Med surg exam 1

What should the nurse do to prepare the unconscious patient for oral care? 1 Use small amounts of water and suction device 2 Place the patient in high Fowler's position 3 Place the patient in the supine position with the head lowered 4 Place the patient in the Fowler's position with the head turned to the side - correct answer 1 A male client is experiencing weakness and is unable to shave himself. When assisting this client with shaving, which of the following would be most important? 1 Ensuring that the face is dry 2 Keeping the skin loose 3 Shaving in the direction of hair growth 4 Angling the razor at 45 degrees - correct answer 3 To avoid cuts, soften the beard with warm towels before shaving. Use soap lather or shaving cream, pull the skin taut, and shave in the direction in which the hair grows to decrease irritation. A nurse is caring for a patient who is unable to perform oral hygiene. The patient has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene? 1 Don sterile gloves before removing the dentures. 2 Use a foam swab to pry the upper dentures loose. 3 Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removing it. 4 Leave the dentures in the patient's mouth and use a toothbrush to brush the teeth. - correct answer 3 Removing the denture plate is a clean procedure. Dentures must be removed to properly clean the patient's mouth and the dentures. A nurse is caring for a patient in restraints. The nurse knows that skin integrity should be assessed how often? 2 hours 3 hours 4 hours 30 minutes - correct answer 4 CMS checks should be done every 30 minutes A hospitalized patient has anti-embolic hose ordered. A nurse discusses the correct use of the stockings with the patient and spouse. Which direction should the nurse include in teaching? 1 If ambulating 10 times for 5 minutes at a time, wearing stockings is unnecessary. 2 The most appropriate time to apply the stockings is before standing to get out of bed in the morning. 3 If the stockings become painful to wear, increase use of pain medication. 4 You can cross your legs while sitting if you are wearing the stockings. - correct answer 2 This will maximize the compression effects and thus lessening the venous distension and development of edema. Frequent ambulation is a positive intervention to prevent DVT formation but should be done in conjunction with anti-embolic stockings. Stockings should be removed twice a day to inspect the skin. Crossing legs impede blood flow and should be avoided with or without the use of stockings. A nurse is teaching a client with diabetes how to care for his feet. The nurse determines that additional teaching is needed when the client states which of the following? 1 "I need to soak them frequently in water." 2 "I should use warm water and a mild soap to clean them." 3 "I can apply lotion to the tops, but not between the toes." 4 "I need to inspect my feet every day." - correct answer 1 Patients with diabetes require special attention to foot care. They have decreased sensation in the feet, placing them at great risk for injury from burns or foreign objects. The feet should be inspected daily, cleaned thoroughly with warm water and a mild soap, and carefully dried, especially between the toes. The feet should not be soaked in water because soaking will dry skin, which may lead to cracking. Lotion or cream can be applied to the tops and bottoms of the feet, but not between the toes. An acute medicine unit of a hospital currently has a number of patients who have tested positive for clostridium difficile (c-diff). Which of the following measure should the nursing staff prioritize in preventing the spread of c-diff to patients who are currently c-diff negative? 1 Reduce the length of stay for c-diff positive patients 2 Constant use of gloves when on the unit 3 Prophylactic antibiotic therapy for c-diff negative patients 4 Diligent hand washing practices - correct answer 4 Rationale: As with all other forms of infection, thorough hand washing is the most important infection control measure. Gloves at all times would not be necessary and prophylactic antibiotics are not typically used. A patient is admitted with a positive culture for methicillin resistant Staphylococcus aureus (MRSA). Which are components of contact precautions? 1 Wearing a mask when working within 3 feet of the patient. 2 Placing the client in a private room. 3 Wearing an N-95 respirator. 4 Placing the client in a negative pressure room. - correct answer 2 Client should be placed in a private room or in a room with a client with the same organism. A nurse is caring for a patient admitted with Hepatitis A. The patient is incontinent of stool. A patient care tech (PCT) is assisting the RN with patient care. The RN determines that the PCT understands correct infection prevention when the PCT is observed: 1 Wearing a mask when taking VS 2 Wearing a gown and gloves when changing the patient's incontinent briefs 3 Wearing gloves when providing perineal care 4 Wearing a gown and gloves when assisting the patient in filling out a menu for lunch - correct answer 2 Hepatitis A is a virus which is present in feces for 2 weeks after symptoms appear. The virus can live for several months outside the body, there fore contact precautions are recommended when caring for clients who are incontinent of stool No need to wear a mask as the virus is not airborne. Wearing gloves for perineal care is correct but is not enough protection, gowns should be worn too. No need to wear PPE when filling out a menu. A student nurse is caring for a client with C diff infection. Which observation made by the faculty indicates that the student needs additional information about this disease? 1 Wearing gloves during a physical assessment 2 Entering the room without first putting on a mask 3 Performing frequent hand hygiene with an alcohol based hand disinfectant 4 Wearing a gown and gloves while providing perineal care - correct answer 3 Alcohol based solutions are not as effective against C diff as is soap and water. Contact precautions are necessary Wearing a mask is not necessary A female patient asks the nurse why she urinates more frequently as she is getting older. Which of the following is the nurse's best response? 1 "As you age, you have increased blood flow to your kidneys." 2 "Your bladder capacity decreases with age." 3 "The number of filtering units in your kidneys increase with age." 4 "It is your body's natural way of keeping the genital tract lubricated as you age." - correct answer 2 An adult client is experiencing hospitalization for the first time. What are the appropriate actions by the nurse to help promote the safety of the client? Select all that apply. A. Maintain a clutter-free client environment B. Keep the client's area well lighted during the night C. Assure the side rails are in up position when client is in the bed D. Examine equipment carefully before using it for client care E. Reorient the client to surroundings whenever necessary 1 A, D, E 2 A, B, D, E 3 A, B, E 4 B, C, D, E - correct answer 1 An older adult patient enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the patient pulled out his IV line and is now attempting to climb over the bedrails. Which of the following phenomena most likely underlies this change in the patient's cognition? 1 Depression 2 Delirium 3 Dementia 4 Disorientation - correct answer 2 Which of the following assessment findings of a 77 year old male patient should signal the nurse of a potentially pathologic finding rather than a normal age related change? 1 The patient's gait is slow and his posture appears stooped 2 The patient claims to her high pitched sounds less clearly than earlier in life 3 The patient states that his urine stream is less strong than in the past 4 The patient is oriented to person and place, but is unsure of the month - correct answer 4 Rationale: Age-related physiological changes include a weakening of bladder emptying, presbycusis, and a slow gait that may be accompanied by a stooped posture. Disorientation to time, however, should always prompt the nurse to perform to further assessment and should never be considered a normal age-related change. A nurse is admitting a patient to a geriatric medicine unit following the patient's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the patient's chance of e