Module 4 Mrs. Smith Safety Flashcards
(135 cards)
1
Q
What are the 4 types of contact precautions?
A
Standard, Contact, Droplet, and Airborne
2
Q
What type of precautions is EVERY single patient on? A. Contact B. Droplet C. Airborne D. Standard
A
D. Standard
3
Q
Definition-
Excessive sleepiness during the day.
A
Hypersomnolence
4
Q
A nurse in a provider’s office is caring for a client who states that, for the past week, “I have felt tired during the day and cannot sleep at night.” Which of the following responses should the nurse ask when collecting data about the client’s difficulty sleeping? (Select all that apply)
A. “Have your working hours changed recently?”
B. “Do you feel confused in the late afternoon?”
C. “Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?”
D. “Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?”
E. “Tell me about any personal stress you are experiencing.”
A
A, C, D, E
5
Q
A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply)
A. Practice muscle relaxation techniques.
B. Exercise each morning.
C. Take an afternoon nap.
D. Alter the sleep environment for comfort.
E. Limit fluid intake at least 2 hr before bedtime.
A
A, B, D, E
6
Q
A nurse is caring for a client who has been following the facility’s routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first?
A. Rub the client’s back for 15 min before bedtime.
B. Offer the client warm milk and crackers at 2100.
C. Allow the client to take a bath in the evening.
D. Ask the provider for a sleeping medication.
A
C. Allow the client to take a bath in the evening.
7
Q
A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A. “I’ll add plenty of carbohydrates to my meals.”
B. “I’ll take a short nap whenever I feel a little sleepy”
C. “I’ll make sure I stay warm when I am at my desk at work.”
D.” It’s okay to drink alcohol as long as I limit it to one drink per day.”
A
B. “I’ll take a short nap whenever I feel a little sleepy.”
8
Q
What does NPO mean?
A
Nothing by mouth.
9
Q
You are caring for a patient who has been experiencing pain with a recent dental procedure. What type of diet should you give the patient? A. Mechanical B. Low fiber C. Pureed D. Clear liquid
A
A. Mechanical
10
Q
If a patient is on a cardiac diet, what type of food should you tell the patient not to intake?
A
Fat and sodium
11
Q
What type of food should be limited in a diabetic diet?
A
starches, fruit, juice, milk, and sugars. and controlled carbohydrate intake
12
Q
To assess a stroke patient for complications secondary to inadequate swallowing, the nurse should do which of the following?
A. Auscultate the patient’s lungs.
B. Place the tip of a tongue depressor on the patient’s posterior tongue.
C. With a penlight, inspect the patient’s uvula and the soft palate.
D. Place fingers on the patient’s throat at the level of the larynx and ask him to swallow.
A
A. Auscultate the patient’s lungs.
13
Q
A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following? A. Chest x-ray B. Swallowing examination C. Nasogastric tube insertion D. Olfactory nerve evaluation
A
B. Swallowing examination
14
Q
Which of the following strategies for enhancing the intake of healthful food is appropriate for an adolescent?
A. Encouraging the adolescent to consume snack foods from the grains food group.
B. Permitting the adolescent to skip breakfast to enhance appetite for later meals.
C. Making healthful food choices more convenient and available for the adolescent.
D. Allowing the adolescent complete autonomy in making food choices.
A
C. Making healthful food choices more convenient and available for the adolescent.
15
Q
Which of the following dietary modifications should an adolescent engaging in sports implement?
A. Increase fats to 30% to 40% of daily kilocalories.
B. Drink water before and after sports activities.
C. Keep protein intake at the same level.
D. Decrease carbohydrates to 30% to 40% of daily kilocalories.
A
B. Drink water before and after sports activities.
16
Q
Which of the following are appropriate choices for a patient prescribed a full liquid diet? (Select all that apply) A. Plain yogurt B. Custard C. Ice cream D. Mashed potatoes E. Pureed meat F. Gelatin
A
A, B, C, F
17
Q
When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures?
A. Do not give the child peanut butter.
B. Have the child drink 28 to 32 ounces of milk daily.
C. Give the child 8 to 12 ounces of fruit juice daily.
D. Do not offer the child raw vegetables.
A
D. Do not offer the child raw vegetables.
18
Q
A nurse is caring for a patient who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the patient with feeding?
A. Provide the patient with a straw.
B. Offer the patient thin fluids.
C. Elevate the head of the bed 45 to 90 degrees.
D. Place food in the weaker side of the mouth.
A
C. Elevate the head of the bed 45 to 90 degrees.
19
Q
A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following?
A. Isolated measurements of height and weight are of greater significance than changes over time.
B. A weight increase of 4 lb in a patient with renal failure indicates retention of 1,000 mL of fluid.
C. The patient should be weighed on the same scale at the same time each day.
D. The ratio of heigh to wrist circumference is the most accurate way to identify obesity.
A
C. The patient should be weighed on the same scale at the same time each day.
20
Q
Which of the following is the primary purpose for asking a patient to keep a 3 to 7-day food diary?
A. To allow the patient to rely on health professionals to identify the problem areas.
B. To determine any changes in the patient’s appetite.
C. To evaluate any significant changes in body weight.
D. To assess the pattern of intake and compare with daily reference intakes.
A
D. To assess the pattern of intake and compare with daily reference intakes.
21
Q
Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits?
A. Identify the food location as though the plate was a clock.
B. Direct the order in which food items are consumed
C. Have the patient tilt their head forward while eating. D. Avoid talking to the patient during mealtime.
A
A. Identify the food location as though the plate was a clock.
22
Q
A nurse should recognize that which of the following is correct regarding albumin level as a diagnostic for nutritional status?
A. Albumin level is a poor short term indicator of protein status.
B. Hydration status does not affect a patient’s albumin level.
C. An albumin level of 3.2 g/dL is within the normal reference range.
D. Albumin level is calculated by keeping a 24 hr record of protein intake.
A
A. Albumin level is a poor short term indicator of protein status.
23
Q
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?
A. Give the client thin liquids.
B. Instruct the client to tuck their chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down and rest after meals.
A
B. Instruct the client to tuck their chin when swallowing.
24
Q
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates
A
D. Carbohydrates
25
```
A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil Soup
```
C. Vanilla custard
26
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply)
A. Older adults are more prone to dehydration than younger adults are.
B. Older adults need the same amount of most vitamins and minerals as younger adults do.
C. Many older men and women need calcium supplementation.
D. Older adults need more calories than they did when they were younger.
E. Older adults should consume a diet in low carbohydrates.
A, B, C
27
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following action should the nurse take to decrease the risk of another fall? Select all that apply.
A. Place a belt restraint on the client when they are sitting on the bedside commode.
B.Keep the bed in its lowest positions with all side rails up.
C. Make sure that the clients call light is in reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.
C, D, E.
28
A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?
A. "I will place the client on their side."
B. "I will go to the nurse's station for assistance."
C. "I will note the time that the seizure begins."
D. "I will prepare to insert an airway."
B. "I will go to the nurses station for assistance."
29
```
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority?
A. Extinguish the fire
B. Activate the fire alarm
C. Move clients who are nearby
D. Close all open doors on the unit
```
C. Move clients who are nearby
30
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority?
A. Complete a fall risk assessment
B. Educate the client and family about fall risks.
C. Eliminate safety hazards from the client's environment.
D. Make sure the client uses assistive aids in their possession.
A. Complete a fall risk assessment.
31
A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?
A. Open the windows in the client's room and allow the smoke to escape.
B. Obtain a class C fire extinguisher to extinguish the fire.
C. Remove all electrical equipment from the client's room.
D. Place wet towels along the base of the door of the client's room.
D. Place wet towels along the base of the door of the clients room.
32
What does R stand for when using RACE?
Rescue
33
What does A stand for when using RACE?
Alarm
34
What does C stand for when using RACE?
Contain
35
What does E stand for when using RACE?
Extinguish
36
What does P stand for when using PASS?
Pull the pin.
37
What does A stand for when using PASS?
Aim at the base of the fire.
38
What does S stand for when using PASS?
Squeeze the handle.
39
What does the last S stand for when using PASS?
Sweep the fire extinguisher from side to side.
40
How many radioactive patient's may a nurse take care of during their shift?
Only 1
41
When should you complete a fall risk assessment?
For each client at admission and at regular intervals.
42
Where should you place a patient's room who is a fall risk?
Near the nurse's station
43
How should you keep the bed positioned for clients who are fall risk?
low position and lock the brakes.
44
```
Nurses must know locations of which of the following in case of a fire? Select all that apply.
A. Fire alarm location
B. Fire extinguishers
C. Fire exits
D. Electrical outlets
```
A, B, C
45
What must you remove before leaving a patient's room, who is having radiation?
Your PPE.
46
Why do you have to make sure not to take ANYTHING outside of a patient's room who is receiving radiation?
So other people and patient's are not exposed.
47
T or F
| There are people who are designated and trained to deal with radiation materials and they will take care of them.
True
48
What is the main focus of a nurse in regards to fall risks, fires, and accidents?
PREVENTION
49
You enter your patient's room and prepare to perform a more thorough skin assessment while bathing him. He seems reluctant to allow you to proceed with this process. You respond appropriately by...
A. Informing him that his lack of hygiene puts the other patients at risk for infection.
B. Asking a nursing assistant to help immobilize the patient while you bathe him.
C. Explaining that you understand his reluctance but must check his skin for injuries.
C. Explaining that you understand his reluctance but must check his skin for injuries.
50
You prepare your patient for bathing. You must place your supplies in reach, and then you...
A. Start the procedure leaving the patient covered with his bed linens.
B. Replace the linens with a bath blanket, then begin the procedure.
C. Remove the patient's bedsheets and blanket and begin the bathing process.
B. Replace the linens with a bath blanket, then begin the procedure.
51
You begin the bathing process, promoting the patients comfort by...
A. Encouraging the patient to assist as much as possible.
B. Performing thee bath procedure as quickly as possible.
C. Educating the patient about the improper hygiene you previously observed.
A. Encouraging the patient to assist as much as possible.
52
While washing the patient's face, you note the presence of cerumen in his left ear canal. You...
A. Use a cotton-tipped applicator to remove the cerumen from the canal.
B. Use a damp cloth or gentle irrigation to loosen the debris from the canal.
C. Continue the bath because cerumen in the ear canal is an expected finding.
B. Use a damp cloth or gentle irrigation to loosen the debris from the canal.
53
You notice that your patient has mild edema of the lower extremities. You encourage venous return by...
A. Massaging the leg tissue deeply while washing the skin.
B. Applying firm pressure to the calves with a kneading motion.
C. Washing his legs using long, gentle, distal to proximal strokes.
C. Washing his legs using long, gentle, distal to proximal strokes.
54
While washing the patient's ankle and feet, you note the absence of hair and that the skin has a glossy appearance. The most likely explanation for these findings is...
A. A fungal infection of the skin
B. A lack of blood flow to these tissues
C. Frequent exposure to cold.
B. A lack of blood flow to these tissues.
55
To reduce the risk of aspiration during the bath, you...
A. minimize youth care, as the patient's gag-reflex is probably diminished.
B. Have another staff member assist you with the procedure.
C. Place the patient in supine position.
B. Have another staff member assist you with the procedure.
56
For an unconscious patient, you know that eye care...
A. Should be provided frequently
B. Includes using the same portion of a soft washcloth to clean both eyes.
C. Requires application of lubricating eye drops.
A. Should be provided frequently
57
While washing the patient's lower back you note an area near the sacrum that is erythematous and showing signs of further breakdown. You...
A. Massage the area to improve circulation to the skin
B. Gently wash the area with soapy water to help keep it clean.
C. Rub the area briskly with a towel after rinsing it to dry it thoroughly.
B. Gently wash the area with soapy water to help keep it clean.
58
The first step of foot care is to assess the client's fingers, toes, feet, and nails. You assess that the radial pulse and dorsalis pedis of each hand and foot. It is important to check these pulses because it lets you know if the client...
A. Is dehydrated
B. Has adequate blood flow to extremities.
C. Has any problems in his heart.
B. Has adequate blood flow to extremities.
59
While performing a complete bed bath for a patient, the nurse should...
A. Raise the room temperature
B. Completely remove the linens
C. Add soap to the water in the basin before beginning the bath.
D. Complete the bathing for one side of the body at a time.
A. raise the room temperature
60
A nurse is caring for a patient who is on long-term bed rest and requires frequent linen changes due to excessive diaphoresis. Which of the following is the priority rationale for frequent linen changes?
A. Moisture from excessive diaphoresis can cause skin breakdown.
B. Moisture on the sheets can cause discomfort to the patient.
C. It provides an opportunity to frequently evaluate the patient's skin on his back side.
A. Moisture from excessive diaphoresis can cause skin breakdown.
61
A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient?
A. "I'll swab the patient's mouth with lemon-glycerin swabs."
B. "I'll swab the patient's mouth with mouthwash."
C. "I'll swab the patient's mouth with chlorhexidine."
D. "I'll swab the patient's lips with a very small amount of mineral oil."
C. "I'll swab the patient's mouth with chlorhexidine."
62
When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include?
A. Inform the patient when morning hygiene care is provided at the hospital.
B. Schedule to provide care to the patient and her roommate at the same time.
C. Ask the patient in what order she typically performs her morning routine.
D. Plan to provide care before the next scheduled dose of pain medication.
C. Ask the patient in what order does she typically performs her morning routine.
63
A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection?
A. Massaging the reddened area of the patient's skin.
B. Washing eyes from the outer canthus to the inner canthus.
C. Washing the patient from the shoulder down to the fingertips with smooth, short strokes.
D. Cleaning the least-soiled areas prior to cleaning the most soiled areas.
D. Cleaning the least-soiled areas prior to cleaning the most soiled areas.
64
A nurse observes an assistive personnel make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task?
A. The AP records the task when it is completed.
B. The AP wears sterile gloves while making the bed.
C. The AP makes a mitered corner with the blanket and spread.
D. The AP reuses the patient's blanket and spread.
D. The AP reuses the patient's blanket and spread.
65
A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse?
A. "Since you are not eating we can wait and do it before bedtime."
B. " Oral care is still important even though you are not eating."
C. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out."
D. "We will wait until your family gets here to help."
B. "Oral care is still important even though you are not eating."
66
```
You are washing your hands with nonantimicrobial soap and water prior to repositioning a patient in bed. During the handwashing procedure, it is important to...
A. Make sure that the water is hot
B. Continue for at least 15 seconds
C. Use a liquid soap preparation
D. Remove rings and watches first.
```
B. Continue for at least 15 seconds
67
To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this it that....
A. Drying provides the full antiseptic effect.
B. Residual alcohol can easily stain clothing
C. Excess gel could transfer to the patient
D. Slippery gel can make you drop supplies
A. Drying provides the full antiseptic effect
68
Standard precations mandate...
A. Rinsing gloves that become visibly soiled during use.
B. Using antimicrobial soap for routine handwashing
C. Disinfecting hands immediately after removing gloves
D. Keeping gloves on when touching environmental surfaces.
C. Disinfecting hands immediately after removing gloves
69
```
Contact precautions would be mandated for a hospitalized adult patient diagnosed with...
A. hepatitis B
B. measles
C. Meningitis
D. Infectious diarrhea
```
D. infectious diarrhea
70
```
After completing a procedure that required donning PPE consisting of a gown, N95 Respirator, a face shield, and gloves. Which of the following should the nurse remove first when removing PPE separately?
A. the gloves
B. the gown
C. the face shield
D. the N95 respirator
```
A. the gloves
71
```
you are about to irrigate a patient's open wound. Besides gloves, which other item of PPE must you wear?
A. a sterile gown
B. goggles
C. face shield
D. an N95 respirator
```
C. a face shield
72
```
Which product can affect the permeability of gloves?
A. antimicrobial soap and water
B. alcohol-based antiseptic gel
C. petroleum-based hand lotion
D. water-based hand lotion
```
C. petroleum-based hand lotion
73
```
You are caring for a patient diagnosed with mycoplasma pneumonia. Droplet precautions have been instituted, so you must...
A. wear a respirator
B. protect your eyes
C. use an air filter
D. wear shoe covers
```
B. protect your eyes
74
A patient has a healthcare-associated infection. (HAI). This terminology means that the patient....
A. became infected due to compromised immunity
B. was infected during a therapeutic procedure
C. inhaled pathogens in a healthcare setting
D. acquired an infection while hospitalized
D. acquired an infection while hospitalized
75
```
A nurse should recognize that which of the following is an indication for oxygen therapy?
A. respiratory rate 32/min; anxiety
B. Dyspnea; PaO2 90 nm Hg
C. Chest pain, FiO2 65% for 4 days
D. Tachypnea; SaO2, 90%
```
D. Tachypnea; SaO2, 90%
76
A home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must...
A. clean the mask with soapy water every day
B. reposition the elastic band frequently
C. apply petroleum jelly around the inside the nares
D. make sure there is adequate condensation in the tubing
B. reposition the elastic band frequently
77
Administering oxygen therapy with a nonrebreather mask has which of the following advantages?
A. offers the highest oxygen concentration of the low-flow systems
B. provides oxygen concentration of 40% to 60%
C. Incorporates a design that requires minimal monitoring of the patient
D. is designed for safety once the mask's valves and flaps are sealed
A. offers the highest oxygen concentration of the low-flow systems
78
```
A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated for this patient?
A. simple face mask
B. nasal cannula
C. venturi mask
D. face tent
```
C. venturi mask
79
```
Oxygen therapy is prescribed for a patient who is brought to an emergency department in the early stages of hypoxia. When assessing this patient, the nurses should expect to find which of the following clinical indicators?
A. elevated blood pressure
B. decreased respiratory rate
C. cyanosis
D. peripheral edema
```
A. elevated blood pressure
80
```
A patient has been receiving oxygen PRN via nasal cannula for 4 hr. Which of the following assessment findings help indicate that oxygen therapy has been effective?
A. respiratory rate 14/min
B. SaO2; 90%
C. cardiac output 5.6 L/min
D. PaCO2; 68 mm Hg
```
A. respiratory rate 14/min
81
```
A nurse is caring for a client who is receiving internal tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?
A. Supine
B. Semi-Folwer's
C. Semi-prone
D. Trendelenburg
```
B. Semi-Fowler's
82
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 additional staff to assist with the transfer
C. Use a transfer belt and assist the client back into bed.
D. Determine the client's ability to help with the transfer
D. Determine the client's ability to help with the transfer
83
A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?
A. "Lie on your back with your head and shoulders supported by a pillow"
B. "Have your head turned to the side while you lie on your stomach"
C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table"
D. "Lie on your side with your top arm resting on the bed and your weight on your hip"
C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table"
84
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 repositioning a client
B. Avoid twisting your spine or bending at the waist
C. Keep your knees slightly lower than your hips when sitting for long periods of time
D. Use smooth movements when lifting and moving clients
E. Take a break from repetitive movements every 2 to 3 hours to flex and stretch your muscles
A, B, D
85
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should 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 my center of gravity is, the more stability I have"
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"
B, C, D.
86
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADL's. Which of the following rationales for self-care should the nurse communicate to the family?
A. Allowing the client to function independently will strengthen muscles and promote healing.
B. The client needs privacy at times for self-reflecting and organizing life.
C. The client's sense of loss can be lessened through retaining control of some areas of life.
D. Performing ADL's is a requirement prior to discharge from an acute care facility.
C. The client's sense of loss can be lessened through retaining control of some areas of life.
87
```
A nurse is caring for a patient who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states " I told myself that I would go through with the surgery and quit smoking. If I could just live long enough to attend my child wedding." Based on the Kubler- Ross model, which stage of grief is the client experiencing?
A. Anger
B. Denial
C. Bargaining
D. Acceptance
```
C. Bargaining
88
A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, " I hate them for leaving me." Which of the following statements should the nurse make to facilitate the mourning for the partner? Select all that apply.
A. "Would you like me to contact the chaplain to come and speak with you?"
B. "You will feel better soon. You have been expecting this for a while now."
C. "Let's talk about your children and how they are going to react."
D. "You know, it's quite normal to feel anger toward your loved one at this time."
E. "Tell me more about how you are feeling."
A, D, E
89
```
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include?
A. Regular breathing patterns
B. Warm extremities
C. Increased urine output
D. Decreased muscle tone
```
D. Decreased muscle tone
90
A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? Select all that apply.
A. Remove the dentures from the body
B. Mae sure the body is lying completely flat
C. Apply fresh linens and place a clean gown on the body
D. Remove all equipment from the bedside
E. Dim the lights in the room
C, D, E
91
What are the 5 stages of grief in the Kubler-Ross model?
```
Denial
Anger
Bargaining
Depression
Acceptance
```
92
Which stage of the Kubler-Ross model is this?
| "The client has difficulty believing in an expected or actual loss."
Denial
93
Which stage of the Kubler-Ross model is this?
| "The client directs anger toward the self, others, a deity, objects, or the current circumstances."
Anger
94
Which stage of the Kubler-Ross model is this?
| "The client negotiates for more time or a cure."
Bargaining
95
Which stage of the Kubler-Ross model is this?
| "The client is overwhelmingly saddened by the inability to change the situation"
Depression
96
Which stage of the Kubler-Ross model is this?
| "The client acknowledges what is happening and plans for the future by moving forward."
Acceptance
97
A nurse is performing mouth care for a patient who is unconscious. Which of the following actions should the nurse take?
A. Turn the clients head to the side
B. Place two fingers in the client's mouth to open it
C. Brush the client's teeth once per day
D. Inject a mouth rinse into the center of the client's mouth.
A. turn the clients head to the side
98
```
A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?
A. Face
B. Feet
C. Chest
D. Arms
```
A. face
99
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?
A. Give the client thin liquids
B. Instruct the client to tuck their chin when swallowing
C. Have the client use a straw
D. Encourage the client to lie down and rest after meals
B. Instruct the client to tuck their chin when swallowing
100
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A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup
```
D. lentil soup
101
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all that apply.
A. Older adults are more prone to dehydration than younger adults are.
B. Older adults need the same amount of most vitamins and minerals as younger adults do.
C. Many older men and women need calcium supplementation.
D. Older adults need more calories than they did when they were younger.
E. Older adults should consume a diet low in carbohydrates.
A, B, C.
102
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?
A. "I spent my whole life dreaming about retirement, and now I wish I had my job back."
B. "It's been so stressful for me to have to depend on my child to help around the house."
C. "I just heard my friend Al died. That's the third one in 3 months."
D. "I keep forgetting which medications I have taken during the day."
D. "I keep forgetting which medications I have taken during the day."
103
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? Select all that apply.
A. "Eat three large meals a day"
B. " Eat your meals in front of the television"
C. "Eat foods that are easy to eat, such as finger foods"
D. "Invite family members to eat meals with you"
E. "Exercise every day to increase appetite"
C, D, E.
104
A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? Select all that apply.
A. Human papillomavirus (HPV) immunization
B. Pneumococcal immunization
C. Yearly eye examination
D. Periodic mental health screening
E. Annual fecal occult blood test
B, C, D, E.
105
A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? Select all that apply.
A. Increase protein intake to increase muscle mass
B. Decrease fluid intake to prevent urinary incontinence
C. Increase calcium intake to prevent osteoporosis
D. Limit sodium intake to prevent edema
E. Increase fiber intake to prevent constipation
A, C, D, E.
106
```
A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? Select all that apply.
A. Skin thickening
B. Decreased height
C. Nail thickening
D. Increased saliva production
E. Decreased bladder capacity
```
B, C, E.
107
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?
A. The client evaluates their behavior after a social interaction.
B. The client states they are learning to trust others.
C. The client wishes to find meaningful friendships.
D. The client expresses concerns about the next generation.
D. The client expresses concerns about the next generation.
108
A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? Select all that apply.
A. Develop an acceptance of diminished strength and increased dependence on others.
B. Spend time focusing on improving job performance.
C. Welcome opportunities to be creative and productive.
D. Commit to finding friendship and companionship.
E. Become involved with community issues and activities.
B, C, E
109
```
A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiological functions? Select all that apply.
A. Metabolism
B. Ability to he'sr low pitched sounds
C. Gastric secretions
D. Far vision
E. Glomerular filtration
```
A, C, E
110
A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? Select all that apply.
A. Eye examination every 1 to 3 years
B. Decrease intake of calcium supplements
C. DXA screening for osteoporosis
D. Increase intake of carbohydrate in the diet
E. Screening for depressive disorders
A, C, D, E
111
A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?
A. "I am struggling to accept that my parents are aging and need so much help."
B. "It's been so stressful for me to think about having intimate friendships"
C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish"
D. "I love my grandchildren, but my child expects me to relive my parenting days"
B. "It's been so stressful for me to think about having intimate friendships"
112
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's 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 client who has patial-thickness and full-thickness burns to the face, neck, and chest.
113
A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? 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. Instruct ambulatory clients in the hallways to return to their rooms.
B, C, D
114
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. Leave the clothing in place until emergency personnel arrive.
C. Brush the chemical off the skin and clothing
115
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?
A. "I will get the caller off the phone as soon as possible so I can alert the staff."
B. "I will begin evacuating clients using the elevators."
C. "I will not as any questions and just let the caller talk."
D. "I will listen for background noises."
D. "I will listen for background noises."
116
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 stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? Select all that apply.
A. A client who is dehydrated and receiving IV electrolytes and fluid
B. A client who has a nasogastric tube to treat a small bowel obstruction
C. A client who is scheduled for elective surgery
D. A client who has chronic hypertension and blood pressure 135/85 mm Hg
E. A client who has acute appendicitis and is scheduled for an appendectomy.
C, D
117
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing a sterile field?
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 microorganisms into the surgical wound.
D. Keep a box of facial tissues nearby for the client to use during the dressing change.
C. Place a mask on the client to limit the spread of microorganisms into the surgical wound.
118
```
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. The flap farthest from the body.
119
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? Select all that apply.
A. A bottle containing a sterile solution
B. 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
120
A nurse is reviewing hand hygiene techniques with a group of assistive personnel. 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.
121
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
122
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? Select all that apply.
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the door.
D. Cotton bedding and clothing should be replaced with items made of wool.
E. A fire extinguisher should be readily available in the home.
B, C, E
123
```
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heatstroke will have which of the following? A
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
```
A. Hypotension
124
A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding?
A. "I will set my water heater to 130 degrees"
B. "Once my baby can sit up, they should be safe in the bathtub."
C. "I will place my baby on their stomach to sleep"
D. "Once my infant starts to push up, I will remove the mobile from the crib."
D. "Once my infant starts to push up, I will remove the mobile from the crib."
125
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in the teaching?
A. Carbon monoxide as a distinct odor.
B. Water heaters should be inspected every 5 years
C. The lungs are damaged from carbon monoxide inhalation
D. Carbon monoxide binds with hemoglobin in the body
D. Carbon monoxide binds with hemoglobin in the body.
126
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? Select all that apply.
A. Most food poisoning is caused by a virus.
B. Immunocompromised individuals are at increased risk for complications from food poisoning
C. Clients who are at high risk should eat or drink only pasteurized dairy products.
D. Healthy individuals usually recover from the illness in a few weeks.
E. Handling raw and fresh food separately can prevent food poisoning.
B, C, E
127
```
A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which fo the following gross motor skills are expected findings in the next 3 months? Select all that apply.
A. Rolls from back to front
B. Bears weight on legs
C. Walks holding onto furniture
D. Sits unsupported
E. Sits down from a standing position
```
A, B, D
128
A nurse is interviewing safety measures with the parent of an 8-month-old infant. Which fo the following statements made by the parents indicates an understanding of safety for the infant?
A. "My baby loved to play with the crib gym, but I took it out of the crib."
B. "I just bought a soft mattress so my baby will sleep better."
C. "My baby really likes sleeping on the fluffy pillows we just got"
D. "I put the baby's car seat out of the way on the table after I put him in it."
A. "My baby loved to play with the crib gym, but I took it out of the crib."
129
A nurse is reviewing the car seat safety with the patents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include?
A. Use a car seat that has a three-point harness system.
B. Position the car seat so that the infant is rear-facing.
C. Secure the car seat in the front passenger seat of the vehicle.
D. Convert to a booster seat after 12 months.
B. Position the car seat so that the infant is rear-facing.
130
A nurse is assessing a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect? Select all that apply.
A. Sleeps 14-16 hours each day
B. Posterior fontanel closed
C. Pincer grasp present
D. Hands remain in a closed position
E. Current weight is the same as birth weight
A, D, E
131
The mother of a seven-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? Select all that apply.
A. "It might be good to add bananas, as they can help with loose stools"
B. "Let's make a list of all the food your baby is eating so we can spot any problems"
C. "Did the changes begin after you started one particular food?"
D. "Has your baby been vomiting since starting these new foods?"
E. "Most babies react with a little indigestion when you start new foods."
B, C, D.
132
A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? Select all that apply.
A. Store toxic agents in locked cabinets
B. Keep toilet seats up
C. Turn pot handles toward the back of the stove
D. Place safety gates across stairways
E. Make sure balloons are fully inflated
A, C, D
133
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A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? Select all that apply.
A. Building models
B. Working with clay
C. Filling and emptying containers
D. Playing with blocks
E. Looking at books
```
C, D, E
134
A nurse is reviewing nutritional guidelines with the parents of a two-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?
A. "I should keep feeding my son whole milk until he is 3."
B. "It's okay for me to give my son a cup of apple juice with each meal"
C. "I'll give my son about 2 tablespoons of each food at mealtimes."
D. "My son loves popcorn, and I know it is better for him than sweets."
C. "I'll give my son about 2 tablespoons of each food at mealtimes."
135
```
A nurse is reviewing the Centers for Disease Control and Prevention's immunization recommendations with the guardians of preschoolers. Which of the following vaccines should the nurse include in this discussion? Select all that apply.
A. Haemophilus influenza type B
B. Varicella
C. Hepatitis A
D.Polio
E. Seasonal influenza
```
B. Varicella
D. Polio
E. Sesonal influenza
