EXAM 1 Chapter 28, 29, 39, 40, 48 (Infection Control, Hygiene, Activity & Exercise, Immobility, Skin Integrity & Wound Care)

EXAM 1 Chapter 28, 29, 39, 40, 48 (Infection Control, Hygiene, Activity & Exercise, Immobility, Skin Integrity & Wound Care) 1- A 26 year old is being admitted from the recovery room and is identified as at risk for falls. Which of the following best describes the rationale for this nursing diagnosis? Select one: a. Depression b. Surgical tooth extraction c. Pain medication d. History of asthma 2- A cognitively intact bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? Select one: a. Bag bath b. Partial bed bath c. Complete bed bath d. Sponge bath 3- A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? Select one: a. Review the medication list that the patient brought from home. b. Position the patient comfortably on the stretcher. c. Don gloves and other appropriate personal protective equipment. d. Explain the procedure for dressing change to the patient. 4- After providing perineal hygiene an intact male patient, the nurse ensures: Select one: a. The foreskin remains retracted for the glans to dry b. The patient knows to replace the foreskin back over the glans in 15-20 minutes after drying c. The patient knows to use soap and water with hygiene to the glans going forward d. The foreskin is replaced back over the glans5- A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? Select one: a. All of the above b. Race c. Pregnancy status d. Emotional factors Question 6 A nurse is assessing a patients skin. Which patient is most at risk for skin breakdown? Select one: a. A patient who is diaphoretic b. A patient who is afebrile c. A patient with adequate skin turgor d. A patient with strong pedal pulses 7- A nurse is assessing a patients wound. Which nursing observation will the nurse anticipate in a wound healing by secondary intention? Select one: a. Scarring that may be severe b. Minimal loss of tissue function c. Minimal scar tissue d. Permanent dark redness at site 8- A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? Select one: a. Blood pressure sitting 120/64; blood pressure 140/70 standing b. Blood pressure sitting 140/60; blood pressure 130/54 standing c. Blood pressure sitting 130/60; blood pressure 110/60 standing d. Blood pressure sitting 126/64; blood pressure 120/58 standing 9- ulcer open to air and does not apply a dressing. To which patient did the nurse provide care? Select one: a. A patient with a clean Stage Ib. A patient with a clean Stage IV c. A patient with a clean Stage II d. A patient with a clean Stage III 11- A nurse is assisting the patient to perform exercises. Which action will the nurse take? Select one: a. Set the pace for the exercise session. b. Force muscles or joints to go just beyond resistance. c. Stop the exercise if pain is experienced. d. Encourage wearing tight shoes. 12- A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient? Select one: a. Increased diarrhea b. Increased metabolic rate c. Increased appetite d. Altered nutrient metabolism 13- A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? Select one: a. The patient is moaning softly and frowning, with a pinched expression on his face. b. The patient rates his pain a 7 on a scale of 0 to 10. c. The patient winces and guards the area as the nurse gently palpates the abdomen. d. The patient is having trouble sleeping and has become irritable. 14- A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? Select one: a. Sleep assessment b. Muscular strength assessment c. Pulse oximetry assessment d. Sensation assessment15- A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? Select one: a. Chronic drainage of fluid through the incision site b. Drainage that is odorous and purulent c. Report by patient that something has given way d. Protrusion of visceral organs through a wound opening 16- A nurse is inserting an indwelling urinary catheter on a female patient. Which is the most important first step in maintaining a sterile field? Select one: a. Unfold the sterile drape away from your body b. Never turn your back to the sterile field c. When adding sterile supplies, hold 10 to 12 inches above the field and allow them to drop d. Inspect the sterile kit for package integrity, contamination or moisture 17- A nurse is performing passive range of motion (ROM) and splinting on an immobile patient. What is the desired outcome of this intervention? Select one: a. Prevention of atelectasis b. Prevention of joint contractures c. Prevention of pressure ulcers d. Prevention of renal calculi 18- A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? Select one: a. Performing patient hygiene requires a physician order b. During hygiene care do not take the time to learn about patient needs. c. Hygiene care is always routine and expected. d. No two individuals perform hygiene in the same manner. 19- A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel? Select one:a. Identifying immobility hazards b. Determining the level of comfort c. Making an occupied bed d. Assessing circulation 20- A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area?1. Face2. Eyes3. Perineum4. Arm and chest5. Hands and nails6. Back and buttocks7. Abdomen and legs Select one: a. 1, 2, 4, 5, 3, 7, 6 b. 2, 1, 4, 5, 7, 3, 6 c. 2, 1, 5, 4, 6, 7, 3 d. 1, 2, 5, 4, 7, 6, 3 21- A nurse is providing care to a group of patients. Which patient will the nurse see first? Select one: a. A patient on bed rest who has renal calculi and needs to go to the bathroom b. A patient after knee surgery who needs range of motion exercises c. A bedridden patient who has a reddened area on the buttocks who needs to be turned d. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea A nurse is providing oral care to an elderly patient with dentures who has a restricted diet and is receiving nothing by mouth. Which of the following is an appropriate action? Select one: a. Brush dentures and remaining teeth in mouth using toothbrush or swab b. Place your finger in the mouth of the unconscious patient to open the mouth c. Provide oral care daily and as needed to prevent nosocomial pneumonia d. Position patient in Trendelenburg or side-lying position A nurse is providing passive ROM to a patient’s left lower extremity when he encounters resistance in the ankle. What should the nurse do first? Select one: a. Continue slow ROM activity to gently increase mobility b. Stop movement to prevent injuryc. Notify the physician d. Assess the ankle for swelling A nurse is providing skin care for a morbidly obese patient. Which of the following interventions are essential to prevent skin breakdown in bariatric patients? Select one: a. Cleansing the back b. Elevating heels from bed c. Drying beneath the pannus d. Assessing behind the ears when using a nasal cannula A patient develops a urinary tract infection after having an indwelling foley catheter. How is this infection categorized? Select one: a. Adverse reaction b. Treatment related complication c. Nosocomial infection d. Community acquired infection A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? Select one: a. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. b. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? Select one: a. Pulse b. Blood pressure c. Temperatured. Respirations A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? Select one: a. Albumin b. Potassium c. Vitamin E d. Sodium A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement? Select one: a. Contractures developed. b. Muscle strength improved. c. Heart rate decreased. d. Joint mobility maintained A patient with a diabetic foot ulcer is placed on bed rest with the affected foot elevated. Which rationale best supports this intervention? Select one: a. To support a weak patient b. To reduce edema c. To avoid dislodging a DVT d. To decrease metabolic needs A patient with pneumonia is identified as having elevated white blood cell count, elevated temperature, low blood pressure and increase heart rate. Which of the following is the nurse concerned that the patient is developing? Select one: a. Respiratory failure b. Sepsis c. Leukopenia d. Opportunistic infectionDuring the following task, identify whether the situation calls for medical or surgical asepsis: The nurse is suctioning the tracheostomy of a hospitalized patient. Select one: a. Medical b. Surgical During the following task, identify whether the situation calls for medical or surgical asepsis: The nurse is preparing medications for oral administration Select one: a. Medical b. Surgical During the following task, identify whether the situation calls for medical or surgical asepsis: The nurse is caring for a central intravenous access device line Select one: a. Surgical b. Medical The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? Select one: a. Ineffective peripheral tissue perfusion b. Imbalanced nutrition: less than body requirements c. Acute pain d. Risk for infection The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient’s susceptibility to this infectious process? Select one: a. Do you have religious preferences that may impact your care? b. Do you have any children living in the home? c. Do you have a spouse? d. Do you have an chronic health problems?The nurse is bathing a patient and notices movement in the patients hair. What is the best first action for the nurse to take? Select one: a. Use gloves to inspect the hair. b. Implement advanced contact precaution isolation. c. Ignore the movement and continue. d. Apply a lindane-based shampoo immediately. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? Select one: a. A patient who is in observation for chest pain b. A patient who has been admitted for stabilization of heart problems c. A patient who is recovering from a right total hip surgery d. A patient who has been admitted with dehydration The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? Select one: a. Applying an elastic bandage to a medical-surgical patient b. Treating a pressure ulcer on the buttocks of a medical patient c. Assessing a surgical patient for risk of pressure ulcers d. Implementing negative-pressure wound therapy on a stable patient The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? Select one: a. Transport the patient safely and quickly when going to the radiology department. b. Place the patient in a room with negative airflow. c. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. d. Wear a gown, gloves, face mask, and goggles (as needed) for interactions with the patient. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? Select one:a. Avoid accidentally removing the drain. b. Gather supplies. c. Don sterile gloves. d. Provide analgesic medications as ordered. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? Select one: a. Wipe hands with a dry paper towel. b. Wash hands with an antimicrobial soap and water. c. Clean hands with wipes from the bedside table. d. Use an alcohol-based waterless hand gel. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next? Select one: a. Do nothing, as long as the evacuator is compressed. b. Remove the drain; a drain is no longer needed. c. Call the health care provider; a blockage is present in the tubing. d. Chart the results on the intake and output flow sheet. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next? Select one: a. Teach the patient cough etiquette. b. Place the patient on droplet precautions. c. Wear an N95 respirator when entering the patient room. d. Instruct assistive personnel to use soap and water rather than sanitizer. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? Select one: a. High risk for impaired venous return and dementia b. Decreased caloric intake and accelerated wound healingc. High risk for skin infection and low saliva pH level d. Decreased pain sensation and increased risk of skin impairment The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? Select one: a. Partial-thickness repair b. Secondary intention c. Primary intention d. Tertiary intention The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing? Select one: a. The site has started to itch. b. The site is approximated. c. The site is hurting. d. The site has a mass, bluish in color. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use? Select one: a. Standard b. Droplet c. Contact d. Protective environment The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? Select one: a. Do not allow turning in bed because that may lead to redislocation of the leg. b. Assess surfaces exposed to the edges of the cast for pressure areas. c. Keep the patient’s blood pressure low to prevent overperfusion of tissue. d. Restrict the patient’s dietary intake to reduce the number of times on the bedpan.The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse’s action? Select one: a. Inadequate blood flow leads to decreased tissue ischemia. b. Pressure reduces circulation to affected tissue. c. Verbalization of skin care needs is decreased. d. Patients with limited caloric intake develop thicker skin. The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says “I always bathe in the evening.” Which action by the nurse is best? Select one: a. Defer the bath until evening and pass on the information to the next shift. b. Explain the importance of maintaining morning hygiene practices. c. Explain that morning baths are the hospital routine, and the patient will need to adjust to this while inpatient. d. Cancel hygiene for the day and attempt again in the morning. The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility? Select one: a. Explain the risks of immobility to the patient. b. Provide analgesic medication as ordered. c. Turn the patient every 3 hours while in bed. d. Encourage the patient to sit up in the chair. The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?Select one: a. Utilize clean gauze and clean gloves to cleanse a site. b. Allow the solution to flow from the most contaminated to the least contaminated. c. Cleanse in a direction from the least contaminated area. d. Scrub vigorously when applying noncytotoxic solution to the skin. The nurse is completing an assessment of the patient’s skin’s integrity. Which assessment is the priority? Select one: a. Pulse points b. Pressure points c. Breath sounds d. Bowel sounds The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept? Select one: a. “I am thinking I will be ready to go home early next week.” b. “I am so weak and tired. I want to feel better.” c. “I am ready for my bath and linen change right now since I am so disgusting.” d. “I am hoping there will be something good for dinner tonight.” The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? Select one: a. Touching clean protective eyewear b. Staying with the sterile table once it is open c. Accepting sterile supplies from the surgeon d. Standing with hands above waist areaThe nurse is observing the way a patient walks. Which aspect is the nurse assessing? Select one: a. Gait b. Activity tolerance c. Range of motion d. Body alignment The nurse is preparing to lift a patient. Which action will the nurse take first? Select one: a. Attempt to manually lift the patient alone before asking for assistance. b. Assess weight and determine assistance needs. c. Delegate the task to a nursing assistive personnel. d. Position a drawsheet under the patient. The nurse is providing care to a patient who is bedridden. The nurse raises the height of the bed. What is the rationale for the nurse’s action? Select one: a. Allows the nurse to bring feet closer together. b. Prevents a shift in the nurse’s base of support. c. Narrows the nurse’s base of support. d. Shifts the nurse’s center of gravity farther away from the base of support. The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. Which primary goal is the nurse trying to achieve? Select one: a. Prevention of foot fungus b. Prevention of neuropathy c. Prevention of amputation d. Prevention of plantar warts The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift?Select one: a. Halitosis b. Dental carries c. Cheilitis d. Glossitis The nurse is providing perineal care to an unconscious female patient. Which step is most important? Select one: a. Wash front to back to avoid contamination b. Include cleansing the folds between the legs and the labia c. Use soapy water between the labial folds d. Use cool water to avoid temperature sensitivity The nurse is teaching a patient how to use a cane. Which information will the nurse include in the teaching session? Select one: a. Place the cane on the stronger side of the body. b. Place the cane 10 to 15 inches in front of the body when walking. c. Place the cane in front of the body and then move the good leg. d. Place the cane at the top of the hip bone. The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one?1. Grasp the drawsheet firmly near the patient.2. Move the patient and drawsheet to the desired position.3. Position one nurse at each side of the bed.4. Place the drawsheet under the patient from shoulder to thigh.5. Place your feet apart with a forward-backward stance.6. Flex knees and hips and on count of three shift weight from the front to back leg. Select one: a. 1, 4, 5, 6, 3, 2 b. 3, 4, 1, 5, 6, 2 c. 5, 6, 3, 1, 4, 2 d. 4, 1, 3, 5, 6, 2 The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? Select one:a. The absence of physiological signs and symptoms is associated with chronic pain. b. It is likely the patient is a drug seeker and has little or no pain. c. The patient's pain cannot be accurately assessed until the patient has been treated for anxiety. d. The patient's problem is more mental than physical. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? Select one: a. Encourage isometric exercises. b. Dangle the patient at the bedside. c. Suggest a high-calcium diet. d. Maintain a narrow base of support. The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning? Select one: a. When outpatient therapy will no longer be needed b. At the time of admission c. When family When family arrives to see the patient. d. The day before the patient is to be discharged The patient weighs 450 lbs (204.5 kg) and reports shortness of breath with any exertion. The health care provider has recommended beginning an exercise program. The patient states that she can hardly get out of bed and just cannot do anything around the house. Which nursing diagnosis will the nurse add to the care plan? Select one: a. Imbalanced nutrition: less than body requirements b. Impaired physical mobility related to bed rest c. Impaired gas exchange related to shortness of breath d. Activity intolerance related to excessive weight The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? Select one:a. Restrict the patient's fluid intake. b. Place the patient on oxygen. c. Increase the patient's metabolic rate. d. Encourage the patient to cough. How does the nurse best assess what help is needed when mobilizing a patient? Select one: a. Consider diagnosis and gender b. esConsider age and diagnosis c. Consider weight and functional status d. Consider age and functional status Which nursing action will most likely increase a patients risk for nosocomial infection? Select one: a. Uses a clean technique for inserting a urinary catheter b. Uses a sterile bottled solution more than once within a 24-hour period c. Uses a cleaning stroke from the urinary meatus toward the rectum d. Uses surgical aseptic technique to suction an airway Which nursing observation will indicate the patient is at risk for pressure ulcer formation? Select one: a. The patient has fecal incontinence. b. The patient has a raised red rash on the right shin. c. The patient ate two thirds of breakfast. d. The patient ambulates independently with a cane. Which observation indicates that a patient's pain medication has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention? Select one: a. The patient rates her current pain as 3 out of 10 on the pain rating scale. b. The patient is overheard telling her family that she is