A nurse is reviewing hand hygiene techniques with a group of assistive personal (AP). Which of the
following instructions should the nurse include when discussing hand washing? (Select all that apply).
A. Apply 3 to 5 mL of liquid soap to dry hands
B. Wash the hands with soap and water for at least 15 seconds
C. Rinse the hands with hot water
D. Use a clean paper towel to turn off hand faucets
E. Allow the hands to air dry after washing - Answers B, D
A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that
health care professionals are required to report communicable and infectious diseases. Which of the
following illustrate the rationale for reporting? (Select all that apply).
A. Planning and evaluating control and prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks - Answers A, B, C, E
A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The
client has manifestations of which of the following conditions?
A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Tuberculosis - Answers D. Tuberculosis
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph
nodes. The client is experiencing which of the following stages of infection?
,A. Prodromal
B. Incubation
C. Convalescence
D. Illness - Answers D. Illness
A charge nurse is reviewing with a newly hired nurse the difference in manifestation of a localized versus
a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that
apply).
A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse and respiratory rate - Answers A, B, E
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a
suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select
all that apply).
A. Place the client in a room that has negative air pressure of at least six exchanges per hour
B. Wear a mask when providing care within 3 ft of the client
C. Place a surgical mask on the client if transportation to another department is unavoidable
D. Use sterile gloves when handling soiled linens
E. Wear a gown when performing care that might result in contamination from secretions. - Answers B,
C, E
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time
and can follow directions. Which of the following actions should the nurse take to decrease the risk of
another fall? (Select all that apply).
, A. Place a belt restraint on the client when they are sitting on the bedside commode
B. Keep the bed in its lowest position with all side rails up
C. Make sure that the client's call light is within reach
D. Provide the client with nonskid footwear
E. Complete a fall-risk assessment - Answers C, D, E
A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure.
Which of the following statements by a nurse requires further instruction?
A. "I will place the client on their side."
B. "I will go to the nurses' station for assistance."
C. "I will note the time that the seizure begins."
D. "I will prepare to insert an airway." - Answers B. "I will go to the nurses' station for assistance."
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's
priority?
A. Complete a fall-risk assessment
B. Educate the client and family about fall risks
C. Eliminate safety hazards from the client's environment
D. Make sure the client uses assistive aids in their possession - Answers A. Complete a fall-risk
assessment
A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to
safety and the alarm has been activated. Which of the following actions should the nurse take?
A. Open the windows in the client's room to allow smoke to escape.
B. Obtain a class C fire extinguisher to extinguish the fire
C. Remove all electrical equipment from the client's room