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A nurse caring for a client who has an infected wound removes a dressing saturated
with blood and purulent drainage. How should the nurse dispose of the dressing
material?
A. Discard the dressing in the bedside trash receptacle.
B. Dispose of the dressing in a biohazardous waste container.
C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash
receptacle. - ANSWERS-B. Dispose of the dressing in a biohazardous waste container.
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider
suspects has metabolic acidosis. Which of the following results should the nurse expect
to see?
A. pH below 7.35
B. HCO3 above 26 mEq/L
C. PaO2 below 70 mmHg
D. PaCO2 above 45 mmHg - ANSWERS-A. pH below 7.35
A hospice nurse is reviewing the prescriptions for a client who is receiving palliative
care. Which of the following prescriptions should the nurse expect? (Select all that
apply.)
,Provide skin care with a moisture barrier cream.
Administer artificial tear PRN.
Obtain vital signs every 2 hr.
Perform mouth care every hour.
Administer oxygen 2L/min via nasal cannula. - ANSWERS-Provide skin care with a
moisture barrier cream.
Administer artificial tear PRN.
Perform mouth care every hour.
Administer oxygen 2L/min via nasal cannula.
A nurse is planning care for a client who is postoperative and at risk of paralytic ileus.
Which of the following interventions should the nurse plan to take to promote
peristalsis?
A. Increase ambulation.
B. Decrease fluid intake.
C. Increase protein intake.
D. Offer the client the bedpan every 2 hr. - ANSWERS-A. Increase ambulation.
A nurse has completed care procedures for a client who requires airborne precautions.
Which of the following items of personal protective equipment (PPE) should the nurse
remove last?
A. Mask
B. Gloves
C. Gown
D. Goggles - ANSWERS-A. Mask
A nurse is providing teaching to an assistive personnel (AP) about caring for clients with
restraints. Which of the following statements by the AP indicates an understanding of
the teaching?
, A. "I will tie restraints in double knots."
B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is
moved."
C. "I will ensure that restraints fit tightly against the client."
D. "I will put four side rails up if a client is confused." - ANSWERS-B. "I will tie a restraint
to the portion of the bed that moves when the head of the bed is moved."
A nurse is teaching a new group of assistive personnel (AP) about the importance of
hand hygiene. Which of the following statements should the nurse include?
A. "If you wear gloves, you do not have to wash your hands."
B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
C. "Use an alcohol rub when your hands are visibly soiled."
D. "If you don't have an infection, your hands won't infect others." - ANSWERS-B. "Rub
all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
A nurse is planning postoperative care for a client who is scheduled for an ileal conduit
(urinary diversion) procedure. The nurse should include which of the following in the
client's plan of care? (Select all that apply).
Notify the provider immediately if mucus is present in the urine.
Maintain the client on a fluid restriction.
Apply skin barrier around the stoma site.
Educate the client that hematuria is expected following the procedure.
Monitor hourly urine output. - ANSWERS-Apply skin barrier around the stoma site.
Educate the client that hematuria is expected following the procedure.
Monitor hourly urine output.
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the
following types of isolation precautions should the nurse initiate for the client?