Exam #1 Flashcards
The nurse prepares to perform a sterile dressing change on an abdominal incision. The nurse explains the procedure to the client, washes his hands, and sets up the sterile field. The nurse should take which action next?
a) Don sterile gloves
b) Assess the integrity of the abdominal incision
c) Don clean gloves and remove the old dressing
d) Clean the wound with iodine solution as prescribed
c) Don clean gloves and remove the old dressing
A nurse takes blood pressure and records a diastolic pressure of 120mm/Hg. Which action should the nurse do first?
a) Notify the primary health care provider
b) Reassess the blood pressure
c) Notify the nurse in charge
d) Take the other vital signs
b) Reassess the blood pressure
A nurse is assessing the temperature of a patient. When can the nurse expect a patient’s temperature to be at its lowest?
a) 10:00 am
b) 2:00 am
c) 4:00 pm
d) 9:00 pm
b) 2:00 am
The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?
a) Teaching the patient about fall prevention
b) Teaching the patient to take a temperature
c) Teaching the patient to select nutririous foods
d) Teaching the patient about the effects of alcohol
c) Teaching the patient to select nutririous foods
The nurse is carinf for a group of patients. Which patient should the nurse see first?
a) A crying infant with pulse if 165 and respirations of 54
b) A sleeping toodle with a pulse of 88 and respirations of 23
c) A calm adolescent with pulse of 95 and respiration of 26
d) An excercising adult with a pulse of 108 and respiration of 24
c) A calm adolescent with pulse of 95 and respiration of 26
A nurse is caring for a group of patients. Which patient will the nurse see first?
a) A patient with stage IV pressure ulcer
b) A patient with a Braden scale of 18
c) A patient with appendicitis using a heating pad
d) A patient with an incision that is approximated
c) A patient with appendicitis using a heating pad
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
a) Offer the patient his favorite liquids to encourage fluid intake
b) Turn the patient every 2 hours
c) Determine the patient’s risk factors
d) Encourage increased quantities of carbohydrates and fats
c) Determine the patient’s risk factors
* Assesment goes first*
A patient is having trouble reaching the water fountain while holding on to the crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation?
a) Humility
b) Creativity
c) Risk Taking
d) Confidence
b) Creativity
Which action demonstrates a nuse utilizing reflection to improve clinical descision making?
a) Obtains data in an orderly fashion
b) Uses an objection approach to patient situations’
c) Improves a plan of care while thinking back on interventions effectiveness
d) Provides evidence-based explanations and reserach for care of assigned patients
c) Improves a plan of care while thinking back on interventions effectiveness
Which of the following errors in blood pressure assessment will cause a false-high blood pressure reading?
a) Blood pressure cuff too wide
b) Blood pressure cuff too narrow
c) Arm above heart level
d) Arm below heart level
e) Arm is not supported
b) Blood pressure cuff too narrow
d) Arm below heart level
e) Arm is not supported
Put the following steps for removal of protective barriers after leaving the isolation room in order:
a) Remove gloves
b) Perform hand hygiene
c) Removing goggles
d) Remove face mask
e) Remove gown
- -Remove gloves
- -Removing goggles
- -Remove gown
- -Remove mask
- -Perform hand hygiene
The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observations, if made by the instructor, indicates the need for further teaching?
a) The student puts on the right glove and then the left glove
b) The student dons sterile gloves before washing hands
c) The student uses the inner wrapping as a sterile field
d) The student touches a glove on the over-bed table, removes both gloves, and dons another sterile pair
b) The student dons sterile gloves before washing hands
* Hand Hygiene always firts*
The nurse is caring for a client with meningococcal pneumonia and implements which transmission-based precautions for this client?
a) Private room or cohort client
b) Personal respiratory protection device
c) Private room with negative airflow pressure
d) Mask worn by staff when client needs to leave room
a) Private room or cohort client
* Droplet*
A nurse in the rehabilitation unit is preparing to change a dressing in an 82 year old client with a Stage III pressure ulcer. Which intervention should the nurse implement first?
a) Obtain the needed equipment to perform the procedure
b) Remove the client’s old dressing with non-sterile gloves
c) Explain the procedure to the client in understandable terms
d) Check to determine if the client has received pain medication
d) Check to determine if the client has received pain medication
* Always check pain level”
Which of the following are considered subjective data? Select all that apply
a) Patient stating they are short of breath
b) “I have a bruise on my arm”
c) “I am hungry”
d) The assistive personnel reports that the client walks with a limp
e) “I felt dizzy when I walked to the bathroom this morning”
a) Patient stating they are short of breath
c) “I am hungry”
e) “I felt dizzy when I walked to the bathroom this morning”
What does the patient tell you
