Week 1

Question 1

Nature of infection

◦ Entry and ____________ of organism result in disease
◦ ________________ occurs when a microorganism invades the host but does not cause infection
◦ _______________ disease is the infectious process transmitted from one person to another

Answer 1

◦ Entry and multiplication of organism result in disease
◦ Colonization occurs when a microorganism invades the host but does not cause infection
◦ Communicable disease is the infectious process transmitted from one person to another

Question 2

Infectious processes

Answer 2

Incubation period
Prodromal stage
Illness stage

Question 3

Defenses against infection

• Normal flora
• Body defense mechanisms
• Inflammation
• Vascular and cellular responses
• Inflammatory exudate
• Tissue repair

Answer 3

• Normal flora
• Body defense mechanisms
• Inflammation
• Vascular and cellular responses
• Inflammatory exudate
• Tissue repair

Question 4

Exogenous infection Vs Endogenous infection

Answer 4

Exogenous- anything outside of the body entering (bacteria, etc)

Endogenous- Ex) C. Diff- normal flora in our gut becomes infectious

Question 5

Infection prevention

Assessment includes a through investigation.
◦ Review of past diseases, travel history
◦ Immunizations and vaccinations
◦ Status of defense mechanisms
◦ Client susceptibility
◦ Clinical appearance
◦ Laboratory results

Answer 5

◦ Review of past diseases, travel history
◦ Immunizations and vaccinations
◦ Status of defense mechanisms
◦ Client susceptibility
◦ Clinical appearance
◦ Laboratory results

Question 6

Use NANDA-approved diagnoses.
◦ Risk for infection…
◦ Impaired tissue integrity…
◦ Imbalanced nutrition: less than body requirements…

Answer 6

◦ Risk for infection…
◦ Impaired tissue integrity…
◦ Imbalanced nutrition: less than body requirements…

Question 7

Identify goals and outcomes.
◦ Preventing exposure…
◦ Controlling or reducing the extent of infection…
◦ Verbalizes understanding of inf. prevention and control…

Answer 7

◦ Preventing exposure…
◦ Controlling or reducing the extent of infection…
◦ Verbalizes understanding of inf. prevention and control…

Question 8

Infection

When implementing care, consider:
◦ Medical and surgical asepsis
◦ Control or elimination of infectious agents
◦ Control or elimination of reservoirs
◦ Control of portals of entry
◦ Control of transmission
◦ Hand hygiene
◦ Isolation and isolation precautions

Answer 8

◦ Medical and surgical asepsis
◦ Control or elimination of infectious agents
◦ Control or elimination of reservoirs
◦ Control of portals of entry
◦ Control of transmission
◦ Hand hygiene
◦ Isolation and isolation precautions

Question 9

Standard Precautions – for all patients - _______

Answer 9

gloves

Question 10

_________ Precautions – private room – negative pressure – airflow – HEPA masks

Answer 10

Airborne

Question 11

Droplet Precautions – private room or cohort patients – ______

Answer 11

mask

Question 12

________ Precautions – private room or cohort patients, gloves, gowns

Answer 12

Contact

Question 13

_________ Environment – Private room, positive pressure airflow – HEPA masks

Answer 13

Protective

Question 14

Surgical asepsis or sterile technique:
◦ Prevents ______________ of an open wound
◦ Serves to isolate the operative area from the unsterile environment
◦ Maintains a sterile field for surgery

Answer 14

◦ Prevents contamination of an open wound
◦ Serves to isolate the operative area from the unsterile environment
◦ Maintains a sterile field for surgery

Question 15

Infection prevention - Evaluation step

-Measure the ________ of the infection control techniques.
- Compare the client’s actual response with expected ___________.
- If goals are not achieved, determine what steps must be taken.

Answer 15

-Measure the success of the infection control techniques.
- Compare the client’s actual response with expected outcomes.
- If goals are not achieved, determine what steps must be taken.

Question 16

Which is the most likely means of transmitting infection between patients?

A. Exposure to another patient’s cough
B. Sharing equipment among patients
C. Disposing of soiled linen in a shared linen bag
D. Contact with a health care worker’s hands.

Answer 16

D. Contact with a health care worker’s hands.

Question 17

A patient is isolated for pulmonary TB. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention?

A. Provide a dark, quiet room to calm the patient.
B. Reduce the level of precautions to keep the patient from becoming angry.
C. Explain the reasons for isolation procedures and provide meaningful stimulation.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection.

Answer 17

C. Explain the reasons for isolation procedures and provide meaningful stimulation.

Question 18

Mrs. Martin’s son visits her and asks Mary what could have contributed to his mother getting an infection. Mary bases her answer on knowing that Mrs. Martin has a higher risk for developing an infection. What factors make Mrs. Martin more susceptible to infection? Select all that apply.

A. Gender
B. Age
C. Poor nutrition
D. Low blood sugar
E. Stress

Answer 18

Age
Poor nutrition
Stress

Question 19

The most important way to prevent infection is :

Answer 19

hand hygiene

Question 20

it is acceptable to use alcohol-based waterless hand sanitizers for routine decontamination, except when the hands are:

Answer 20

visibly soiled.

Question 21

Risks in Health Care Agency

-Medical errors
-Chemical use
-Falls
-Client-inherent accidents
-Procedure-related accidents
-Equipment-related accidents

Answer 21

-Medical errors
-Chemical use
-Falls
-Client-inherent accidents
-Procedure-related accidents
-Equipment-related accidents

Question 22

Critical Thinking

In client safety, critical thinking is an ongoing process.

• Utilize standards developed by : [2]

Answer 22

American Nurses Association and The Joint Commission.

Question 23

National Patient Safety Goals

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among caregivers
  ◦ EHR
  ◦ SBAR
• Improve the safety of using medications
• Medication reconciliation
• Fall reduction
  -Health care-associated infections
• Encourage patient involvement in own care
  -Reduce risk for fires
  ◦ R.A.C.E
  -Vaccinations of older adults

Answer 23

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among caregivers
  ◦ EHR
  ◦ SBAR
• Improve the safety of using medications
• Medication reconciliation
• Fall reduction
  -Health care-associated infections
• Encourage patient involvement in own care
  -Reduce risk for fires
  ◦ R.A.C.E
  -Vaccinations of older adults

Question 24

During hygiene assess:

◦ Physical limitations
◦ Health promotion practices and needs
◦ Emotional needs

Answer 24

◦ Physical limitations
◦ Health promotion practices and needs
◦ Emotional needs

Question 24

Dermal-epidermal junction
◦ Separates :

Answer 24

dermis and epidermis

Question 25

__________ - Top layer of skin

__________ - Inner layer of the skin

Answer 25

Epidermis - Top layer of skin

Dermis - Inner layer of the skin

Question 26

Pressure ulcer
◦ Pressure sore, decubitus ulcer, or bed sore

Pathogenesis
◦ Pressure _________
◦ Pressure ___________
◦ Tissue __________

Answer 26

◦ Pressure sore, decubitus ulcer, or bed sore

Pathogenesis
◦ Pressure intensity
◦ Pressure duration
◦ Tissue tolerance

Question 27

Risk Factors for Pressure Ulcer Development

-Impaired _________ perception
-Impaired ___________
-Altered level of _______________
-Shear
-Friction
-Moisture

Answer 27

-Impaired sensory perception
-Impaired mobility
-Altered level of consciousness
-Shear
-Friction
-Moisture

Question 28

Classification of Pressur Ulcers

Answer 28

Question 29

Prediction and prevention of pressure ulcers

◦ Norton Scale
- Physical and mental condition, activity, mobility, and continence

◦ Braden Scale
- Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Answer 29

◦ Norton Scale
- Physical and mental condition, activity, mobility, and continence

◦ Braden Scale
- Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Question 30

Factors Influencing Pressure Ulcer Formation and Wound Healing

• Nutrition
• Tissue perfusion
• Infection
• Age
• Psychosocial impact of wounds

Answer 30

• Nutrition
• Tissue perfusion
• Infection
• Age
• Psychosocial impact of wounds

Question 31

Skin integrity/wound assessment

-Presence of ulcers
-Mobility
-Nutrition and fluid status
-Pain
-Existing wounds, appearance, character
-Wound culture

Answer 31

-Presence of ulcers
-Mobility
-Nutrition and fluid status
-Pain
-Existing wounds, appearance, character
-Wound culture

Question 32

Skin integrity/wound - implementation

Health promotion
◦ Topical skin care
- Protect bony prominences, skin barriers for incontinence.
◦ Positioning
- Turn every 1 to 2 hours as indicated.
◦ Support surfaces
- Decrease the amount of pressure exerted over bony prominences.

Answer 32

◦ Topical skin care
- Protect bony prominences, skin barriers for incontinence.
◦ Positioning
- Turn every 1 to 2 hours as indicated.
◦ Support surfaces
- Decrease the amount of pressure exerted over bony prominences.

Question 33

Wound dressings

Dry or moist
◦ Gauze

___________
◦ Protects the wound from surface contamination

___________
◦ Maintains a moist surface to support healing

______________
◦ Uses negative pressure to support healing

Answer 33

Dry or moist
◦ Gauze

Hydrocolloid
◦ Protects the wound from surface contamination

Hydrogel
◦ Maintains a moist surface to support healing

Wound V.A.C.
◦ Uses negative pressure to support healing

Question 34

Skin Integrity and Wound - Heat and Cold Therapy

Answer 34

The health care provider determines the application time for heat.

However, for cold, the maximum time is 20 to 30 minutes

Question 35

Which national organization categorizes injuries as intentional or unintentional?

The Joint Commission (TJC)

Quality and Safety Education for Nurses (QSEN)

Agency for Healthcare Research and Quality (AHRQ)

National Center for Health Statistics (NCHS)

Answer 35

National Center for Health Statistics (NCHS)

Question 36

Which teaching points will the nurse include when teaching a community group about injuries?

Select all that apply.

Unintentional injuries are unplanned incidents.

Unintentional injuries typically result from deliberate acts of violence.

Unintentional injuries do not account for many deaths within the United States.

The risk factors for intentional injuries are better understood than those of unintentional injuries.

Intentional injuries include events such as falls, drownings, and fire-associated injuries.

Answer 36

Unintentional injuries are unplanned incidents.

The risk factors for intentional injuries are better understood than those of unintentional injuries.

Question 37

Falls, drownings, and fire-associated injuries are considered _____________ injuries

Answer 37

unintentional

Question 38

Which organization places a focus on patient safety when evaluating health care agencies for accreditation?

The Joint Commission

World Health Organization

Centers for Disease Control and Prevention

National Institutes of Health

Answer 38

The Joint Commission

Question 39

The Joint Commission reevaluates National Patient Safety Goals every ___ months.

Answer 39

12

Question 40

When teaching a community group about individual safety, which factors would the nurse include?

Select all that apply.

Workplace

Physical age

Developmental level

Neighborhood environment

Participation in school activities

Answer 40

Physical age

Developmental level

Question 41

Which factor is most likely the result of an impaired renal system?

Alteration of senses

Orthostatic hypotension

Impaired excretion of medications

Disruption of the body’s protective barrier

Answer 41

Impaired excretion of medications

Question 42

Which safety risks would the nurse include when teaching the parents of an 18-month-old about safety precautions?

Select all that apply.

Choking on grapes

Drowning in swimming pools

Strangulation from blind cords

Dehydration from sitting in a hot car

Accidental ingestion of medication

Head or neck injury related to trampoline use

Answer 42

Choking on grapes

Drowning in swimming pools

Strangulation from blind cords

Dehydration from sitting in a hot car

Accidental ingestion of medication

Question 43

The nurse recognizes that poisoning symptoms can resemble symptoms of which other disorders?

Select all that apply.

Brain attack

Seizure

Alcohol intoxication

Hypoglycemia

Delirium

Strep throat

Answer 43

Brain attack

Seizure

Alcohol intoxication

Hypoglycemia

Delirium

Question 44

Which teaching would the nurse provide to a patient who asks how to best prepare fruits and vegetables to eat?

Disinfect with an organic household cleaner.

Rinse under running water.

Use a small amount of dish detergent.

Wash in solution made with 1 gallon of water and 1 teaspoon of bleach.

Answer 44

Rinse under running water.

Question 45

Which types of footwear would the nurse recommend to a patient who plans to use a riding lawn mower regularly this summer?

Select all that apply.

Sneakers

Velcro, nonslip shoes

Shoes with sturdy laces

Sandals, as the feet are away from blades

Rubber boots

Answer 45

Velcro, nonslip shoes

Shoes with sturdy laces

Question 46

Nurses are professionally accountable for ___ Quality and Safety Education for Nurses competencies.

Answer 46

six

Question 47

Which statement describes the main goal of the Quality and Safety Education for Nurses (QSEN) project?

Prepare future nurses to advance quality and safety.

Allocate resources for safety program implementation.

Minimize the risk for harm to older adult patients by injury.

Assist nurses to educate patients about safety concerns.

Answer 47

Prepare future nurses to advance quality and safety.

Question 48

Educating patients about electrical cord safety is important in preventing:

Answer 48

fires as frayed electrical cords can start fires.

Question 49

To assess the patient’s risk for exposure to biohazards in the home, which question would the nurse ask?

Do you have air conditioning?

What recreational activities do you engage in?

Is there adequate outside lighting?

Do you or does anyone in the home use hypodermic needles?

Answer 49

Do you or does anyone in the home use hypodermic needles?

Question 50

Which member of the interprofessional team would the nurse consult to evaluate a patient for safe performance of activities of daily living (ADLs)?

Social worker

Physical therapist

Occupational therapist

Unlicensed assistive personnel

Answer 50

Occupational therapist

Question 51

Which member of the interprofessional team would the nurse consult to evaluate a patient who is a fall risk?

Health care provider

Physical therapist

Occupational therapist

Unlicensed assistive personnel

Answer 51

Physical therapist

Question 52

During an assessment, the nurse learns that a patient and child are living in a car. Which member of the interprofessional team would the nurse consult with to evaluate these individuals?

Health care provider

Social worker

Physical therapist

Occupational therapist

Answer 52

Social worker

Question 53

A fire prevention plan must include changing batteries in smoke alarms (detectors) at least every ___ months

Answer 53

6

Question 54

Many hospitals use the acronym RACE to describe emergency fire response. Which terms stand for the letters in RACE?

Rescue, Advise, Comfort, Expedite

Rescue, Alarm, Contain, Extinguish

Restrain, Action, Continue, Emergency

Resuscitate, Action, Control, Emergency

Answer 54

Rescue, Alarm, Contain, Extinguish

Question 55

Which action would the nurse take first when discovering a fire in a patient’s room?

Extinguish the fire.

Contain the fire.

Remove the patient from the room.

Sound the alarm.

Answer 55

Remove the patient from the room.

Question 56

The nurse is caring for a 72-year-old patient who is on bed rest after hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. Upon assessment, the nurse notes an intravenous (IV) infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient’s total score?

Answer 56

75

The patient is a high risk for falls: History of falling—25; Secondary diagnosis—15; Ambulatory aid—0; IV/heparin lock—20; Gait/transferring—0; Mental status—15 = 75 points.

Question 57

A patient with paraplegia is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment?

“Do you have a carbon monoxide detector?”

“Do you have a plan to exit the home in case of an emergency?”

“Where are your medications stored?”

“Do you have a fire extinguisher?”

Answer 57

“Do you have a plan to exit the home in case of an emergency?”

Question 57

The nurse is asking the patient a series of questions about the patient’s activities of daily living. The patient asks the nurse why that information is important. Which nursing response is appropriate?

“The answers to these questions will help us determine if you need any assistance at home.”

“This information will help your health care provider determine if you need to be placed in a skilled nursing facility.”

“The questions are designed to get you to think about going home from the hospital.”

“This is part of our regular patient assessment form that we must complete.”

Answer 57

“The answers to these questions will help us determine if you need any assistance at home.”

Question 57

Which factor is a patient-related fall risk hazard?

Wound drain

Floor surfaces

Intravenous access

Incontinence

Answer 57

Incontinence

Question 58

Which phrase describes medical asepsis?

Absence of all infectious agents

Procedure known as clean technique

Requires use of sterile gloves

Prevents microbial entry into body

Answer 58

Procedure known as clean technique

Medical asepsis is also known as clean technique and includes hand hygiene and gloves to prevent the spread of microorganisms

Question 58

Which statement is correct regarding hand hygiene in the health care setting?

Soap and water effectively reduce microorganisms on visibly dirty hands.

Infectious agents are killed by soap and water when washing hands.

Washing hands with very hot water helps eliminate a greater number of bacteria.

Non–alcohol-based hand sanitizers inhibit microorganism growth on hands.

Answer 58

Soap and water effectively reduce microorganisms on visibly dirty hands.

Question 59

Which practices would be included by the nurse when teaching about standard precautions?
Select all that apply.

Hand hygiene

Cough etiquette

Patient cleanliness

Safe injection practices

Use of personal protective equipment (PPE)

Answer 59

Hand hygiene

Cough etiquette

Safe injection practices

Use of personal protective equipment (PPE)

Question 59

An effective alcohol-based hand scrub must contain at least __ percent alcohol.

Answer 59

60

Question 59

The nurse removes PPE in the following order:

Answer 59

gloves, eyewear, gown, mask, shoe covers.

Question 59

Which precaution would the nurse take when handling needles (sharps) to prevent an accidental needlestick?

Recapping the needle after use

Using a needleless system whenever possible

Placing covered intravenous (IV) cannulas securely in the trash

Flushing needles with water before disposing of them

Answer 59

Using a needleless system whenever possible

Question 59

As a member of the infection control committee, which action would the nurse suggest to help control transmission of respiratory infections among staff during influenza season?

Role model wearing gloves during patient care.

Speak to peers about obtaining their immunizations.

Teach hand hygiene to unlicensed assistive personnel.

Post signs in bathrooms demonstrating cough etiquette.

Answer 59

Post signs in bathrooms demonstrating cough etiquette.

Question 60

Which transmission-based precaution would the nurse take for a seriously ill patient being admitted for influenza?

Avoid admitting through the reception area.

Admit to an airborne infection isolation room.

Obtain an N95 disposable respirator mask.

Provide a mask for the patient if leaving the room.

Answer 60

Provide a mask for the patient if leaving the room.

Question 61

Which source is best for the nurse to recommend for patients interested in information about the updated immunization schedule for adults?

Their health care provider’s clinic or office

The Centers for Disease Control and Prevention (CDC) immunization website

Any health care provider at a local pharmacy

The US government website

Answer 61

The Centers for Disease Control and Prevention (CDC) immunization website

Question 62

Which home care intervention helps reduce the transmission of infections?

Reporting infections as early as recognized

Using disposable dishes and utensils

Soaking clothing in bleach solution

Isolating the infected individual from others

Answer 62

Reporting infections as early as recognized

Question 63

Which diseases can the federal government order patients to be isolated and/or quarantined for?
Select all that apply.

Smallpox

Human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS)

Measles

Cholera

Yellow fever

Diphtheria

Answer 63

Smallpox

Cholera

Yellow fever

Diphtheria

Question 64

Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room?

Mask

Gown

Hair cover

Sterile gloves

Answer 64

Mask

Question 65

Which intervention would a nurse anticipate specifically for a patient suspected of meningitis?

Antibiotics

Lumbar puncture

Inputs and outputs

Complete blood count

Answer 65

Lumbar puncture

A lumbar puncture is a test specifically used to help with the diagnosis of meningitis

Question 66

A lumbar puncture is a test specifically used to help with the diagnosis of ______________

Answer 66

meningitis

Question 67

Which term describes the administration of a medication by a nurse?

Dependent intervention

Independent intervention

Interdependent intervention

Nurse-initiated intervention

Answer 67

Dependent intervention

Dependent interventions require a written or an oral prescription from a health care provider and include the administration of a medication.

Question 68

Which infection would require a nurse to don a fitted N95 respiratory mask?

Tuberculosis

Influenza

Pneumonia

Methicillin-resistant Staphylococcus aureus (MRSA)

Answer 68

Tuberculosis

Question 69

Which infection would prompt the nurse to implement contact precautions?

Hepatitis A

Streptococcal pneumonia

Influenza

Chickenpox

Answer 69

Hepatitis A

Hepatitis A is transmitted by direct contact from person to person. The nurse would implement contact precautions.

Question 70

Which infection would require a patient to be admitted to the airborne infection isolation room?

Pharyngeal diphtheria

Meningococcal sepsis

Staphylococcus aureus

Varicella zoster

Answer 70

Varicella zoster

This pathogen causes chickenpox. It is highly contagious and requires admitting the patient to an airborne infection isolation room.

Question 71

Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick?

Personal

Community

Home

Employee

Answer 71

Personal

The nurse staying home is a personal action taken to help reduce the transmission of infection to other staff members and patients.

Question 72

Which action can communities engage in to help reduce infections among their citizens?

Encouraging and facilitating immunization programs

Providing containers for used needle disposal to patients

Assisting with health care environment modifications

Educating patients about home infection control measures

Answer 72

Encouraging and facilitating immunization programs

Question 73

Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field?

Health care provider touched sterile field one-half inch from edge

Health care provider reached over sterile field to pick up a towel

Masked assistant talked over the sterile field

Sterile packages opened facing away from body

Answer 73

Health care provider reached over sterile field to pick up a towel

Reaching over the sterile field does contaminate the sterile field. The nurse would recognize this as a breach in surgical asepsis and call it to the attention of the health care provider.

Question 74

Which procedure is necessary for equipment being used to enter a sterile body cavity?

Sanitization

Disinfection

Sterilization

Decontamination

Answer 74

Sterilization

Question 75

A temperature below ________ indicates that an infection has resolved.

Answer 75

100.4°F (38°C)

Question 76

Which aspect of the general history would the nurse focus on when caring for a patient with a hypothesis related to an infection?

Recent travel

Tobacco abuse

Previous pregnancies

History of hypertension

Answer 76

Recent travel

Question 77

Which cue would support the nurse with a hypothesis of meningitis?

Cough

Hematuria

Neck stiffness

Abdominal pain

Answer 77

Neck stiffness

Neck stiffness is a cue associated with meningitis. Additional cues that a nurse would anticipate include fever, headache, and confusion.

Question 77

Which cue would indicate an infection to a nurse caring for a patient 2 days after a cesarean section?

Productive cough

Clean surgical wound

Pain on ambulation

Vaginal bleeding

Answer 77

Productive cough

A productive cough would support the presence or raise the suspicion of a respiratory tract infection and require further evaluation. Postsurgical patients are at an increased risk for atelectasis and respiratory infections.

Question 78

With whom would the nurse collaborate first when setting goals for a patient with a surgical wound at risk for infection?

Health care team

Caregiver

Patient

Therapist

Answer 78

Patient

Question 79

Which goal is realistic for a nurse caring for a patient postoperatively?

Patient’s wound will have no drainage after surgery.

Patient will be fever free on the second postoperative day.

Patient’s incision will heal without signs of infection by day 10.

Patient will be pain free by the first postoperative day.

Answer 79

Patient’s incision will heal without signs of infection by day 10.

Question 80

Which measurable goal would a nurse develop for a patient who is experiencing chest discomfort from a cough related to a respiratory infection?

Coughing will improve within 12–24 hours of initiation of treatment.

Patient complaints of chest discomfort from cough will decrease within 4 days.

Productive cough will decrease within 48 hours of starting treatment.

Patient will verbalize decreased chest discomfort related to cough within 2 days.

Answer 80

Patient will verbalize decreased chest discomfort related to cough within 2 days.

This goal is measurable because it addresses the patient’s problem of chest discomfort related to cough, and patient verbalizations are measurable data.

Question 81

Which cue would support the nurse with a hypothesis of a Urinary Tract Infection?

Cough

Hematuria

Neck stiffness

Abdominal pain

Answer 81

Hematuria

Hematuria is a cue associated with a urinary tract infection. Additional cues that a nurse would anticipate include fever, polyuria, dysuria, and foul-smelling, cloudy urine.

Question 82

Which patient behavior supports the nurse’s hypothesis of a knowledge deficit?

Refusal to eat yogurt served on lunch tray

Inability to perform incisional care

Explanation from patient about correct diet

Untouched informational booklets at bedside

Answer 82

Inability to perform incisional care

This behavior supports the nurse’s hypothesis of a knowledge deficit. The patient either lacks the knowledge about how to perform the procedure or needs instruction and practice performing the procedure.

Question 83

Which nursing hypothesis would the nurse add to the care plan after noting an open pressure injury on the patient’s coccyx during assessment?

Lack of Knowledge

Impaired Skin Integrity

Impaired Nutritional Status

Acute Pain

Answer 83

mpaired Skin Integrity

Impaired Skin Integrity is the nursing hypothesis the nurse should place on the patient’s care plan. It addresses the patient’s open pressure injury.

Question 84

Mnemonic for blood cells frequency

Answer 84

Never Let Monkeys Eat Bananas

Question 85

Which white blood cells are responsible for the signs and symptoms of inflammation?

Neutrophils

Monocytes

Eosinophils

Basophils

Answer 85

Basophils

Basophils release vasoactive mediators, such as histamine, which are responsible for the signs and symptoms of inflammation: redness, heat, swelling, and pain.

Question 86

Which patient finding is indicative of a localized infection?

Tachycardia

Fatigue

Abscess

Chills

Answer 86

Abscess

An abscess is a patient finding indicative of a localized infection because it is limited to a specific area, such as a boil or dental pocket.

Question 87

Erythrocyte sedimentation rate (ESR)
The ESR is elevated during active:

Answer 87

inflammation. Because infection causes inflammation, it is also elevated during infection.

Question 88

Which living substance functions as an antigen?

Toxins

Chemicals

Drugs

Proteins

Answer 88

Proteins

Question 89

Which type of immunity serves as the body’s first line of defense by providing immediate protection against foreign antigens?

Active immunity

Passive immunity

Adaptive immunity

Innate immunity

Answer 89

Innate immunity

Innate immunity serves as the body’s first line of defense and provides immediate protection against foreign antigens.

Question 90

Which term describes a microorganism that causes serious disease?

Pathogen

Antigen

Virulent

Invasive

Answer 90

Pathogen

Question 91

Which mechanism explains how normal flora protects against infection?

Inhibits microorganisms from colonizing

Prevents pathogens from entering circulation

Destroys infectious agents on body surfaces

Neutralizes and eliminates foreign antigens

Answer 91

Inhibits microorganisms from colonizing

Question 92

Which body system has proteins with antimicrobial properties and promotes phagocytosis?

Respiratory system

Gastrointestinal system

Integumentary system

Musculoskeletal system

Answer 92

Respiratory system

Question 93

Which immune response is mediated by circulating antibodies that coat antigens and target them for destruction?

Humoral immunity

Innate immunity

Adaptive immunity

Cellular immunity

Answer 93

Humoral immunity

Humoral immunity is also known as antibody-mediated immunity. It uses specialized cells to produce antibodies that respond to foreign antigens or pathogens.

Question 94

___________ immunity is also known as antibody-mediated immunity. It uses specialized cells to produce antibodies that respond to foreign antigens or pathogens.

Answer 94

Humoral

Question 95

Which cells are responsible for the production of antibodies?

T-helper cells

Phagocytes

B lymphocytes

Macrophages

Answer 95

B lymphocytes

Question 96

Which adaptive immune system cells release interleukins to stimulate antibody production by B cells?

Complements

Macrophages

T-helper cells

Basophils

Answer 96

T-helper cells

Question 97

Which function would a nurse recognize as an adaptive immune response?

Initiating the inflammatory response

Producing chemical mediators

Phagocytizing foreign substances

Triggering lymphocyte production

Answer 97

Triggering lymphocyte production

Question 98

Which type of immunity initially protects a person from infection after receiving a skin laceration?

Adaptive immunity

Innate immunity

Humoral immunity

Passive immunity

Answer 98

Innate immunity

Question 99

Which component is part of innate immunity and participates in the inflammatory response?

Leukocytes

Helper cells

Cytotoxic T cells

Immunoglobulins

Answer 99

Leukocytes

Leukocytes, or white blood cells (WBCs), are important components participating in inflammation. They provide defense through phagocytosis, enzymes, and cleaning up debris after the inflammatory response.

Question 100

A microorganism is considered to be resistant if it cannot be stopped by the use of __
or more antibiotics.

Answer 100

2

Question 101

Which phenomenon causes microbial resistance?

Microorganisms adapting to their environment

Infectious agents developing greater virulence

Pathogens changing replication patterns

Bacteria developing protective outer coats

Answer 101

Microorganisms adapting to their environment

Question 102

Which factor that contributes to antimicrobial resistance is considered an infection control issue?

Congested health settings

Patient nonadherence

Population of urban centers

Lack of patient education

Answer 102

Congested health settings

An infection control issue is that of overcrowding of hospitals and clinics where both infected and well persons are exposed to infected persons and thus pathogens.

Question 103

health care–associated infection (HAI) are infections acquired by patients while___________________________________within the health care setting.

Answer 103

receiving treatment for other conditions

Question 104

Which pathogen cannot be treated with antibiotics because it has a protective envelope?

Bacterium

Virus

Fungus

Parasite

Answer 104

Virus

Question 105

Which precaution would be implemented for a patient admitted for suspected West Nile virus?

Contact

Droplet

Airborne

Standard

Answer 105

Standard

Standard precautions would be implemented for this patient because West Nile virus is transmitted by a vector, specifically mosquitos. There are no other precautions required for vector-transmitted pathogens.

Question 106

Which factor is most likely to contribute to the development of a health care–associated respiratory infection in an ambulatory diabetic patient receiving an intravenous antibiotic?

Excessive activity

Decreased oxygenation

Current comorbidity

Incorrect antibiotic

Answer 106

Current comorbidity

Diabetes mellitus places the patient at increased risk for development of a health care–associated infection.

Question 107

Which rationale explains why antibiotic use in animals contributes to human antimicrobial resistance?

Creates a reservoir of potentially resistant bacteria

Allows for greater exposure to multiple pathogens

Promotes new vectors as sources of transmission

Lack of hygiene and sanitation in animal holding areas

Answer 107

Creates a reservoir of potentially resistant bacteria

Use of antibiotics to treat livestock and fish as a preventive measure is overuse of antibiotics. This contributes to antimicrobial resistance by creating a reservoir of potentially resistant bacteria.

Question 108

Which statement is phrased as a desired outcome for a pediatric patient being treated for head lice?

Child’s hair will be cleansed with medicated shampoo daily.

Bed linens will be washed in hot, soapy water once weekly.

Child refrains from sharing personal items with school classmates.

Mother will find no evidence of lice in the child’s hair within 1 week.

Answer 108

Child refrains from sharing personal items with school classmates.

This is a desired outcome, meaning the goal of teaching the child not to share personal items is being met. The child is refraining from sharing personal items at school.

Question 109

Which action by the nurse demonstrates a collaborative approach to improving a patient’s ability to perform self-hygiene and personal care?

Assigning the unlicensed assistive personnel (UAP) to comb the patient’s hair

Partnering with the occupational therapist

Asking the family to care for the patient’s needs

Reporting on patient needs to the oncoming nurse

Answer 109

Partnering with the occupational therapist

Partnering with the occupational therapist is collaboration because both health care team members work together to plan interventions for the common goal of improving the patient’s ability to perform self-hygiene and personal care.

Question 110

Which action would the nurse take when a patient requests a same gender caregiver for hygiene and personal care because of cultural preferences?

Request the family to provide care.

Collaborate with social services.

Accommodate the patient’s wishes.

Assess the patient’s hygiene needs.

Answer 110

Accommodate the patient’s wishes.

Question 111

Which example shows a correctly stated hygiene and personal care long-term goal?

Patient will shower independently by the end of 1 month.

Self-care deficit will be resolved within 3 to 6 days.

Patient will use toothbrush to perform oral hygiene without assistance.

Within 24 hours, patient will bathe with the help of one person.

Answer 111

Patient will shower independently by the end of 1 month.

Question 112

A patient exhibits matted hair and caked mud and debris under fingernails and toenails. Which nursing hypothesis would the nurse select?

Activity Intolerance

Pressure Ulcer/Injury

Self-Care Deficit

Impaired Oral Mucous Membrane

Answer 112

Self-Care Deficit

Question 113

The nurse would give extra attention to assessing for infections on and around the nails in a patient with which condition?

Halitosis

Pediculosis

Diabetes

Dandruff

Answer 113

Diabetes

Patients with diabetes are prone to infections on and around the nails because of decreased circulation and a weakened immune system.

Question 114

Which skin conditions might be present if a patient is having an allergic reaction to something he or she touched?

Answer 114

Contact dermatitis

Rash

Question 115

Which piece of clothing would the nurse remove when looking for excoriations?

Socks

Pants

Headband

Adult diaper

Answer 115

Adult diaper

A patient wearing an adult diaper indicates the skin is exposed to stool and urine, which is a major risk factor for excoriation and skin breakdown.

Question 116

When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment?

Open wound over the sacrum

Red, scaly lesion on buttocks

Purplish discoloration under the cheek

An infected surgical wound

Answer 116

Open wound over the sacrum

Question 117

Which type of injury results in a puncture wound?

Paper cut

Dog bite

Popped blister

Black eye

Answer 117

Dog bite

Question 118

A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider?

Presence of pediculosis

Halitosis related to poor oral hygiene

Oily, matted, and tangled hair

Warm, moist, and intact skin

Answer 118

Presence of pediculosis

Pediculosis, or a lice infestation of the body hair, warrants immediate treatment and a phone call to the health care provider for prescriptions. This is not a normal finding and requires treatment before it spreads to other patients and health care staff.

Question 119

Which patient situation indicates that a sink bath is appropriate?

Needs support while standing

Requires assistance to move from bed to sink

Can perform part of the sink bath independently

Provides own bathing supplies

Answer 119

Can perform part of the sink bath independently

Question 120

Which action by a female patient lets the nurse know the patient has understood perineal care teaching?

The patient washes her perineum with a circular motion beginning at the urinary meatus.

The patient washes her perineum from front to back using a clean washcloth.

The patient washes her perineum from back to front with a clean washcloth.

The patient washes her perineum lightly to prevent tissue damage.

Answer 120

The patient washes her perineum from front to back using a clean washcloth.

Question 121

For which reason is it contraindicated for a patient with peripheral neuropathy to soak the feet?

Can cause increased circulation

Can cause tissue drying and increase risk for infection

Is painful for the patient

May make patient unable to walk

Answer 121

Can cause tissue drying and increase risk for infection

Question 122

Which type of massage is best for patients with deep muscle tension?

Petrissage

Effleurage

Tapotement

Percussion

Answer 122

Petrissage

Question 123

Which type of bath is appropriate for an older adult patient who ambulates with a cane and has a history of unsteadiness?

Sink bath

Chair shower

Partial bed bath

Complete bed bath

Answer 123

Chair shower

A chair shower is the best option for a patient with a history of ambulatory unsteadiness.

Question 124

Which benefit does a sitz bath provide for a new mother?

Regulates skin pH

Eliminates pediculosis

Decreases swelling

Decreases halitosis

Answer 124

Decreases swelling

A sitz bath is used after childbirth to decrease swelling, inflammation, and pain.

Question 125

Which action must the nurse perform before a patient receives a shower?

Ensure the patient would like to take a shower.

Make sure a shower chair is available.

Determine if the patient will take a stand-up shower or use a shower chair.

Check the health care provider’s prescription to determine if showering is safe.

Answer 125

Check the health care provider’s prescription to determine if showering is safe.

Question 126

A nurse is instructing a newly blind patient how to clean the eyes. Which instruction would the nurse provide?

Use plain water and wipe from the outer canthus to the inner canthus.

Use soapy water and wipe from the inner canthus to the outer canthus.

Use sterile water and wipe from the outer canthus to the inner canthus.

Use plain water and wipe from the inner canthus to the outer canthus.

Answer 126

Use plain water and wipe from the inner canthus to the outer canthus.

Eyes should be washed from the inner canthus to the outer canthus using plain water.

Question 127

Which action is taken for a patient receiving oxygen with a nasal cannula to prevent nasal passages from drying?

Humidifying the oxygen

Warming the oxygen

Cooling the oxygen

Lowering the oxygen

Answer 127

Humidifying the oxygen

Humidifying the oxygen can help relieve dryness in the nasal passages when oxygen is delivered via nasal cannula.

Question 128

Which function is associated with sebaceous glands?

Keep the hair and skin soft.

Generate new hair.

Keep particles from entering the body.

Cool the body.

Answer 128

Keep the hair and skin soft.

Sebaceous glands are an accessory organ of the skin that secretes sebum, which keeps the hair and skin soft.

Question 128

Patients being treated with _________________ are very susceptible to oral infections, dryness, and tissue damage.

Answer 128

chemotherapy

Question 129

Proper perineal care is extremely important for females as they are prone to which condition?

Fungal infections of the skin folds

Acne

Bruises

Urinary tract infections

Answer 129

Urinary tract infections

Question 130

Which statement by the nurse best expresses the proper approach to perineal care to a patient of the opposite sex?

“If you don’t want me to do it, you can do it yourself!”

“I’ll be fast and efficient, as if I was never even there.”

“I’ll get the health care provider to do it, but I don’t know how long that will take.”

“If at any time you feel uncomfortable, please let me know.”

Answer 130

“If at any time you feel uncomfortable, please let me know.”

Question 131

The nurse is tasked with catheter insertion on a patient of Middle Eastern descent who is of the opposite sex. Which approach would the nurse take when initiating the procedure?

Avoid eye contact throughout the entire procedure.

Knock first, explain the procedure, and ask for the patient’s comfort level.

Ask for help from the health care provider to perform the procedure.

Ask for help from family to convince the patient to allow the procedure

Answer 131

Knock first, explain the procedure, and ask for the patient’s comfort level.

Question 132

A nurse is caring for an older adult woman with advanced dementia who is incapable of self-care. However, the patient insists on brushing her own teeth at bedtime. Which action would the nurse take?

Allow her to brush her own teeth independently.

Allow her family to brush her teeth for her.

Get another nurse to brush the patient’s teeth.

Allow her to brush her teeth with supervision.

Answer 132

Allow her to brush her teeth with supervision.

Question 133

Which component of the integumentary system is the first line of defense against microorganisms?

Nails

Sweat glands

Skin

Hair

Answer 133

Skin

Question 134

Which description regarding the subcutaneous skin layer is correct?

Produces melanin

Can be called the dermis

Provides a cushioning effect

Is the outermost layer of the skin

Answer 134

Provides a cushioning effect

The subcutaneous skin layer, which consists of adipose tissue, provides a cushioning effect for internal organs.

Question 135

Which function will be compromised if the dermis is injured?

Immune response

Temperature regulation

Blood supply to the skin

Protection for internal organs

Answer 135

Blood supply to the skin

Supplying blood to the skin is a function of the dermis; thus, if this area is injured, the blood supply will be negatively affected.

Question 136

Which response is a result of poor perfusion to the skin?

Development of maceration

Excessive collagen formation

Reduced production of fibroblasts

Increased migration of cells that help skin regenerate

Answer 136

Reduced production of fibroblasts

Question 136

Which substance provides the skin with color?

Keratin

Melanin

Collagen

Elastin

Answer 136

Melanin

Question 137

Which patient situation is an example of friction?

A patient sitting up in bed

A patient who has diabetes

A patient lying in the same position for 4 hours

A patient’s leg rubbing against the side rail of a bed

Answer 137

A patient’s leg rubbing against the side rail of a bed

Question 138

Which statement about ultraviolet light is accurate?

Ultraviolet light A (UVA) penetrates the dermis.

Both UVA and UVB affect the subcutaneous layer.

Ultraviolet light B (UVB) penetrates skin more deeply.

Both UVA and UVB affect hemoglobin’s ability to carry oxygen.

Answer 138

Ultraviolet light A (UVA) penetrates the dermis.

Question 139

Which change is associated with aging of the skin?

Thinned dermis, resulting in increased elastin production

Decreased melanocytes, resulting in loss of hair color and decreased risk for skin cancer

Increased production of Langerhans cells, resulting in decreased resistance to infections

Reduced insulation and cushioning, resulting in an increased risk for skin trauma and heat loss

Answer 139

Reduced insulation and cushioning, resulting in an increased risk for skin trauma and heat loss

Reduced insulation and cushioning increase the risk for skin trauma and heat loss. Without cushioning over bony prominences, older adults are at risk for injuries to the skin.

Question 140

Which wound is classified as a closed wound?

Bruise

Abrasion

Surgical incision

Puncture wound

Answer 140

Bruise

Question 141

Which information would the nurse share with a patient about wound healing by tertiary intention?

The wound will heal quickly with minimal scarring.

The wound will have approximated edges in several days.

The wound will be immediately sutured for about 7 to 10 days.

The wound will be closed later when the infection risk is reduced.

Answer 141

The wound will be closed later when the infection risk is reduced.

Question 142

Which term describes the last phase of wound healing?

Maturation

Coagulation

Proliferative

Inflammatory

Answer 142

Maturation

Maturation, or remodeling, is the last phase of wound healing. During maturation, collagen continues to be deposited, and scars are formed and strengthened.

Question 143

Which primary objective does the proliferative phase of wound healing achieve?

Clotting of blood

Producing granulation tissue

Scarring of the wound

Cleaning of the wound by macrophages

Answer 143

Producing granulation tissue

The proliferative phase begins the process of producing granulation tissue that is red and beefy in appearance.

Question 144

Which complication allows visceral organs to be exposed through an incision?

Fistula

Dehiscence

Evisceration

Hemostasis

Answer 144

Evisceration

Evisceration is the total separation of tissue layers, allowing protrusion of visceral organs through an incision.

Question 145

Which definition of a fistula is correct?

Muscular layer of tissue that forms after wound healing

Creation of new blood vessels during wound healing

Nervous system pathway between two areas of the body

Abnormal connection between two internal organs

Answer 145

Abnormal connection between two internal organs

A fistula is an abnormal channel between two internal organs or between an internal organ and the skin.

Question 146

Which statement regarding the skin is accurate?

It has a minimal role in body temperature.

It is closely linked to personal identity.

It has no role in cultural perception.

It alerts a person to danger through electrolyte balance.

Answer 146

It is closely linked to personal identity.

Question 147

Which cells join the epidermis and dermis and are arranged in a single layer?

Basal cells

Melanocytes

Fibroblasts

Keratinocytes

Answer 147

Basal cells

Basal cells compose a single layer of active cells that join the epidermis and dermis.

Question 148

Which response is likely when a patient who has a full-thickness wound receives a steroid?

Healing time will slow.

Infection will be eliminated.

Malnutrition will result.

Shear will be decreased.

Answer 148

Healing time will slow.

Steroids, which are antiinflammatories, interrupt the inflammatory process, making patients prone to infections and slow healing.

Question 149

Which characteristic accurately describes the dermis?

Consists of dead skin cells

Is an area for sebaceous glands

Has the same thickness regardless of location

Contains adipose tissue

Answer 149

Is an area for sebaceous glands
Sebaceous (oil) glands are located in the dermis.

Question 150

Which strategy would the nurse use to classify a burn?

According to drainage

According to source of burn

According to the skin layer damaged

According to contamination factor

Answer 150

According to the skin layer damaged

Question 151

Which phase of wound healing is characterized by a patient who reports that the bumpy and granular injured site “bleeds easily”?

Maturation

Unstageable

Proliferative

Inflammatory

Answer 151

Proliferative

The proliferative phase is the phase of healing and repair in which new tissue bleeds easily and has a granular and bumpy texture.

Question 152

Agency for Healthcare Research and Quality (AHRQ)

AHRQ provides evidence-based practice for _________ care guidelines, and the nurse would use its guidelines.

Answer 152

wound

Question 153

Which food would the nurse suggest the patient consume to increase zinc in the diet for wound healing?

Apricots

Kiwi

Fish

Molasses

Answer 153

Fish

Question 154

Which patient scenario would prompt the nurse to question a prescription for cold therapy?
Correct Answer
Exactly!

Has a strong pulse

Has edema present

Has an absence of cyanosis

Has 16 respirations per minute

Answer 154

Has edema present

Question 155

Which piece of equipment would the nurse likely obtain for a patient who has a prescription for therapy that is primarily heat only?

Pack

Sitz bath

Moist soak

Moist compress

Answer 155

Sitz bath

Question 156

Which cue alerts the nurse that a patient receiving cold therapy is improving?

Edema

Psychological relaxation

Increased blood flow to area

Relief from muscle spasms

Answer 156

Relief from muscle spasms

Question 157

Which solution would the nurse obtain to clean a patient’s arm wound?

Dakin’s solution

Povidone-iodine

Hydrogen peroxide

Normal saline

Answer 157

Normal saline

Question 158

Which cue is relevant for a patient who has a wound?

Living in a northern state

Having a high creatinine level

Being male

Having a low prealbumin level

Answer 158

Having a low prealbumin level

A low prealbumin level is a relevant cue regarding a wound because it indicates that protein levels are low and could affect wound healing.

Question 159

Which type of fluid would the nurse likely observe if the patient was hemorrhaging?

Serous

Serosanguineous

Sanguineous

Purulent

Answer 159

Sanguineous

Question 160

____________ fluid is bright red, and it indicates bleeding that is observed in hemorrhaging.

Answer 160

Sanguineous

Question 161

____________ the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision.

Answer 161

Palpating

Question 162

Safety restraints - they are used:

Answer 162

as the last resort.

Other options: provide distraction, sitter/family

Question 163

Stage 1 pressure ulcer

Answer 163

intact skin with non-blanchable redness

Question 164

Stage 2 pressure ulcer

Answer 164

Partial-thickness skin loss involving epidermis, dermis, or both

Question 165

Stage 3 pressure ulcer

Answer 165

Full-thickness tissue loss with visible fat

Question 166

Stage 4 pressure ulcer

Answer 166

Full-thickness tissue loss with exposed bone, muscle, or tendon

Question 167

Wound healing

Primary - staples, sutures

Secondary - open wounds / wet to dry dressing changes

Tertiary - delayed primary closure (big hole; leave it open; heals over time with antibiotics/surgery..). Rare.

Answer 167

Primary - staples, sutures

Secondary - open wounds / wet to dry dressing changes

Tertiary - delayed primary closure (big hole; leave it open; heals over time with antibiotics/surgery..). Rare.

Question 168

Tertiary intention of wound healing:

Answer 168

delayed primary closure

Question 169

◦ _________ Scale
- Physical and mental condition, activity, mobility, and continence

Answer 169

Norton

Question 170

◦ _________ Scale
- Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Answer 170

Braden

Question 171

RACE stands for

Answer 171

Rescue, Alarm, Contain, Extinguish

Question 172

Nursing process steps

Answer 172

ADPIE

Assessment
Diagnosis
Planning
Implementation
Evaluation

Question 173

Reactive hyperemia occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than _______ and the surrounding tissue does not blanch.

Answer 173

1 hour

Question 174

Palpable changes in the consistency of the tissue underlying a bony prominence, often described as “_________,” is an indication that pressure damage has occurred

Answer 174

spongy

Question 175

Thirty-degree lateral inclined position.
This position best reduces pressure on bony prominences where ___ frequently develop. Pillows and foam wedges may be used for support and protection in this position.

Answer 175

PI

Question 176

Purulent refers to something that contains or produces ______ . [an indication that an infection is likely]

Answer 176

pus

Question 177

To reduce the effects of moisture on the client’s skin, which intervention should be implemented?

Apply a moisture-repellent ointment to intact skin areas.

Rinse ulcerated areas with an alcohol-based irrigating solution.

Position a plastic-lined pad under the buttocks.

Apply moist heat to the area following exposure to feces.

Answer 177

Apply a moisture-repellent ointment to intact skin areas.

Question 178

The client infected with methicillin-resistant Staphylococcus aureus (MRSA) should be cared for using _________ precautions when there is potential for wound drainage and debris to splatter during care.

Answer 178

contact

The mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces.

Question 179

What is the purpose of wet to dry dressing?

Mechanically debride the tissue.

Facilitate tissue healing.

Decrease risk of infection.

Preserve granulation tissue.

Answer 179

Mechanically debride the tissue.

Question 180

Incorrectly labeled medications are the responsibility of the :

Answer 180

pharmacist

Question 181

_____________ must be deposited in the bone to increase bone density.

Answer 181

Calcium

Question 182

The _________ Scale assesses many risk factors that may contribute to pressure sores.

Answer 182

Braden

Question 183

How should the nurse assess for orthostatic hypotension?

Measure the client’s pulse while the client is in the sitting and standing positions.

Measure the client’s blood pressure while the client is in the lying and standing positions.

Take the client’s pulse and blood pressure when the client is in the lying and sitting positions.

Take the client’s blood pressure and pulse while the client is in the lying, sitting, and standing positions.

Answer 183

Take the client’s blood pressure and pulse while the client is in the lying, sitting, and standing positions.

Orthostaic hypotension can occur when the client has been lying or sitting for a prolonged period and quickly rises to an erect position. The systolic blood pressure must drop a minimum of 20 points to be considered orthostatic hypotension.

Question 184

Chain of infection

Answer 184

Infectious agent
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Host

Question 185

ABC’s

Answer 185

Priorities

Airway
Breathing
Circulation

Question 186

Physical hazards include

Answer 186

lighting
bathroom hazards
reckless behaviors
rugs
fire
cords
bed height
transmission of pathogens

Question 187

Individual risk factors impacting pt safety:

Answer 187

lifestyle
impaired mobility
sensory / communication impairment
lack of safety awareness
improper infection prevention of caregivers

Question 188

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs?

A. The electricity was turned off 3 days ago.

B. The water comes from the county water supply.

C. A son and family recently moved into the home.

D. This home is not furnished with a microwave oven.

Answer 188

A. The electricity was turned off 3 days ago.

Question 189

National Patient Safety Goals

Answer 189

Improve accuracy of patient ID, effectiveness of communication among caregivers (EHR [electronic health record], SBAR), safety of using meds

Medication reconciliation

Fall reduction

Reduction of healthcare associated infections

Encourage patient involvement

Reduce risk for fires

Question 190

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?

A. Do nothing, no harm has occurred.

B. Notify the health care provider.

C. Complete an incident report.

D. Assess the patient.

Answer 190

B. Notify the health care provider.

Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

Question 191

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.)

A. Smoking in bed helps me relax and fall asleep.

B. We never leave candles burning when we are gone.

C. We use the same space heater my grandparents used.

D. We use the RACE method when using the fire extinguisher.

E. There is a fire extinguisher in the kitchen and garage workshop.

Answer 191

A. Smoking in bed helps me relax and fall asleep.

C. We use the same space heater my grandparents used.

D. We use the RACE method when using the fire extinguisher.

Question 192

Signs of local inflammatory process:

Answer 192

heat
redness
pain
tenderness
swelling
edema
loss of function

Question 193

Positive VS negative pressure

Answer 193

Positive pressure- HIGH pressure inside - air leaves room - protects PT
Negative pressure- LOW pressure inside - air does not leave room - protects outsiders

Question 194

What precautions are used for CMV, HIV, Hepatitis B/C, Aspergillosis

Answer 194

Standard

Question 195

What will the nurse wear by pts who have TB, SARS, or avian influenza?

Answer 195

N-95 mask

Question 195

What precautions are used for pertussis, influenza A/B, MRSA, Meningitis, RSV, Mumps, Rubella?

Answer 195

Droplet

Question 196

What precautions are used for MRSA, VRE, Adenovirus, diarrhea, C. Diff., Rotavirus, E. Coli, Enterovirus, Salmonella, Hep. A., Shingles, Herpes Simplex, RSV, Lice, Scabies, Chicken Pox?

Answer 196

Contact

Question 197

Clean VS Sterile technique

Answer 197

Clean- reduce the number of pathogens; administration of meds, tube feeding, daily hygiene

Sterile technique- eliminates all pathogens; dressing changes, catheterizations, surgical procedures

Question 198

Factor’s influencing personal hygiene

Answer 198

obesity
body image
homelessness
socioeconomics
culture
preferences
beliefs/ motivation

Question 199

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when
planning hygiene care?

a. Hygiene care is always routine and expected.
b. No two individuals perform hygiene in the same manner.
c. It is important to standardize a patient’s hygienic practices.
d. During hygiene care do not take the time to learn about patient needs.

Answer 199

b. No two individuals perform hygiene in the same manner.

Question 200

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says “I always bathe in the evening.” Which action by the nurse is best?

a. Defer the bath until evening and pass on the information to the next shift.

b. Tell the patient that daily morning baths are the “normal” routine.

c. Explain the importance of maintaining morning hygiene practices.

d. Cancel hygiene for the day and attempt again in the morning.

Answer 200

a. Defer the bath until evening and pass on the information to the next shift.

Question 201

6 rights of med administration

Answer 201

Patient
Medication
Dose
Route
Time
Documentation

Question 202

Wound Healing (Primary, Secondary, tertiary intentions)

Answer 202

Primary- surgery; neatly approximated; surgical incision; fine scar
Secondary- wounds from trauma/injury/infection, irregular margins; larger scar
Tertiary- delayed suturing; deeper scar

Question 203

Wound repair- 4 step process

Answer 203

Hemostasis
Inflammatory
Proliferative
Maturation

Question 204

___________ - partial or total separation of wound layers

Answer 204

Dehiscence

Question 205

__________ - abnormal passage from an internal organ to to the surface of the body or between 2 internal organs

Answer 205

Fistula

Question 206

__________ - an abnormal proliferation of scar tissue

Answer 206

Keloid

Question 206

___________ scar - similar to keloid but growth confined w/in boundaries of original skin defect & may respond to treatment; may look red

Answer 206

hypertrophic

Question 207

_____________ - when a large area of skin is damaged and lost, resulting in a scar that pulls the edges of the skin together, causing a tight area of skin

Answer 207

Contracture

Question 207

_________ - scarring that forms between unconnected, internal organs

Answer 207

Adhesion

Question 208

A wound vac uses ________________ to support healing

Answer 208

negative pressure

sucks out drainage

Question 209

Jackson-pratt removes wound drainage from

Answer 209

tube and reservoir

Question 210

A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity?

A. an afebrile patient

B. A patient who is diaphoretic

C. A patient with strong pedal pulses

D. A patient with adequate skin turgor

Answer 210

B. A patient who is diaphoretic

Question 211

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse’s action?

A Inadequate blood flow leads to decreased tissue ischemia.

B Patients with limited caloric intake develop thicker skin.

C Pressure reduces circulation to affected tissue.

D Verbalization of skin care needs is decreased.

Answer 211

C Pressure reduces circulation to affected tissue.

Question 212

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient’s medical record?

Answer 212

Healing Stage III pressure ulcer

Question 213

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of

a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.

Answer 213

c. Full-thickness wound repair.

Question 214

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair?

Eschar

Slough

Granulation

Purulent drainage

Answer 214

Granulation

Question 215

A nurse is assessing a patient’s wound. Which nursing observation will indicate the wound healed by secondary intention?

a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe

Answer 215

d. Scarring that may be

A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

Question 216

The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and
granulating. Which health care provider’s order will the nurse question?

a. Use a low-air-loss therapy unit.
b. Irrigate with Hydrogen peroxide
c. Apply a hydrogel dressing.
d. Consult a dietitian.

Answer 216

b. Irrigate with Hydrogen peroxide

Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin’s solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds.

Question 217

Wounds should only be irrigated with

Answer 217

saline

no chemicals

Question 218

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility?

a. Explain the risks of immobility to the patient.
b. Turn the patient every 3 hours while in bed.
c. Encourage the patient to sit up in the chair.
d. Provide analgesic medication as ordered

Answer 218

d. Provide analgesic medication as ordered

[pain meds could help their pain which would allow them to move more]

Question 219

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign?

a. Ineffective tissue perfusion
b. Risk for infection
c. Imbalanced nutrition: less than body requirements
d. Acute pain

Answer 219

a. Ineffective tissue perfusion

Question 220

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment?

A. Mobility
B. Hyperemia
C. Induration
D. Blanching
E. Temperature of skin
F. Nutritional Status

Answer 220

B. Hyperemia
C. Induration
D. Blanching
E. Temperature of skin