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The nurse has delegated activities of daily living (ADL) care
of a patient with a large wound that is draining. Which of
the following should the nurse instruct the nurse assistant
to report back to her?
A
A The wound has a foul odor.
B Drainage is decreased.
C The patient's temperature is slightly below normal.
D The patient does not complain of discomfort.
How should the nurse identify a patient before obtaining
a laboratory specimen?
A Use at least two patient identifiers.
A
B Look at the chart before entering the room.
C Ask the patient his name.
D Check the patient's armband twice.
The nurse needs to obtain a sterile urine specimen for
culture and sensitivity (C&S) from a patient who has an
indwelling catheter. The catheter was placed the night
before. What must the nurse do to obtain the specimen?
B
A Obtain the urine from the drainage bag.
B Clamp the drainage tubing for 10 to 15 minutes.
C Draw urine using a 20-mL syringe.
D Insert the needle into the silicone catheter.
The nurse understands that the priority nursing action
needed when medical asepsis is used includes
A handwashing.
A
B surgical procedures.
C autoclaving of instruments.
D sterilization of equipment
When teaching about the procedure for capillary punc-
ture, the nurse instructs a patient to
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A hold the finger upright.
B use the central tip of the finger.
C
C allow the antiseptic to dry completely
D vigorously squeeze the end of the finger.
Which of the following measures is appropriate when a
nurse is washing his or her hands?
A Use very hot water.
C
B Leave rings and watches in place.
C Lather for at least 15 to 20 seconds.
D Keep the fingers and hands up and the elbows down.
Before entering the room of a patient on isolation where
all protective barriers are required, the nurse first puts on
the (GMEG)
A gown.
A
B gloves.
C eyewear.
D mask/respirator.
None of the above
In international (military) time, 4:08 PM is 1608
A client refuses a p.o. medication and provides the nurse
with a reason for refusing the medication. What should
the nurse's action be?
A Inform the client they cannot refuse a medication. D
B Report it to the nurse manager.
C Administer the medication by an injectable route.
D Document the refusal and inform the prescriber.
The nurse is caring for a patient who is bleeding. To
control bleeding, apply a dressing.
A
A pressure
B alginate
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C foam
D hydrocolloid
The patient with a nasogastric (NG) tube in place may
experience skin breakdown
A in the nose
B on the tongue A
C behind the ears
D around the lips
None of the above
The physician expects that the patient's wound will have
an output of close to 500 mL/day. The nurse anticipates
placement of which of the following?
A Dry sterile dressing C
B Jackson-Pratt (JP) drain
C Hemovac drain
D no drain
The patient is admitted to the pediatric unit with severe
pertussis. The nurse explains to the parents and the child
that they will be treated with the use of
A airborne precautions C
B standard precautions
c droplet precautions
D contact isolation
The nurse is caring for a patient who had a colostomy
placed 5 days earlier. The nurse notes that the stoma is
red and moist. Which action should the nurse take?
A Notify the physician immediately. C
B Apply pressure.
C Document the condition of the stoma.
D Change the appliance pouch.
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What should the nurse do upon noting bleeding around
a dressing at an intravenous (IV) catheter insertion site?
A Discontinue the IV
B
B Assess the insertion site
C Leave the dressing intact but reinforce it
D Elevate and apply warm compress
Which of the following steps is necessary when a patient
is prepared for intravenous (IV) catheter insertion?
A Shaving the hair from the site
B Selecting a proximal site in an extremity C
C Applying a tourniquet 4 to 6 inches above the selected
site
D Vigorously taping and massaging the selected vein
The nurse needs to specifically prevent air emboli that
may result from intravenous (IV) therapy. What should the
nurse make sure to do to prevent air emboli?
A Use a needleless system. B
B Prime the tubing completely.
C Check for medication compatibility.
D Select a larger-gauge needle or catheter.
Which activities related to urinary elimination may be del-
egated to a nursing assistive personnel (NAP)?
A Catheterization
B
B Positioning the patient
C Evaluating alternatives to catheter use
D Assessing urinary drainage
The nurse is preparing to give a medication by intravenous
(IV) bolus. When assessing the patient's IV insertion site,
B
the nurse notes that it is warm, reddened, and tender.
What action should the nurse take first?