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BSN-206 Final
Weekly ISB Accumulation: Study Guide for Final
| Question | Answer |
|---|---|
| Which of the following patients would require follow up: a. a newborn w/a respiratory rate of 40 breaths pm b. an adolescent w/a respiratory rate of 16 breaths pm c. a child w/a respiratory rate of 20 bpm d. an adult w/a respiratory rate of 10 bpm | d. an adult w/a respiratory rate of 10 breaths per minute |
| Which of the following vital signs for an older adult would be acceptable (norm limits) a. T-96.8, P-60, R-18, BP 160/90, O2 93% b. T-97.0, P-60, R-16, BP 116/78, O2 95% c. T-98.0, P-76, R-22, BP 110/70, O2 88% d. T-98.6, P-56, R-20, BP 120/80, O2 91% | b. T-97.0, P-60, R-16, BP 116/78, O2 95% |
| The nurse has delegated the task of temperature assessment to the NAP. Which info should be provided to the NAP? a. type of temp requried b. pts dx c. what changes to report immediately to nurse d. the freq for taking/monit the temp e. patients age | a. type of temperature required c. what changes to report immediately to the nurse d. the frequency for taking or monitoring of the temperature |
| Which of the following situations may affect a patient's vital signs? a. time of day b. pain rated as a 7/10 c. moving from lying to standing position d. isolation precautions e. occupation | a. time of day b. pain rated as a 7/10 c. moving from lying to standing position |
| The nurse will take the patient's vital signs preop and record them. Why is it necessary to take vital preop? | a. ensure equipment is calibrated and functional >b. verify pt is not experiencing any complications that may contraindicate surgery >c. to provide pt w/reassurance that they are being cared for by competent staff d. determine if pt is "feeling funny" |
| The NAP reports to the nurse a 65-year old patients blood pressure is 160/98. What is the appropriate initial response of the nurse? | >>a. assess the patients blood pressure b. document this as a normal finding in an elderly patient c. instruct the NAP to obtain a full set of vital signs d. ask the NAP if pt is nauseous |
| Which patient would it be appropriate for the nurse to delegate vital signs? a. New admission to the hospital b. Patient w/recent complain of headache c. Patient transferred fro ICU d. Elderly nursing home resident | d. elderly nursing home patient |
| Which person would be expected to have the lowest body temperature? a. a 16 year old who ran 1 mile b. a child playing softball c. a 80-yr old who walked half a mile d. a toddler who is febrile | c. a 80-yr old who walked half a mile |
| The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? | a. Change the red thermometer probe and take the patient's temperature rectal >>b. Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature c. take pt's temp using axillary route and add 1 deg F |
| For which patient would a tympanic thermometer be the preferred thermometer to use? | >a. a tachypneic who is receiving oxygen by nasal cannula b. a newborn that required continuous temperature monitoring c. a marathon runner who developed weakness during the race d. a ped pt who had tubes surgically placed in ears |
| Which of the following patients would require frequent assessment of their temperature? [select all] | a. a child who is below the normal ht/wt for his age >b. a young adult with a WBC of 15,000 >c. an adult female in the recovery room following a hysterectomy >d. a pt receiving a blood transfusion for chronic anemia e. elderly pt who needs assistance |
| The NAP reports that the patient temp is 39 def C (102.2F). Which of the following are appropriate nursing actions? [select all] | a. limit pts fluid intake b. place pts feet in a tub of cool water w/ice >>c. remove pt's blankets >>d. administer an antipyretic to the pt as ordered e. apply a hyperthermia blanket as ordered |
| Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? [select all] | >a. insert the red-tipped therm in pts mouth b.blue-tipped probe to assess axillary temp c.wait for a tone to read tympanic therm d.pull the pinna up, back, and out in an adult when using tympanic >e. The single-use chemical dot therm is used & reused |
| Identify the factors that ay have an affect on an elderly patient's temperature: [select all] a. room temperature b. drinking a cold glass of water c. infection d. pts height e. participation in PT exercises | a. room temperature b. drinking a cold glass of water c. infection e. participation in PT exercises |
| If a 52 year old patient has a normal temperature, what range should the patient's temperature fall within? a. 35-36 C (95-96.8F) b. 96.8-100.4 F (36-38C) c. 37-39C (98.6-102.2F) d. 96.8-98.6F (36-37C) | b. 96.8-100.4 F (36-38C) |
| A newborn pt's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? a. chemical dot b. rectal electronic c. temporal artery d. tympanic | c. temporal artery |
| The task of pulse assessment could be delegated to the NAP for which of the following patients? | >>a. a radial pulse on a pt w/a 1200 mL fluid restrict b. a femoral pulse following a lower leg amp c. a radial pulse of a pt in ER w/CP >>d. temporal pulse of a child e. an apical pulse of a pt who is to receive a cardiac drug |
| Which of the following pts wold be at risk for having an alteration in peripheral pulse? [select all] a. a pt w/alzheimers b. pt who was just dx w/cancer c. a pt w/ PVD d. a pt who is receiving bolus IV fluids e. elderly pt w/ T1DM who is healthy | b. pt who was just dx w/cancer c. a pt w/ PVD d. a pt who is receiving bolus IV fluids |
| Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? | a. check the carotid pulses one side at a time b. reassess the radial pulse for 30s >>c. auscultate the apical pulse for quality and rate d. check the radial pulse on the opposite side |
| What is the normal pulse range for an adult? a. 90-140 bpm b.120-160 bpm c. 60-100 bpm d. 50-80 bpm | c. 60-100 bpm |
| The nurse should routinely auscultate the apical pulse w/the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. True or False | False |
| In which of the following patients would the nurse expect to find a decrease in pulse rate? [select all] | a. a student who is getting ready to take an exam b. a pt who experienced a bleeding episode c. a newborn following a heelstick >>d. a pt returning from the operating room >>e. a pt who received morphine for pain |
| The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? [select all] | a.assessing for a pulse on the thumb side of the wrist b.assessed the pts BP before taking the pts pulse c.failed to auscultate the pts wrist w/a stethoscope d.assessing for a pulse on the ulnar side e.pressing down too hard on the pts radial site |
| What is an appropriate nursing intervention for an adult patient w/a RR of 30 breaths per minute? [select all] | a.tell pt their breaths are being counted so the pt will breathe slower b.admin a bronchodilator that will decr RR c.record normal RR in pts EMR >d.count RR again for full 1m >e.assess physiologic factors that may be causing the pt to breath so fast |
| Which of the following may increase both rate and depth of respiration? [select all] | >a. walking 1 mile briskly >b. feeling anxious during a test c. head injury from an accident d. using a bronchodilator prior to exercise e. taking an opioid to relieve pain f. 7/10 pain >g. having an addiction to amphet/coce h. smoking |
| When assessing the RR, the nurse has a difficulty seeing the pts chest rise and fall w/insp.&exp. What is the nurses's best action? | a. have another nurse assess RR b. document inability to visualize insp./exp >>c. move the pts arm over their chest and feel rise/fall of chest d. remove pts gown for better visual of chest mvmnt. |
| How can the nurse best obtain an accurate measurement of a patient's RR? | a. assess resps while pt is talking b. auscultate lung sounds, asking pt to take deep breath in nose, out through mouth >>c. continue to act as though taking the pts pulse while observing rise/fall of pts chest d. inform pt when monitoring respirations |
| The nurse is validating the NAPs skill w/ respiratory rate assessment. which of the following actions, if made by the NAP, indicates further instruction is needed? | >>a. when pt inhales, the NAP counts that as one, and exhale = 2 b. when pts RR<12 or >20, count RR for 1 min c. when pts RR is irregular, count for 1 min d. after taking pulse, hold pts wrist, moving the arm across pts chest and focus on pts breathing |
| The nurse assesses the BP in both arms a newly admitted pt. Why would the nurse do this? | a. practice technique >>b. determine if there is a difference in readings c. verify BP reading is 10 mmHg higher in dominant arm d. assess for a pulse deficit and record this as baseline |
| Which of the following pts would be considered HTN after having 2+ consistent readings of these values? | a. AfAm pt w/a systolic BP of 100 >>b. a football player w/diastolic BP of 94 c. elderly pt w/a systolic BP of 88 d. pregnant woman w/a diastolic BP of 67 |
| For which pt should yo avoid using a leg pressure cuff (thigh cuff) to assess BP? a. pt who is a double arm amputee b. pt w/a DVT c. pt w/a hx of stroke d. pt a/an arteriovenous shunt located in forearm for hemodialysis | b. pt w/a DVT |
| The student nurse is unsure of the BP measurement. What should the student nurse do first? a. wait 30s and repeat measurement on same arm b. assess BP in other arm c. get nurse to assess BP d. determine if the pt received an antiHTN medication | b. assess BP in other arm |
| It's 0700 and the nurse takes the VS of a post-op pt and find his BL is elevated. Which of the following could explain the cause for this alteration in BP? | a. pt has a temp of 99.0F when assessed rectally b. pt has been NPO since midnight before surg. >>c. pt complains fo 9/10 pain d. body is compensating for the cool environment of surgical site |
| The pt has a hx of L.mastectomy. Where should the nurse take the pts BP? a. right arm b. left arm c. right leg d. left leg | a. right arm |
| The nurse is unable to obtain a BP reading using an electronic BP machine on a post-op pt. The machine reads "error". What priority action should the nurse take? | a. reattempt using a diff electronic BP machine b. notify the healthcare provider of this change in condition c. increase pts rate of IV fluids >>d. take pts BP manually |
| The NAP reports to the nurse the patient's respirations are 32 and the pt is complaining of SOB. What is the best action by the nurse at this time? | a. request NAP to obtain pulse ox and report back b. ask NAP to obtain and doc. full VS >>c. assess the pt, including pulse ox reading d. notify provider of changes |
| Which pt is at high risk for the pulse ox alarm to sound? a. pt w/a continuous reading of 84% b. pt who is receiving O2 via/ face mask c. pt who has an intermittent pulse ox reading of 95% d. pt w/a HR of 64 bpm | a. pt w/a continuous reading of 84% |
| A pt complains of feeling excessively tired. Which statement, if made by NAP, indicates further instruction is necessary? | >>a.I will turn the cont pulseox alarms off at night so you can sleep b.I can give you a back massage to help you relax c.If the finger clip is bothering you, I can attach a probe to your ear d.I will notify the nurse that you need your sleeping med |
| The NAP tells the nurse the pts pulse ox is 85% on RA. What nursing action(s) should the nurse take? [select all] | a. start O2 at 2L by cannula >>b. reassess the pts pulse ox >>c. place pt in high-fowlers d. have NAP take VS >>e. assess the pts resp & card status |
| The nurse reads the following entry in a pts EMR. The pt has an order for SpO2 Q4. What is the best action? 0800: unable to obtain pulseox reading. attemptd x2 fingers/hand. pts fingers cool to touch. pt states artif nails. pt on 2L. Respir: nonlabored | a. remove one of pts acrylic nail and attemp reading b. place pts hands under warm water and attemp reading >>c. have NAP use diff. site (ear) d. nothing further |
| An elderly pt was admitted to a med unit w/severe fluid/electrolyte imbalance. His family says he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety w/o having to use restraints? [select all] | a. use a security cam to monitor pt >>b. make staff assignments for pts adjacent rooms >>c. activate the bed alarm when the pt is in bed >>d. perform nurse toilet and turn on comfort & safety round hrly e. admin IV fluids to reverse fluid imbal. |
| a pt is admitted to a med unit w/pna. She is able to ambulate on her own to the bathroom. What safety precautions should be take for this pt? [select all] | >a. explain use of call light >b. keep bed in low, locked position c. keep side rails up when pt is in bed d. place a bedside commode near bed w/back to wall >e. ensure pathway to b.room is clear >f. keep pts personal items on the overbed table |
| The nurse walking down the hospital corridor glances into the pts room & sees the pts feet and legs sticking out from the bathroom door.The nurse immediately goes into the room & determines that the pt has fallen.What actions should be taken? [select all] | >a. call for assistance >b. assess for injury >c. notify provider d. avoid moving pt until provider arrives >e. assess situation for precipitous factors f. apply restraint after return pt to bed >g. fill out occurrence report |
| Which of the following are appropriate safety measures for the use of a wheelchair? [select all] | >>a. brakes are locked when pt is being trans into chair b. brakes on side near bed are locked when pt is being trans into chair c. keep footplates low for trans >>d. back the chair in/out of elevator >>e. seat pt in chair w/butt against back of seat |
| Which of the following pts is at greatest risk for experiencing a fall? a. a confused pt w/a hx of previous fall b. pt who ambulates by holding onto furniture c. recently admitted pt d. pt who wears glasses to read | a. a confused pt w/a hx of previous fall |
| A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies [select all] a. prolonged bed rest b. hypovolemia c. low body weight d. antihypertensives e. room temp | a. prolonged bed rest b. hypovolemia d. antihypertensives |
| The nurse is getting a patient with right-sided weakness up in a chair. One what side of the bed should the nurse place the chair? a. on the patients left side b. on the patient's weak side c. it doesn't matter d. whichever the pt prefers | a. on the patients left side |
| The nurse is planning tasks for the day. Which of the following pts would require repositioning at this time? [select all] | >>a. pt in correct body alignment who was turned 2 hrs ago b. pt who has been sitting a chair for 10 min >>c. comfortable pt w/paraplegia who has been sitting for 30 min d. pt who was repositioned for comfort 30 min after being moved into bed |
| Which of the following patients should be allowed to lie back down? | a.pt who was transfer to chair & says she was more comfortable in bed. Providers orders = in chair 2xd b. pt BP is 120/80. transfer, BP now 112/78 >c. pt who complains of dizz/nausea when on bedside d. pt whose BP is 110/70 prior to trans. now = 125/80 |
| Which of the following techniques is used to assess muscle strength in a pt? a. palpate the muscle b. observe the pt at rest c. apply an opposing force/resistance d. percuss the muscle | c. apply an opposing force/resistance |
| What is an increased thoracic curvature, common in older adults, called? a. Swayback b. Kyphosis c. Scoliosis d. Lordosis | b. Kyphosis |
| Neck flexion and extension should be: a. 90 deg b. 45 deg c. 30 deg d. 70 deg | b. 45 deg |
| Which of the following findings in a musculoskeletal assessment would be considered abnormal? (select 2) a. Bogginess b. Symmetry c. Nodules | a. Bogginess c. Nodules |
| What does a goniometer measure? a. angles of extension & flexion b. muscle strength c. cranial nerve function d. joint stability | a. angles of extension & flexion |
| The nurse is helping a pt w/hemiparesis take a few steps. a gait belt has been applied. The pt is using a cane. Where should the nurse stand in relation to the pt? a. on the pts weak side b. infront of the pt c. on the pts strong side d. behind the pt | a. on the pts weak side |
| The nurse is preparing to initiate ambulation w/a pt who is recovering from a stroke. What info will help the nurse determine how far to walk? | a. review the EMR to see how far the pt has walked during the past several thera ambulations b. review EMR of pts who are at similar point in their stroke rehab >>c. ask the pt how far she would like to go d. review the providers order |
| The nurse has applied a gait belt to a post-op pt to facilitate ambulation. W/in a few feet of the bed, the pt begins to complain of dizziness & leans heavily on the nurse. What wold be the nurses's initial response? | a. attempt to sit the pt down on a chair just a few steps away b. try to hold to pt up until the dizziness passes c. call for assistance in aloud but calm voice >>d. slowly lower pt to the floor |
| The nurse is preparing to delegate the ambulation of a pt w/the use of a gait belt to NAP. Which statement made by the NAP required the nurse to f/u? | >>a. I will use the under-axillae technique to help him up to a standing pos b. I will be sure to put nonskid slippers on the pt before getting him up to ambulate c. I will grasp the gait belt in the mid of the pts back |
| The nurse is ambulating a pt w/a gait belt when he says he feels sick to his stomach. What would the nurse do? a. return pt to bed or chair b. ease him to floor c. encourage the pt to complete the distance of ambulation d. help him to restroom | a. return pt to bed or chair (whichever is closer) |
| When preparing to move a pt in bed, what will the nurse do first? a. assemble adequate help to move the pt b. assess the pts ability to help w/moving c. decide on the most effective means of moving the pt d. determine pts weight | b. assess the pts ability to help w/moving |
| When preparing to move a pt in bed w/the help of an assistant, which posture will both caregivers use to ensure their own safety? a. stand w/feet together b. flex hips & knees c. shift body weight from back leg to front leg d. stand w/knees locked | b. flex hips & knees |
| A pt who weights 200 lbs needs to be moved up in bed w/the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? a. the nurse can carry out this move alone b. minimum of 2 c. none d. at least 3 | d. at least 3 |
| In which position will the nurse place the pt to move him/her up in bed? a. sitting in the bed b. supine w/head of the bed at 30 degree angle c. supine w/the head of bed flat d. prone w/head of bed flat | c. supine w/the head of bed flat |
| A pt will be moved up in bed w/the use of a friction-reducing device. How will the nurse place this device under the pt? | a. sit the pt up in bed, place the device behind shoulders b. lift pt to place the device directly under him/her >>c. roll pt from side-side, and place the device under the draw sheet d. remove the draw sheet, and replace it w/the device |
| Which pt is most at risk of developing permanently impaired mobility? | a. 11 yr boy w/fractured pelvis during a fall b. 55 yr woman w/mental illness who is malnourished c. 79 yr man recovering from surg. >>d. 72 yr woman hospitalized w/anemia assoc w/diabetic neuropathy |
| The nurse notes that a pts L.elbow is resistant to ext/flex while performing ROM exercises. What is the appropriate nursing action? | a. inform provider that pt is uncooperative w/exercise >>b. perform ROM to L.elbow until resistance is met c. omit all ROM exercise until provider is notified d. move joint though ROM exercises |
| The nurse is performing passive shoulder & elbow exercises for a pt who is recovering from surg. to remove a soft-tissue tumor in upper arm. Why does the nurse cup one hand around the pts elbow & support the forearm & wrist during the ROM exercises? | a. to listen for crepitus in joint >>b. to ensure stability while exercising the joint c. to assess the pts muscle tension d. to keep the arm above the level of the heart |
| Which of the following are basic guidelines when assisting a pt w/passive ROM? | a. exerc should be performed w/o support to each joint b. exerc should be done frequently to lessen pain for the pt >>c. each joint is exercised to the point of resistance but not pain d. exerc should be continued until the point of fatigue/pain |
| Why would the nurse ask a PT to perform passive ROM exercises for a pt w/lower extremity injuries sustained in a motor vehicle crash? | a. pt is reluctant to perform the exerc. b/c he is worried about re-injury >>b. pt has orthopedic trauma c. pt is an older adult or has chronic condition d. pt has pain exacerbated by exerc |
| When preparing to safely transfer a pt from a bed to wheelchair using a transfer belt, the nurse would do what first? | a. determine whether to transfer the pt to a w.chair or chair >>b. assess the pts physiological capacity to transf. c. assess pts vial signs d. coordinate extra help |
| Which instruction would the nurse give a pt who is able to assist w/transfer from a bed to a wheelchair using a transfer belt? | a. please tell me how I can best help you get up off the bed & stand up b. when I count to three, please rock yourself into a standing pos. >>c. push down on the mattress w/both hands & stand when I count to 3 d. hold my waist while I help you stand |
| A pt lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the pt to the side of the bed? | a. help pt put on skid-resistant footwear b. place the transfer belt over the pts clothing c. position the chair so that the pt will move toward his/her stronger side >>d. raise the head of the bed 30 degrees |
| The nurse is preparing to transfer a pt w/left sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the pt to assume? | >>a. place stronger leg forward & weaker leg toward the back b. place both feet together on the floor c. extend both of your legs & feet d. place your weaker foot forward & your stronger leg toward the back |
| A pt had been transferred to a wheelchair w/a transfer belt. What is one action the nurse would take to position the pt safely in the chair? | a. ask the pt to rate his/her pain level b. remove wheelchair leg rests c. remove the transfer belt >>d. lower foot rests, and place the pts feet on them |
| What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? a. lower the head of the bed b. elevate the head of the bed c. remove the pts eyeglasses d. have the pt cross the arms over the chest | d. have the pt cross the arms over the chest |
| When preparing for sage pt transfer using a hydraulic lift, the nurse performs which action first? | a. arranges for at least 3 healthcare personnel to assist b. makes sure the pt agrees to the intervention c. applies clean gloves >>d. assess the pt for weakness, dizziness, or postural hypotension |
| Which position is used when applying the sling to transfer a pt from the bed to a chair w/a hydraulic lift? a. prone b. side-lying c. sims d. supine | d. supine |
| Which action would decrease a pts pain before a transfer w/a hydraulic lift? | >>a. admin a prescribed analgesic 30-60 min before transfer b. explain procedure before transfer c. step the transfer if pt expresses/displays physical signs of pain d. postpone transfer if pt reports having physical pain/anxiety before the transfer |
| When using a hydraulic lift to transfer a pt from the bed to a chair, when does the nurse turn off the check valve? | a. when the nurse removes the straps b. after pts eyeglasses are removed c. after pt crosses arms over chest >>d. as soon as the pt had been placed in chair |
| When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? | >>a. to identify potential risk for DVT b. to identify improper pt positioning c. to determine whether a sequential compression device is needed d. to select proper stocking size |
| Which condition is not associated w/venous stasis, part of Virchow's triad? a. immobility b. pregnancy c. anxiety d. obesity | c. anxiety |
| Why does the nurse remove the pts elastic stockings at least once per shift? a. to air out stockings and allow sweat to evaporate b. to wash legs w/a disposable bath product c. to permit skin to breathe d. to check the skin for irritation/breakdown | d. to check the skin for irritation/breakdown |
| Why might the nurse choose not to apply a pair of prescribed elastic stockings to a pts legs? a. the pts skin is irritated b. the pt has become fully ambulatory c. pt will have a scheduled bath in a few hours d. pt says they are too tight | a. the pts skin is irritated |
| The nurse discovers the NAP has been using moisturizer on pts legs before applying the stockings. What is the best action by the nurse? | a. explain that moisturizer may cause excessive skin softening, which can lead to breakdown b. inspect pts skin for color variations >>c. instruct NAP to use small amount of cornstarch/powder d. ask pt if he/she is allergic to moisturizer |
| A pt was dx w/a UTI. The pt has been drinking fruit juice & has increased his fluids but has failed to take his antibiotic because it cause GI upset. 3 days later, he presents to the clinic w/fever, malaise, nausea, & vomiting. What might be supspected? | a. pt probably has flue >>b. pt may now have systemic infection c. pt is displaying signs of localized infection d. pt is experiencing an allergic response to medication |
| The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: a. surgical asepsis (sterile technique) b. medical asepsis (clean technique) c. droplet precautions d. standard precautions | a. surgical asepsis (sterile technique) |
| On entering station 1, the nurse dons a pair of clean gloves. the nurse sees the the pt has a gunshot wound of the chest and is concerned there may be splattering of infectious materials. the nurse applies goggles, a mask, and a gown. What is this called? | >>a. following standard precautions b. using medical sepsis c. using surgical asepsis d. infection control to prevent a HAI |
| A nurse assists a pt w/a Foley catheter to ambulate down the hall. The nurse holds the catheter bag below the level of the pts bladder. What link in the chain of infection is the nurse breaking by doing so? | a. portal of exit >>b. portal of entry c. reservoir d. host susceptibility |
| The nurse manager is reviewing the use of standard precautions w/the staff. Which of the following should be included in the review? [select all] | >>a. SPs are used to protect you from potential contact w/blood & body fluids >>b. SPs should be observed in every pt encounter c. SPs refer only to use of gloves, not masks, eye protect, or gowns d. SPs used once infection type is ident |
| A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standrads are appropriate to include in the presentation? [select all] | >a. ster. barrier has been permeated by moistr is contam >b. ster. object/field out of vision or an object below persons waist=contam c. ster. field/object cant become contam by air >d. any doubt = unster. >e. all items used w/in ster. field is ster. |
| a nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? | a. washing hands w/soap&water is the only effective means for stopping spread of germs >>b. immunizations help protect children from being hosts c. large containers of hand san. should be available d. toys are typically the reservoir of pathogen growth |
| The nurse is caring for 4 individuals. Which pt wold be most at risk for infection? a. pt who is receiving immunosuppressive medication b. pt who is unable to shower w/o assistance c. pt w/a hx of latex allergy d. pt who exercises daily in pool | a. pt who is receiving immunosuppressive medication |
| a nurse reads the following in a pts EMR: 92 yr old complains of frequent non-prodctive cough. Taking PO steroids. Denies having pna vax. Based on this info, what factors place this pt at risk for being a suspect host? | >a. hospitalized b. nutritional status >c. age d. gender >e. vaccination status >f. medical therapy |
| The nurse is preparing an in-service on medical asepsis. Which of the following should be included in the presentation? [select all] | a.use sterile gloves if contact w. nonintact skin b.artific nails should be < 1/4in >c.nail polish shouldn't be chipped >d.cough hygiene practices should be followed e. gown & gloves are sufficient PPE for splash risk >f.know pts risk to infection |
| When should you perform hand hygiene? [select all] a. before applying gloves to insert an IV b. after documenting in pts EMR c. after moving a pt u pin bed d. before assessing a pts VS e. before touching clean linens | a. before applying gloves to insert an IV c. after moving a pt up in bed d. before assessing a pts VS |
| Why are the hands rinsed with the fingertips held lower than the wrist? | >>a. water flows fro the least to the most contaminated area, rinsing microorganisms into the sink b. to keep sleeves from getting wet c. it is necessary to ensure that all surfaces of the hands, are cleansed d. to loosen and remove dirt & bacteria |
| What is the best nursing practice to reduce the potential transmission of microorganisms w/in the health care setting? a. bagging all linen b. performing had hygiene c. keeping catheter bags empty d. wearing gloves | b. performing had hygiene |
| Under which circumstance(s) should hand washing be repeated? [select all] | >>a. hands touch the sink during hand washing >>b. areas under fingernails remain soiled c. cracked areas are noted on the nurses hands d. hands are free of visible soiling e. hands are lowered below waist level |
| When is it acceptable to use antiseptic hand rub rather than soap and water? [select all] | >a. after adjusting a cannula on pt >b. after removing gloves from changing a wound c. when nurses hands are cracked >d. after moving pts belongings on the bedside table e. after pt develops skin tear and blood is on nurse hand f. when pt has c.diff |
| The nurse is observing the NAP hand hygiene. Which of the following, requires intervention by the nurse? [select all] The NAP: | a. washes hands bef/aft clean gloves b. uses 3-5 mL of soap >c. takes pts BP and leaves room to doc. d.washes hads w/soap when dirty >e. puts pts socks on, then feeds pts f. moves pts IV pole and uses sanitizer >g. uncovrd cut on nd-hand |
| The NAP complains of hands hurting and being chapped. What would be appropriate suggestion? [select all] | >a. use hand lotion from individual container b. decr freq of HH until healed c.wear clean LF gloves at all times >d. rinse/dry hand thoroughly >e. avoid excessive amount of soap |
| Which of the following are symptoms of systemic infection? [select all] a. edema b. redness c. fatigue d. fever e. nausea & vomting f. pain/tenderness | c. fatigue d. fever e. nausea & vomting |
| When preparing to provide mouth care to a pt who is in a come, the nurse first ensures pt safety by doing what? a. assessing the pts gag reflex b. connecting suction equpmt c. inspect pts oral cav. d. placing bed in flat pos. | a. assessing the pts gag reflex |
| The nurse is planning to insert an oral airway into an unconscious pt before mouth care. In which direction is the airway initially inserted into the pts mouth? | a. the curve angled toward pts L.cheek >>b. upside down, or w/curve facing up c. curve angled toward the pts R.cheek d. right side up, or w/curve facing down |
| When brushing the teeth of an unconscious pt, why is the toothbrush held so that its bristles are at a 45-deg angle to the gum line? | a. ensure bristles reach all surf b. give nurse a firm grip on handle c. reduce pressure on sens. oral tissues >>d. allow bristles to reach beneath gum line |
| What must a nurse avoid when brushing the tongue of an unconscious pt? a. dislodgin bacteria b. using suction c. moistening the oral mucosa d. stimulating gag reflex | d. stimulating gag reflex |
| The nurse is preparing t ogive a pt a bath using disposable bath-in-a-bag product. What should the nurse do first? a. obtain a washbasin b. remove pts gown c. gather towels/cloths d. warm product in microwave | d. warm product in microwave |
| What can the nurse do to keep the pt fro becoming chilled while receiving a bath w/a disposable bath-in-a-bag product? | a. wash product off skin w/warm/moist cloth b. dry each body part w/warmed towel after wash c.keep pts gown on for bath >>d. lightly cover pt w/a bath towel |
| The nurse has washed a pts arms. Which area should the nurse wash next? a. chest b. legs c. hands d. abdomen | c. hands |
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paulage