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The most effective way to break the change of infection is by:
a. Performing hand hygiene
b. Wearing gloves
c. Placing patients in isolation
d. Providing private rooms for all patients
A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. Your best immediate intervention is to:
a. Use surgical technique to change the dressing
b. Reassure the patient and recheck the wound later
c. Notify the health care provider and support the patient's fluid and nutritional needs
d. Alert the patient and caregivers to the presence of an infection to ensure care after discharge
A patient has an indwelling catheter. You recognize that the catheter represents a risk for urinary tract infection because:
a. It keeps an incontinent patient's skin dry
b. It can get caught in the linen's or equipment
c. It obstructs the normal flushing action of urine flow
d. It allows the patient to remain hydrated without having to urinate
You have redressed a patient's wound and now plan to administer a medication to the patient. It is important to:
a. Remove gloves and perform hand hygiene before leaving the room
b. Remove gloves and perform hand hygiene before administering the medication
c. Leave the gloves on to administer the medication
d. Leave the medication on the bedside table to avoid having to remove gloves
You need to wear a gown when working with a patient:
a. If the patient's hygiene is poor
b. If the patient has AIDS or hepatitis
c. If you are assisting with medication administration
d. If blood or body fluids may get on your clothing from a task you plan to perform
Identify when the nurse should remove gloves and perform hand hygiene. Select all that apply:
a. Only after wound care
b. When leaving the room
c. When you have completed all tasks for the patient
d. When the specific task you put them on for is completed
The most likely means of transmitting infection between patients is:
a. Exposure to another patient's cough
b. Disposing of soiled linen in a shared linen bag
c. Disposing of soiled linen in a shared linen bag
d. Contact with a health care worker's hand
Your ungloved hands come in contact with the drainage from the patient's wound. To clean your hands you should:
a. Wash them with soap and water
b. Use an alcohol-based hand cleaner
c. Rinse them and use the alcohol-based hand cleaner
d. Wipe them with a paper towel
A patient is placed on contact precautions for an infection with a resistant organism. You notice the patient seems to be depressed and withdrawn. The best intervention is to:
a. Lower the lighting and reduce noise to calm the patient
b. Reduce the level of precautions to permit greater interaction with the patient
c. Explain the reason for contact precautions and answer the patient's questions
d. Limit family and other caregiver visits to reduce the risk of spreading the infection
After coming in contact with a patient on isolation, visitors are encouraged to:
a. Wear gloves before eating or handling food
b. Leave the facility to prevent contamination of others.
c. Perform hand hygiene upon leaving the patient's room
d. Use an empty room to talk with family members
A 68-year-old woman whose husband died last year walks into the wellness clinic of the assisted living facility. She reports that she feels depressed and tired all the time. She provides you with a list of medications, one of which her health care provider altered in the last 3 weeks, atenolol, a beta-adrenergic blocker. Knowing that beta-adrenergic blockers have the potential to cause hypotension and bradycardia, which vital signs can you delegate to the clinics nursing assistant? Select all that apply.
a. Blood pressure
b. Temperature and respiratory rate
c. Oxygen saturation
d. Heart rate
A patient's blood pressure is 102/58 mm Hg in the right arm. On the patient's last visit, the blood pressure was 142/60 mm Hg in the left arm. What is your priority nursing action?
a. Repeat the blood pressure in the right arm.
b. Obtain the blood pressure in the left arm.
c. Allow the patient to relax for 15 minutes.
d. Notify the health care provider.
A 53-year-old man has just returned from the post-anesthesia care unit (PACU) following a small bowel resection. He has smoked 2 packs per day since he was 18 years old. His admission vital signs obtained by the nursing assistant are heart rat 114 beats per minute, BP 118/72 mm Hg, tympanic temperature 97.8⁰ F, respiratory rate 8 breaths per minute, and SpO2 94% using 3 L of oxygen via nasal cannula. How do you describe his vital signs?
a. Bradycardia with apnea
b. Tachycardia with hypoxia
c. Bradycardia and bradypnea
d. Tachycardia and bradypnea
Thirty minutes after returning from the PACU your patient's pulse oximeter alarms, and you note the SpO2 is 89%. While she was sleeping, the oxygen cannula fell out of her nose. What is your priority nursing action?
a. Reposition the oximeter probe
b. Reposition the nasal cannula
c. Obtain the patient's respiratory rate while asleep
d. Shake the patient to see if she wakes.
Poor oxygenation of the blood ordinarily will affect the pulse rate and cause it to become:
You dangle your patient on the side of the bed 6 hours after surgery. The nursing assistant obtains a blood pressure of 92/58 mm Hg while he is sitting. The difference between his postoperative BP of 118/58 mm Hg and the sitting blood pressure is described as:
a. Hypotensive response to surgery
b. Normal response to repositioning
c. Orthostatic hypotension
d. Side effect of fluid shift
You help your patient get out of bed 1 day after surgery for a bowel obstruction. He complains of dizziness and nausea. Your immediate action is to:
a. Assist him to a supine position
b. Assess blood pressure
c. Report findings to the nurse in charge
d. Question the patient about palpitations
Following surgery, your patient's systolic blood pressure drops 25 mm Hg when you are helping him out of bed. What is the likely cause for the change in blood pressure?
a. Pain caused by movement
b. Blood loss during surgery
c. Increase in heart rate as a result of stress
d. Movement too soon after surgery
You have assigned routine vital signs to a new nursing assistant recently hired by your clinical manager. You notice that the nursing assistant's last three patients have had unusually low blood pressures that you have had to reconfirm. What is the most likely reason for the low blood pressures that the nursing assistant is obtaining?
a. BP cuff was too wide for arm circumference.
b. Bladder was inflated and deflated too slowly.
c. Patient's arm was not supported during measurement.
d. BP cuff was not wrapped evenly around arm.
An experienced nursing assistant complains about the vital signs that a newly hired nursing assistant has been asked to retake a BP that the newly hired nursing assistant has taken 3 times this week. As the RN, what action do you take?
a. Do not delegate vital signs to the newly hired nursing assistant.
b. Delegate only temperature and respiratory rate to the newly hired nursing assistant.
c. Report the newly hired nursing assistant to your supervisor.
d. Observe the newly hired nursing assistant as she obtains a blood pressure and pulse on a patient.
The nurse conducts a patient assessment on a 72-year-old woman and finds a capillary refill time of 4 seconds, a nail bed angle of 160 degrees, hardened nails, and splint hemorrhages. Which findings are abnormal? Select all that apply.
a. Capillary refill
b. Nail bed angle
c. Hardened nails
d. Splinter hemorrhages
To correctly palpate the patient's skin for temperature, the nurse uses the:
a. base of the hand
b. fingertips of the hand
c. dorsal surface of the hand
d. palmar surface of the hand
The patient's respiratory assessment reveals bilateral high pitched, continuous musical sounds heard loudest upon expiration. The nurse interprets these sounds as:
While auscultating heart sounds, the nurse documents that S1 is heard best at the apex. This sound (S1) correlates with closure of the:
a. aortic and mitral valves
b. mitral and tricuspid valves
c. aortic and pulmonic valves
d. tricuspid and pulmonic valves
To assess the patient's posterior tibial pulse, the nurse palpates:
a. behind the knee
b. over the lateral malleolus
c. in the groove behind the medial malleolus
d. lateral to the extensor tendon of the great toe
To spread the breast tissue evenly over the chest wall during an examination, the nurse asks the patient to lie supine with:
a. hands clasped just about the umbilicus
b. both arms overhead with palms upward
c. the dominant arm straight alongside the body
d. the ipsilateral arm overhead with a small pillow under the shoulder
Assessment of which body system requires you to perform auscultation before palpation?
a. head and neck
The nurse is teaching a patient how to perform a testicular self-examination. The nurse instructs the patient:
a. "Contact your health care provider if you feel a painless pea-size nodule."
b. "The testes are normally round and movable and have a lumpy consistency."
c. "The best time to do a testicular self-examination is before your bath or shower."
d. "Perform a testicular self-examination every week to detect signs of testicular cancer."
The patient is being assessed for range of joint movement. The nurse asks the patient to move the arm away from the body, evaluating the movement of:
The nurse asks the patient to smile, frown, and raise and lower the eyebrows; these actions evaluate cranial nerve number:
a. VII - facial
b. V - trigeminal
c. III - oculomotor
d. XII - hypoglossal