A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. Which of the following information should the nurse include in the teaching?
-assign the client to a room with a negative airflow system.
-use alcohol-based hand sanitizer ...
RN FUNDAMENTALS CONTENT MASTERY PRACTICE
TEST
A charge nurse is discussing the responsibility of nurses caring for clients who have a
clostridium difficile infection. Which of the following information should the nurse include
in the teaching?
-assign the client to a room with a negative airflow system.
-use alcohol-based hand sanitizer when leaving the client's room.
-clean contaminated surfaces in the clients room with a phenol solution.
-have family members wear a gown and gloves when visiting. - Answer-- Have family
members wear a gown and gloves when visiting.
A nurse is giving change-of-shift report about a client they admitted earlier that day who
has pneumonia. Which of the following pieces of information is the priority for the nurse
to provide ?
-admitting diagnosis
-breath sounds
-body temperature
-diagnostic test results - Answer--breath sounds
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which
of the following task should the nurse delegate?
-Ambulating a client who is postoperative
-Inserting an indwelling urinary catheter for a client
-Demonstrating the use of an incentive spirometer to a client
-Confirming that a client's pain has decreased after receiving an analgesic. - Answer--
Ambulating a client who is postoperative.
A nurse enters a clients room and finds her on the floor. The client's roommate reports
that the client was trying to get out of bed and fell over the side rail onto the floor. Which
of the following statements should the nurse document about this incident ?
-"incident report completed"
-"client climbed over the side rails"
-"client found lying on floor"
-"client was trying to get out of bed" - Answer--"Client found lying on floor"
A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take ?
-wear sterile gloves when removing the old dressing.
-warm the irrigation solution to 40.5* C (105* F)
,-cleanse the wound from the center outward.
-use a 20-ml syringe to irrigate the wound. - Answer--cleanse the wound from the center
outward.
A nurse is admitting a client who has rubella. Which of the following types of
transmission-based precautions should the nurse initiate?
A nurse is providing discharge teaching for a client who has a new prescription for a
home oxygen concentrator. Which of the following instructions should the nurse provide
to the client and his family? (Select all that apply).
-check the cord routinely for frays or tearing
-keep the unit at least 1.2m (4 feet) away from a gas stove.
-consider purchasing a generator for a power backup.
-observe for signs of hypoxia
-select synthetic clothing and bedding. - Answer--check cord routinely for frays or
tearing.
-consider purchasing a generator for power backup
-observe for signs of hypoxia
A nurse is calculating a client's fluid intake over the past 8hr. Which of the following
items should the nurse plan to document on the clients intake and output record as 120-
ml of fluid?
-2 cups of soup
-1 quart of water
-8 oz of ice chips
-6 oz of tea - Answer--8 oz of ice chips
A nurse is caring for a client who has tuberculosis. Which of the following actions should
the nurse take? ( select all that apply)
-place the client room with a negative-pressure airflow
-wear gloves when assisting a client with oral care.
-limit each visitor to 2-hr increments.
-wear a surgical mask when providing client care.
-use antimicrobial sanitizer for hand hygiene - Answer--place the client in a room with
negative-pressure airflow
-wear gloves when assisting the client with oral care
-use antimicrobial sanitizer for hand hygiene
, A nurse is caring for a client who is refusing a blood transfusion for religious reasons.
The client's partner wants the client to have the blood transfusion. Which of the
following actions should the nurse take?
-ask the client to consider a direct donation
-withhold the blood transfusion
-request a consultation with the ethics committee
-ask the clients family to intervene - Answer--withhold the blood transfusion
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the
following statements should the nurse identify as an indication that the client
understands the teaching?
-"when descending stairs, I will first shift my weight to my right leg."
-"I should place my crutches 12 inches in-front and to the side of each food"
-"as I sit down, I will hold one crutch in each hand."
-"I will make sure the shoulder rest are snug against my armpits." - Answer--"when
descending stairs, I will first shift my weight to my right leg"
A nurse has accepted a verbal prescription "for three tenths of a milligram of
levothyroxine IV stat" for a client who has myxedema coma. How should the nurse
transcribe the dosage of this medication in the clients medical record?
A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following findings indicates that the catheter requires irrigation?
-Urine has an unusual order.
-Urine specific gravity is 1.035.
-Bladder scan shows 525 ml of urine
-Urine is positive for ketones. - Answer--Bladder scan shows 525 ml of urine
A nurse is assessing an adult client who has been immobile for the past 3 weeks. For
which of the following finding should the nurse intervene?
- Erythema on pressure points
- lower extremity pulse strength 2+
- fluid intake of 3000 ml per day.
- one bowel movement ever other days - Answer--Erythema on pressure points
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings
through an open system. Which of the following actions should the nurse take first?
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