FUNDAMENTALS OF NURSING PRACTICE A AND B TEST BANK. QUESTIONS WITH ANSWERS.

A nurse observes a staff member. The nurse recognizes that the staff member uses standard precautions appropriately. What does the nurse observe? The staff member places contaminated linens in a leak proof bag The nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS The staff member irrigates an abdominal wound wearing a gown and gloves The nurse removes gloves after bathing a client and puts on clean pair of gloves to bathe another. -The staff member places contaminated linens in a leak proof bag-prevent contact with skin and mucous membranes -The nurse wears gloves when taking the blood pressure of a client diagnosed with AIDS -Wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes. Not necessary to wear gloves when taking blood pressure -The staff member irrigates an abdominal wound wearing a gown and gloves -Should also wear mask or eye protection if splashes or sprays of blood or body fluid might occur -The nurse removes gloves after bathing a client and puts on clean pair of gloves to bathe another -Always wash hands between contacts with pts. Wash hands immediately after removing gloves. Overview Standard Precautions Used with all clients to prevent health care associated infections. Apply to blood, all body fluids, and secretions. Wash hands immediately on contact with blood or body fluids. As soon as gloves are removed, between pt contact, between procedures or tasks with the same pt, wear gloves when touching blood, body fluids, or before touch mucous membranes or non-intact skin, wear mask, face shield, and gown if splashes and sprays likely. A pt. has a BMI of 17kg/m2. What is the best description of the pts body weight? Underweight Normal weight Overweight Obese -Underweight-BMI of less than 18.5 is underweight -Normal weight- Normal BMI is 18.5-24.9 -Overweight- Overweight BMI is 25.0-29.9 -Obese- Obese BMI is 30.0-30.9 Overview BMI BMI estimates body fat. Allows health care provider to counsel about risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis A 4 year old is about to have surgery. A nurse plans to care for the child. Which of the following fears most important for the nurse to consider? Fear of separation Fear of mutilation Fear of losing independence Fear of losing control -Fear of mutilation- Preschool children are frightened of invasive procedures because they fear mutilation. Allow child to play with models of equipment. Encourage expression of feelings -Fear of losing independence-Fear of adolescent. Involve adolescent in procedures and therapies. Express understanding of concerns -Fear of losing control- Fear of school age child. Explain procedures in simple terms allow choices when possible -Fear of separation-Fear of toddle. Teach parents to expect regression. Overview Age-Appropriate preparation -Preschool Preschooler runs well, jumps rope, dresses without help. Has a 2100 word vocabulary, ties shoes, imitates adult patterns and roles. Offer playground material. Housekeeping toys. Coloring books. Use bicycle helmet. Safety restraints in car. Teach to look both ways before crossing street. Before surgery, a client will receive a liver scan. Which statement best describes a liver scan? The client will stand in front of a large machine that takes x-ray pictures of liver The clients skin will be lubricated with oil and ultrasound pictures will be taken The client will be asked to lie still while a scanning probe is passed back and forth over the body The client will be strapped to a table and irradiated by a cobalt scanner -The client will be asked to lie still while a scanning probe is passed back and forth over the body- Client will be placed in many different positions, but must lie still during scan, no follow up care is necessary -The client will be strapped to a table and irradiated by a cobalt scanner- Client will receive IV injection of radioactive colloid, which is taken up by the liver and spleen. Liver and spleen are scanned -The client will stand in front of a large machine that takes x-ray pictures of liver- Scan is nuclear medicine technique -The clients skin will be lubricated with oil and ultrasound pictures will be taken-Ultrasound used to image soft tissues such as liver spleen pancreas and gall bladder. A pt. is treated for a wound infection. A nurse provides routine care. What is the most important for the nurse to do? Send samples of wound drainage for culture Assess the perfusion in the area Evaluating the results of the blood culture. Check and record the clients temp -Evaluating the results of the blood culture.-A client with a wound infection is at risk for bacteremia or other complications such as glomerulonephritis. Nurse should evaluate for temp elevation. -Send samples of wound drainage for culture-Would be done initially -Assess the perfusion in the area-Assess for indication of inflammation -Evaluating the results of the blood culture.-Health care provider will order appropriate antibiotics. Place client on contact precautions