SOLVED QUESTIONS AND FULL SOLUTION
GRADED A+
◉ In which situation would standard precautions be adequate?
Select all that apply.
- While talking with a client with a moist, productive cough
- While assisting a client with oral care
- While ambulating a client after a procedure
- While inserting an intravenous catheter
- When changing a dressing for a client with MRSA.
Answer: While assisting a client with oral care
While ambulating a client after a procedure
While inserting an intravenous catheter
◉ The nurse notices a blood pressure cuff in the client's room with
spots of dried blood on it. What
should be the nurse next action?
- Clean it with a wet rag.
,- Disinfect it with a chemical cleaner.
- Sterilize it with an autoclave.
- Report it to the charge nurse.
Answer: Disinfect it with a chemical cleaner.
◉ A client with dementia becomes belligerent and combative when
the nurse attempts to give him a
tub bath. How should the nurse proceed?
- Call for assistance to help the patient into the bathtub.
- Wait for the patient to calm down, then give him a towel bath.
- Allow the patient to go without bathing for a day or two.
- Ask another staff member to attempt the tub bath..
Answer: Wait for the patient to calm down, then give him a towel
bath.
◉ The nurse asks the unlicensed assistive personnel to complete
morning care for an older adult.
What is included with this request? Select all that apply.
- Back massage
- Hair care
,- Bathing
- Toileting
- Oral care.
Answer: Hair care
Bathing
Toileting
Oral care
◉ Which statements about bed making are correct? Select all that
apply.
- When making an occupied bed, the rails should be up on the side
where the nurse is working.
- Making the bed in a hospital is like making a bed at home.
- A poorly made bed can contribute to the development of pressure
ulcers.
- Draw sheets are used to help lift and turn heavier patients.
- The bed linens should be changed before the bath occurs..
Answer: A poorly made bed can contribute to the development of
pressure ulcers.
Draw sheets are used to help lift and turn heavier patients.
, ◉ The nurse is bathing a client with a raised red rash on the
shoulders and back. What should be the
nurse's next actions? Select all that apply.
- Discuss the body image problems created by the presence of the
rash.
- Moisturize the skin to prevent drying.
- Assess for further inflammatory reactions.
- Wash the skin thoroughly each day with hot water and soap.
- Ask whether the client has any allergies..
Answer: Assess for further inflammatory reactions.
Ask whether the client has any allergies.
◉ What are the most important considerations when performing
oral hygiene for an unconscious
critical client? Select all that apply.
- Use a padded tongue blade when providing oral care.
- Perform oral hygiene at least twice a day.
- Moisturize lips every 2 hours.
- Avoid the use of mouthwash.