A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan?
a. Change bags of IV solution every 72 hours.
b. Perform hand hygiene before touching IV tubi...
A nurse is planning care to prevent a catheter-related blood stream infection for a client
who is receiving IV fluid therapy. Which of the following interventions should the nurse
include in the plan?
a. Change bags of IV solution every 72 hours.
b. Perform hand hygiene before touching IV tubing.
c. use hydrogen peroxide to cleanse IV insertion site.
d. Assess the IV insertion site every 12 hr for redness. correct answers b. Perform
hand hygiene before touching IV tubing
Explanation: The nurse should perform thorough hand hygiene before touching any part
of the infusion system or the client to reduce the risk of catheter-related blood stream
infections.
A newly licensed nurse asks a charge nurse where to find information about scope of
practice for registered nurses. Which of the following responses should the charge
nurse make?
a. "The National Institutes of Health website contains this information."
b. "The state board of nursing can provide this information."
c. The facility's legal department write a summary of scope of practice."
d. "The Nurse Licensure Compact defines a nurse's scope of practice." correct
answers b. "The state board of nursing can provide this information."
explanation: Each state develops a nurse practice act, which defines scope of practice
for nurses in that state. This practice act is available on the board of nursing website for
each state.
A nurse is caring for a client who is 2 days postoperative following an above-the-knee
amputation. The client states he is experiencing a dull, burning pain in the leg that was
amputated. Which of the following actions should the nurse take to treat the client's
neuropathic pain?
a. inform the client that phantom limb pain is not real.
b. administer a beta-blocking medication to the client.
c. place the client on a soft mattress.
d. loosen the bandage on the client's residual limb. correct answers b. administer a
beta-blocking medication to the client.
explanation: The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.
,A nurse is creating a plan of care for a client who is non-ambulatory and has bladder
and bowel incontinence. Which of the following interventions should the nurse include to
prevent skin breakdown?
a. use a sheepskin device to pad the client's pressure points.
b. apply cornstarch to the perineal area after bathing the client.
c. massage the client's skin and pressure points every 12 hr.
d. offer the client a glass of water every 2 hr when re-positioning. correct answers d.
offer the client a glass of water every 2 hr when re-positioning.
explanation: The nurse should offer the client a glass of water every 2 hr on the client's
re-positioning schedule. This helps prevent dehydration, which increases the risk of skin
breakdown.
a nurse is teaching a young adult female client about health screening for breast
cancer. Which of the following statements by the client indicates an understanding of
breast self-examination (BSE)?
a. "I should perform a BSE about 1 week before my period each month."
b. "I should use the fingers of my right hand to feel for lumps in my right breast."
c. "I should report a lump in my breast if it remains for two consecutive BSEs."
d. "I should expect to feel a firm ridge along the bottom curve of each breast." correct
answers d. "I should expect to feel a firm ridge along the bottom curve of each breast."
explanation: The nurse should instruct the client that a firm ridge is expected along the
bottom curve of each breast. The client should be able to feel this area during the BSE.
Performing a BSE promotes breast self-awareness so that the client knows how her
breasts normally feel. This awareness increases the client's ability to identify changes
that require further evaluation and treatment.
A nurse is caring for an adolescent client who is in critical condition following a motor
vehicle crash in which he is the passenger. The client's parent shouts at the nurse,
asking why her son is dying instead of the driver. Which of the following actions should
the nurse take to provide emotional support to the parent?
a. encourage the parent to speak with the family of the driver of the car.
b. inform the parent that anger is a natural response when dealing with loss.
c. ask the parent to leave and come back later after she has calmed down.
d. contact a clergy member to come and speak with the parent. correct answers b.
inform the parent that anger is a natural response when dealing with loss.
explanation: The nurse should identify that the parent is in the anger stage of grief. The
nurse should assist the parent to understand that anger is a natural response to loss
and encourage her to talk about her feelings.
A nurse is teaching an older adult client about accessing electronic resources for health
care information on the internet. Which of the following statements should the nurse
include in the teaching?
, a. "websites that are evidence-based avoid placing direct links to other evidence-based
websites on their home pages."
b. "Websites that market products are credible as long as the products are beneficial
for health care."
c. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from
government agencies."
d. "Website forums with the opinions of other clients provide factual and trustworthy
information." correct answers c. "Websites ending in 'dot-gov' are reliable sites for
obtaining health information from government agencies."
explanation: The nurse should teach the client how to select reliable internet websites
when researching health care information. The nurse should identify that websites
ending in ".gov" (government agencies) and ".edu" (educational organizations) are
considered reliable and credible sources for health information. Websites ending in
".com" should not be used for researching credible health care information.
A nurse enters a client's room and finds the client lying on the floor. The client states
that on the way to the bathroom her "knee locked," causing her to fall. Which of the
following actions should the nurse take first?
a. ask an assistive personnel to help return the client to her bed.
b. complete an incident report.
c. check the client for injuries.
d. document objective detail about the client's condition in the medical record. correct
answers c. check the client for injuries.
explanation: The first action the nurse should take when using the nursing process is to
assess the client. The nurse should first check the client for injuries and measure vital
signs to help determine physiologic stability. The nurse should also inform the provider
of the client's fall and of the assessment findings
A nurse is teaching a client who has rheumatoid arthritis about chronic pain
management. Which of the following statements by the client indicates and
understanding of the teaching?
a. "I should stop participating in my bowling league."
b. "I should take a cool shower in the morning to relieve stiffness."
c. "I should decrease my intake of foods containing purine."
d. "I should use a warm paraffin dip for my hands and feet." correct answers d. "I
should use a warm paraffin dip for my hands and feet."
explanation: The nurse should instruct the client to dip her hands and feet in warm
paraffin to alleviate pain and stiffness. The client can more easily perform hand and
finger exercises following the treatment.
A community health nurse is planning prevention strategies for hypertension among
members of her community. The nurse should identify that which of the following ethnic
groups in the community is at greatest risk of developing hypertension?
, a. african americans
b. hispanic americans
c. european americans
d. native americans correct answers a. african americans
explanation: Evidence-based practice indicates that individuals of African-American
ethnicity have the highest prevalence of hypertension. Therefore, the nurse should
identify community members of this ethnicity are at greatest risk of developing
hypertension
A nurse is preparing to extinguish a small fire in a client's room. Which of the following
actions should the nurse take when using the fire extinguisher?
a. aim the fire extinguisher at the top of the flames.
b. pump the handles of the fire extinguisher up and down three times.
c. sweep the fire extinguisher in a circular motion until the fire is extinguished.
d. slide the pin on top of the fire extinguisher straight out. correct answers d. slide the
pin on top of the fire extinguisher straight out.
explanation: The nurse should pull the pin on the top of the fire extinguisher to allow for
use to extinguish the fire.
A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In
which order should the nurse take the following actions?
a. measure gastric residual volume.
b. aspirate 5 mL of gastric contents.
c. flush the NG tube with 30 mL of water.
d. assist the client to an upright position.
e. test the pH of gastric aspirate. correct answers d. assist the client to an upright
position.
b. aspirate 5 mL of gastric
e. test the pH of gastric aspirate
a. measure gastric residual volume.
c. flush the NG tube with 30 mL of water.
A nurse is caring for a 47-year-old female client who has urinary incontinence. Which of
the following actions should the nurse take first?
a. teach client how to perform pelvic exercises.
b. obtain a specimen from the client for culture.
c. instruct the client to keep a daily record of episodes.
d. Provide nutritional education for the client. correct answers b. obtain a specimen
from the client for culture.
explanation: The first action the nurse should take when using the nursing process is
assessment. The nurse should obtain a urine specimen from the client to rule out a
urinary tract infection
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller HopeJewels. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.99. You're not tied to anything after your purchase.
