Capstone: Fundamentals 2
(COPY) The nurse can use antimicrobial sanitizer for hand hygiene when caring for a client with
TB - ANS-The nurse can use antimicrobial sanitizer for hand hygiene when caring for a client
with TB
\(COPY) When initiating an IV inserting the catheter up to the hub reduces the risk of
contamination along the length of the catheter - ANS-When initiating an IV inserting the catheter
up to the hub reduces the risk of contamination along the length of the catheter
\A 30-60 ml syringe should be used when irrigating a wound (COPY) - ANS-A 30-60 ml syringe
should be used when irrigating a wound
\A charge nurse is discussing the responsibility of nurses caring for clients who have clostridium
difficult. Which of the following information should the nurse include in teaching?
A) assign the client to a room with a negative air flow system
B) use alcohol-based hand sanitizer when leaving the clients room
C) clean contaminated surfaces in the clients room with phenol solution
D) have family members wear a gown and gloves when visiting - ANS-D
\A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following
indicates to the charge nurse that the sterile field is contaminated?
A) outer edge of the sterile field is touching a bottle
B) first fold is opened away from the body
C) sterile objects are held above the waist
D) sterile field is opened on a wet surface - ANS-D
\A client is scheduled for surgery. The intraoperative nurse finds a necklace on a client after
anesthesia has been administered. Which of the following interventions should be initiated
A) leave the necklace on the client
B) give the necklace to a family member
C) place the necklace in the clients chart
D) notify security for placement of the necklace - ANS-D
\A client who is nonambulatory notices the nurse that there is a fire in the trashcan. After
confirming the first which of the following actions should the nurse take next?
A) call the emergency fire code
B) extinguish the fire
C) confine the fire
D) evaculate the patient
*look up acronym RACE - ANS-D
\A nurse contacts the facility interpreter to explain a therapeutic procedure for a client who does
not speak English. Which of the following guidelines should the nurse follow when working with
the interpreter
A) speak slowly to allow the interpreter to interpret each word
B) explain the purpose of the communication to the interpreter
C) address the interpreter when explaining the procedure information
, D) supplement words with gestures and nonverbal reinforcement - ANS-B
\A nurse in a long term care facility is planning to perform hygiene care for a new resident.
Which of the following assessment questions is the nurses priority before begging this
procedure?
A) when do you usually bathe, in the morning or evening?
B) do you prefer a bath or shower?
C) at what temperature do you prefer your bath water
D) are you able to help with your hygiene care/ - ANS-D
\A nurse in a long term care facility notes client coughing frequently during meals and suspects
dysphagia. The nurse should assess the pt for which of the following behavioral signs of
dysphagia
A) storing food in the mouth
B) sipping warm liquids
C) chewing excessively
D) refusing soft foods - ANS-A
\A nurse is assessing a client who reports increased pain following PT. which of the following
questions should the nurse ask when assessing the quality of the clients pain
A) is your pain constant or intermittent
B) what would you rate your pain on a scale of 0-10
C) does the pain radiate
D) is the pain sharp or dull - ANS-D
\A nurse is assisting a client with ROM of the neck. Which of the following should the nurse
suggest to promote neck rotation
A) move her head backward
B) touch her chin to her chest
C) touch her ear to shoulder
D) move her head from side to side - ANS-D
\A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines
that the client has developed phlebitis and removes the IV catheter. Which of the following
actions should the nurse take?
A) place a warm compress over the IV site
B) record the findings in the clients chart
C) notify the clients PCP
D) prepare to insert a new IV catheter - ANS-A
\A nurse is caring for a client who has dementia. Which of the following interventions should the
nurse take to minimize the risk of inure to this client?
A) use a bed exit alarm system
B) raise 4 side rails while client is in bed
C) apply one soft wrist restraint
D) dim the lights in the clients room - ANS-A
\A nurse is caring for a client who has left sided paralysis after CVA. pt is unable to bear his
weight. Which of the following is an appropriate transfer method
A) use a draw sheet and have 2 AP help move pt
B) use a hydraulic life and have an AP help move pt
(COPY) The nurse can use antimicrobial sanitizer for hand hygiene when caring for a client with
TB - ANS-The nurse can use antimicrobial sanitizer for hand hygiene when caring for a client
with TB
\(COPY) When initiating an IV inserting the catheter up to the hub reduces the risk of
contamination along the length of the catheter - ANS-When initiating an IV inserting the catheter
up to the hub reduces the risk of contamination along the length of the catheter
\A 30-60 ml syringe should be used when irrigating a wound (COPY) - ANS-A 30-60 ml syringe
should be used when irrigating a wound
\A charge nurse is discussing the responsibility of nurses caring for clients who have clostridium
difficult. Which of the following information should the nurse include in teaching?
A) assign the client to a room with a negative air flow system
B) use alcohol-based hand sanitizer when leaving the clients room
C) clean contaminated surfaces in the clients room with phenol solution
D) have family members wear a gown and gloves when visiting - ANS-D
\A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following
indicates to the charge nurse that the sterile field is contaminated?
A) outer edge of the sterile field is touching a bottle
B) first fold is opened away from the body
C) sterile objects are held above the waist
D) sterile field is opened on a wet surface - ANS-D
\A client is scheduled for surgery. The intraoperative nurse finds a necklace on a client after
anesthesia has been administered. Which of the following interventions should be initiated
A) leave the necklace on the client
B) give the necklace to a family member
C) place the necklace in the clients chart
D) notify security for placement of the necklace - ANS-D
\A client who is nonambulatory notices the nurse that there is a fire in the trashcan. After
confirming the first which of the following actions should the nurse take next?
A) call the emergency fire code
B) extinguish the fire
C) confine the fire
D) evaculate the patient
*look up acronym RACE - ANS-D
\A nurse contacts the facility interpreter to explain a therapeutic procedure for a client who does
not speak English. Which of the following guidelines should the nurse follow when working with
the interpreter
A) speak slowly to allow the interpreter to interpret each word
B) explain the purpose of the communication to the interpreter
C) address the interpreter when explaining the procedure information
, D) supplement words with gestures and nonverbal reinforcement - ANS-B
\A nurse in a long term care facility is planning to perform hygiene care for a new resident.
Which of the following assessment questions is the nurses priority before begging this
procedure?
A) when do you usually bathe, in the morning or evening?
B) do you prefer a bath or shower?
C) at what temperature do you prefer your bath water
D) are you able to help with your hygiene care/ - ANS-D
\A nurse in a long term care facility notes client coughing frequently during meals and suspects
dysphagia. The nurse should assess the pt for which of the following behavioral signs of
dysphagia
A) storing food in the mouth
B) sipping warm liquids
C) chewing excessively
D) refusing soft foods - ANS-A
\A nurse is assessing a client who reports increased pain following PT. which of the following
questions should the nurse ask when assessing the quality of the clients pain
A) is your pain constant or intermittent
B) what would you rate your pain on a scale of 0-10
C) does the pain radiate
D) is the pain sharp or dull - ANS-D
\A nurse is assisting a client with ROM of the neck. Which of the following should the nurse
suggest to promote neck rotation
A) move her head backward
B) touch her chin to her chest
C) touch her ear to shoulder
D) move her head from side to side - ANS-D
\A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines
that the client has developed phlebitis and removes the IV catheter. Which of the following
actions should the nurse take?
A) place a warm compress over the IV site
B) record the findings in the clients chart
C) notify the clients PCP
D) prepare to insert a new IV catheter - ANS-A
\A nurse is caring for a client who has dementia. Which of the following interventions should the
nurse take to minimize the risk of inure to this client?
A) use a bed exit alarm system
B) raise 4 side rails while client is in bed
C) apply one soft wrist restraint
D) dim the lights in the clients room - ANS-A
\A nurse is caring for a client who has left sided paralysis after CVA. pt is unable to bear his
weight. Which of the following is an appropriate transfer method
A) use a draw sheet and have 2 AP help move pt
B) use a hydraulic life and have an AP help move pt
