Matching questions
1-238 of 238
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Which response by a nurse to a client's fear that his wide bed with traction equipment
might prevent him from being moved to safety if a fire occurred on the unit
demonstrates the most respect for the client's concerns?
Give this one a try later!
We would disconnect your traction, lift you to the floor with a sheet, and
pull you to a safe area.
9. Which actions does the nurse recommend for a night shift co-worker, who just
experienced a sharps injury from a known HIV-positive source client, to take
immediately? Select all that apply.
A. Go to the emergency department immediately for a tetanus booster vaccination.
B. Immediately use an alcohol-based handrub on the injured area. C. Notify employee
health tomorrow morning when it opens.
D. Ask your sex partner to have HIV testing as soon as possible.
,E. Wash the injured area immediately for at least 1 minute with soap and water.
F. Make an appointment with the nursing department and request a transfer to an area
where direct physical contact with a client is not expected.
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9. E
E. Wash the injured area immediately for at least 1 minute with soap and
water
The first step with a sharps injury from a known HIV-positive source is to
wash the hands thoroughly with soap and water for at least 1 minute. Using
an alcohol-based handrub is not sufficient for this purpose. Although the
co-worker should go immediately to the emergency department, the
purpose is to initiate postexposure prophylaxis and begin documentation,
not to get a tetanus booster (irrelevant to this situation). Notifying
employee health to continue documentation and prophylaxis is important
but cannot be done immediately. The co-worker's sex partner should have
HIV testing relatively soon, but not immediately, to determine his or her
current status. There is no legal, ethical, or medical reason for the co-
worker to avoid direct physical contact with clients.
When would the nurse expect to culture a client's pressure injury wound?
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16. C When clinical or systemic signs of infection are present
Wound culturing is not routinely performed, unless there is lack of healing
and signs of persistent infection are present. If performed, a tissue culture
is done. Clinical indicators of infection (e.g., cellulitis, exudate changes,
increase in injury size or depth) and systemic signs of bacteremia (e.g.,
fever, elevated white blood cell [WBC] count) are used to diagnose an
infection.
,30. Which client symptom appearing 2 weeks after an extended camping trip does
the nurse associate with the possibility of Lyme disease?
A. Acute confusion
B. Sudden onset of difficulty swallowing
C. Sudden onset of painful, swollen joints
D. Persistent watery diarrhea and weight loss
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30. C. Sudden onset of painful, swollen joints
In the early and localized stage I, the client appears with flulike symptoms,
erythema migrans (round or oval, flat or slightly raised rash often in a bull's
eye pattern), and pain and stiffness in the muscles and joints. Symptoms
begin within 3 to 30 days of the bite of an infected tick, but most present in
7 to 14 days. Gastrointestinal problems are not usually associated with
Lyme disease. Acute confusion is not present in stage I but can be a part of
stages II and III.
What priority complication would the nurse suspect when assessing a client with an
electrical electrical burn that has an entrance wound on the right shoulder and an exit
wound through the left side ribs?
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, 33. B Cardiac dysrhythmias
An electrical injury occurs when an electrical current enters the body.
Tissue injury occurs when electrical energy converts to heat energy as it
travels through the body. Once the current penetrates the skin causing the
entry wound, it flows through the body damaging tissues in its path until
leaving the body at the exit wound. The path of this client's electrical injury
flows across the chest through the myocardium causing damage to the
heart, which can lead to dysrhythmias.
What is the priority action for the nurse to take for a client who has just been
diagnosed with scabies?
Give this one a try later!
24. B Place the client on Contact Precautions
Scabies is an infectious mite infestation of the skin that can be transmitted
by both direct and indirect contact. This infection is not oral and does not
cause fever. In addition, it has no deleterious effect on kidney function.
The Braden Scale was developed for assessing pressure ulcer risks. Identify the
subscales of this tool. (6)
Give this one a try later!
1-238 of 238
Click a definition to match it with a term
Which response by a nurse to a client's fear that his wide bed with traction equipment
might prevent him from being moved to safety if a fire occurred on the unit
demonstrates the most respect for the client's concerns?
Give this one a try later!
We would disconnect your traction, lift you to the floor with a sheet, and
pull you to a safe area.
9. Which actions does the nurse recommend for a night shift co-worker, who just
experienced a sharps injury from a known HIV-positive source client, to take
immediately? Select all that apply.
A. Go to the emergency department immediately for a tetanus booster vaccination.
B. Immediately use an alcohol-based handrub on the injured area. C. Notify employee
health tomorrow morning when it opens.
D. Ask your sex partner to have HIV testing as soon as possible.
,E. Wash the injured area immediately for at least 1 minute with soap and water.
F. Make an appointment with the nursing department and request a transfer to an area
where direct physical contact with a client is not expected.
Give this one a try later!
9. E
E. Wash the injured area immediately for at least 1 minute with soap and
water
The first step with a sharps injury from a known HIV-positive source is to
wash the hands thoroughly with soap and water for at least 1 minute. Using
an alcohol-based handrub is not sufficient for this purpose. Although the
co-worker should go immediately to the emergency department, the
purpose is to initiate postexposure prophylaxis and begin documentation,
not to get a tetanus booster (irrelevant to this situation). Notifying
employee health to continue documentation and prophylaxis is important
but cannot be done immediately. The co-worker's sex partner should have
HIV testing relatively soon, but not immediately, to determine his or her
current status. There is no legal, ethical, or medical reason for the co-
worker to avoid direct physical contact with clients.
When would the nurse expect to culture a client's pressure injury wound?
Give this one a try later!
16. C When clinical or systemic signs of infection are present
Wound culturing is not routinely performed, unless there is lack of healing
and signs of persistent infection are present. If performed, a tissue culture
is done. Clinical indicators of infection (e.g., cellulitis, exudate changes,
increase in injury size or depth) and systemic signs of bacteremia (e.g.,
fever, elevated white blood cell [WBC] count) are used to diagnose an
infection.
,30. Which client symptom appearing 2 weeks after an extended camping trip does
the nurse associate with the possibility of Lyme disease?
A. Acute confusion
B. Sudden onset of difficulty swallowing
C. Sudden onset of painful, swollen joints
D. Persistent watery diarrhea and weight loss
Give this one a try later!
30. C. Sudden onset of painful, swollen joints
In the early and localized stage I, the client appears with flulike symptoms,
erythema migrans (round or oval, flat or slightly raised rash often in a bull's
eye pattern), and pain and stiffness in the muscles and joints. Symptoms
begin within 3 to 30 days of the bite of an infected tick, but most present in
7 to 14 days. Gastrointestinal problems are not usually associated with
Lyme disease. Acute confusion is not present in stage I but can be a part of
stages II and III.
What priority complication would the nurse suspect when assessing a client with an
electrical electrical burn that has an entrance wound on the right shoulder and an exit
wound through the left side ribs?
Give this one a try later!
, 33. B Cardiac dysrhythmias
An electrical injury occurs when an electrical current enters the body.
Tissue injury occurs when electrical energy converts to heat energy as it
travels through the body. Once the current penetrates the skin causing the
entry wound, it flows through the body damaging tissues in its path until
leaving the body at the exit wound. The path of this client's electrical injury
flows across the chest through the myocardium causing damage to the
heart, which can lead to dysrhythmias.
What is the priority action for the nurse to take for a client who has just been
diagnosed with scabies?
Give this one a try later!
24. B Place the client on Contact Precautions
Scabies is an infectious mite infestation of the skin that can be transmitted
by both direct and indirect contact. This infection is not oral and does not
cause fever. In addition, it has no deleterious effect on kidney function.
The Braden Scale was developed for assessing pressure ulcer risks. Identify the
subscales of this tool. (6)
Give this one a try later!
