pale nail beds in both hands
D. Thick skin on the soles of the feet
E. Numerous light brown macules on the fac - A D E
A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply.)
A. Thin, parchment-like skin
B. Loss of adipose tissue
C. Dehydration
D. Diminished skin elasticity
E. Excessive dryness and wrinklin - B C D
A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (Select all that apply.)
A. Range of motion [Show Less]