Final #3 Flashcards
A nurse is caring for a client who fell at a nursing home. The client is alert and oriented x4 and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?
(Select all that apply)
a) Place a belt restraint on the client when he is sitting on the bedside commode
b) Keep the bed in its lowest position with all side rails up
c) Make sure the client’s call light is within reach
d) Provide the client with nonskid footwear
e) Complete a fall risk assessment
c) Make sure the client’s call light is within reach
d) Provide the client with nonskid footwear
e) Complete a fall risk assessment
The nurse is assigned to care for 4 clients. In planning the client rounds, which client should the nurse assess first?
a) A client is scheduled for a chest x-ray
b) A client requiring daily dressing changes
c) A post-operative client preparing for discharge
d) A client receiving nasal oxygen who had difficulty breathing during the previous shift
d) A client receiving nasal oxygen who had difficulty breathing during the previous shift
The nurse is caring for a client with a wound infected with MRSA. The most appropriate infection control precautions for MRSA include which intervention?
a) A room with positive pressure airflow
b) A private room. gown, gloves, and a face shield
c) Private room with negative pressure airflow
d) Mask or respiratory protection device and gown
b) A private room. gown, gloves, and a face shield
The UAP tells the nurse that the client has a blood pressure of 78/46 and a pulse of 116 using a vital sign machine. Which intervention should the nurse implement first?
a) Notify the healthcare provider immediately
b) Have the UAP check the vital signs manually
c) Place the clients in reverse Trendelenburg position
d) Assess the client’s cardiovascular status
d) Assess the client’s cardiovascular status
A nurse is instructing a client who has an injury of the left lower extremity about using a cane. Which of the following instructions should the nurse include? (Select all that apply)
a) Hold the cane on the right side
b) Keep two points of support on the floor
c) Place the cane 38 cm (15 inches) in front of the feet before advancing
d) After advancing the cane, move the weaker leg forward
e) Advance the stronger leg so that it aligns evenly with the cane
a) Hold the cane on the right side
b) Keep two points of support on the floor
d) After advancing the cane, move the weaker leg forward
A nurse is irrigating a wound of a patient who is on contact precautions. Which nursing actions are appropriate when caring for this patient? (Select all that apply)
a) Done goggles for irrigation
b) Wearing a respirator device when giving care
c) Washing hands immediately after removing soiled gloves
d) Ensuring that negative air pressure in the room is maintained
e) Removing the gown before the gloves when leaving the room
a) Done goggles for irrigation
c) Washing hands immediately after removing soiled gloves
A nurse is preparing to administer medications through an NG tube that is connected to suction. To administer the medication, the nurse should take which action?
a) Position the client supine to assist in medication absorption b) Aaspirate the NG tube after medication administration to maintain patency
c) Clamp the NG tube for 30-60 minutes following administration of the medication
d) Change the suction setting low intermittent for 30 minutes after medication administration
c) Clamp the NG tube for 30-60 minutes following administration of the medication
A client has been placed on a clear liquid diet. The nurse should provide the client with which items are allowed to be consumed on the client’s diet? (Select all that apply)
a) Broth
b) Coffee
c) Gelatin
d) Pudding
e) Vegetable juice
f) Pureed Vegetables
a) Broth
b) Coffee
c) Gelatin
A client has an indwelling catheter and reports a need to urinate. Which of the following actions should the nurse take?
a) Check to see whether the catheter is patent
b) Reassure the client that it is not possible to urinate
c) Recatheterize the bladder with a larger gauge catheter
d) Collect a urine sample for analysis
a) Check to see whether the catheter is patent
A nurse is working with a newly licensed nurse who is administering medication to the clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention?
a) Taking all the medications out of the unit dose wrappers before entering the client’s room
b) Checking with the provider when a single dose requires administration of multiple tables
c) Administering a medication then looking up the usual dosage range
d) Relying on another nurse to clarify a medication prescription
b) Checking with the provider when a single dose requires administration of multiple tables
A primary health provider prescribes a medication that the nurse must administer via the intramuscular route. Which site should the nurse eliminate from considering because it has the highest potential for injury when administering an intramuscular injection?
a) Vastus lateralis
b) Rectus femoralis
c) Ventrogluteal
d) Dorsogluteal
d) Dorsogluteal
A nurse is administering an intradermal injection. At which angle should the nurse insert the needle?
a) 90-degree angle
b) 45-degree angle
c) 30-degree angle
d) 15-degree angle
d) 15-degree angle
The nurse is assessing the correct placement of a nasogastric tube. The nurse aspirates the stomach contents, cheks the gastric pH and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?
a) Retest the pH using another strip
b) Document the NG tube is in the correct place
c) Check for placement by auscultating for air injected into the tube
d) Call the MD to request a prescription for a chest radiograph
d) Call the MD to request a prescription for a chest radiograph (X-ray)
The following medications are listed on a client’s MAR. Which medication orders should the nurse question?
a) Lasix 40mg, PO, STAT
b) Ampicillin 500 mg, Q6 Hrs. IVPB
c) Humulin L (Lente) insulin 36 units subcutaneously, every morning before breakfast
d) Codeine Q8 Hrs. PO, PRN for pain
d) Codeine Q8 Hrs. PO, PRN for pain
No dosage
When turning an immobile bedfast client without assistance, which action by the nurse best ensures client safety?
a) Securely grasp the client’s arm and leg
b) Put the side rails up on the opposite side
c) Correctly position and use a turn sheet
d) Lower the head of the client’s bed
b) Put the side rails up on the opposite side
