NURSING PROCESS EXAM 2 QUESTIONS WITH 100% COMPLETE SOLUTIONS

NURSING PROCESS EXAM 2 QUESTIONS WITH 100% COMPLETE SOLUTIONS A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? 1) Fever 2) Intact skin 3) Inflammation 4) Lethargy - answerIntact skin A client with a stage II pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? 1) A clean gown and gloves must be worn when in contact with the client. 2) Everyone who enters the room must wear an N-95 respirator mask. 3) All linen and trash must be marked as contaminated and sent to biohazard waste. 4) Place the client in a room with a client with an upper respiratory infection. - answerA clean gown and gloves must be worn when in contact with the client. A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One 1) admitted with unstable diabetes mellitus. 2) who underwent surgical repair of a perforated bowel. 3) with a stage III sacral pressure ulcer. 4) admitted with a urinary tract infection. - answeradmitted with unstable diabetes mellitus. Which action demonstrates a break in sterile technique? 1) Remaining 1 foot away from nonsterile areas 2) Placing sterile items on the sterile field 3) Avoiding the border of the sterile drape 4) Reaching 1 foot over the sterile field - answerReaching 1 foot over the sterile field What is the rationale for handwashing? Handwashing is expected to remove: 1) transient flora from the skin. 2) resident flora from the skin. 3) all microorganisms from the skin. 4) media for bacterial growth. - answertransient flora from the skin. You are the nurse caring for a patient who is on contact precautions for a wound infection. The patient's daughter comes to visit her mother, and comes out to the nurse's station wearing disposable gloves. What information do you give her daughter regarding contact precautions? 1) Perform hand hygiene on entering her mother's hospital room. 2) Review contact precautions, hand hygiene, and glove use. 3) Remove gloves when leaving her mother's hospital room. 4) Provide the daughter with an extra box of gloves for her mother's room. - answerReview contact precautions, hand hygiene, and glove use. You are changing your patient's sterile dressing and reach across the sterile field. Which nursing action is most appropriate? 1) Remove your sterile gloves and tell the patient you will be right back. 2) Obtain new sterile supplies and set up a new sterile field. 3) Pick up the sterile dressing with your gloved hand and tape it in place. 4) Ring the call bell to ask someone to bring you another pair. - answerObtain new sterile supplies and set up a new sterile field. You are the nurse caring for a patient who recently had abdominal surgery. Her daughter tells you that she wants her mother to keep her Foley catheter in place because it will be easier for her mother. What should you tell the patient and her daughter about catheter use and urinary tract infections? Select all that apply. 1) Long-term indwelling catheter use is associated with urinary tract infections. 2) Support the daughter in judging that the catheter needs to stay in place. 3) Explain that the patient can ask for assistance to walk to the bathroom. 4) Inform her that handwashing is the best way to prevent urinary tract infection. - answer1) Long-term indwelling catheter use is associated with urinary tract infections. 3) Explain that the patient can ask for assistance to walk to the bathroom. Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown - answerWashing hands Which change in hygiene practices may be necessary as the patient ages? 1) Brushing teeth twice a day 2) Bathing every other day 3) Decreasing moisturizer use 4) Increasing soap use - answerBathing every other day A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Select all that apply. 1) Male nursing assistant 2) Male licensed practical nurse 3) Female graduate nurse 4) Female registered nurse - answer3) Female graduate nurse 4) Female registered nurse A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity? ______________ - answerDehydration The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding? 1) Maceration 2) Abrasion 3) Excoriation 4) Pressure ulcer - answerPressure ulcer The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? 1) Bathe the patient's entire body using 8 to 10 washcloths. 2) Assist the patient to a chair and provide bathing supplies. 3) Saturate a towel and blanket in a plastic bag, and then bathe the patient. 4) Assist the patient to the bathtub and provide a bath chair. - answerBathe the patient's entire body using 8 to 10 washcloths. For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skinfolds? Select all that apply. 1) Cover the mattress with a sheepskin. 2) Keep the linens wrinkle free. 3) Separate the skinfolds with towels. 4) Apply petrolatum barrier creams. - answer2) Keep the linens wrinkle free. 3) Separate the skinfolds with towels The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? "Teach the patient to: 1) use an electric razor for shaving." 2) apply skin moisturizer." 3) use less soap when bathing." 4) floss teeth daily." - answeruse an electric razor for shaving." A patient has sustained a spinal cord injury and is no longer able to get in and out of the bathtub without assistance. Which nursing diagnosis appropriately addresses this problem? 1) Total Self-care Deficit 2) Bathing Self-care Deficit 3) Dressing Self-care deficit 4) Activity Intolerance - answerBathing Self-care Deficit Which scheduled hygiene care is usually thought of as including a back massage to help the patient relax? 1) Afternoon care 2) Early morning care 3) Morning care