1. A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium
difficile infection. which of the following information should the nurse include in the teaching?
Assign the client to a room with a negative airflow system.
A client who has a Clostridium difficile infection requires a private room, but a negative airflow
system is not
necessary.
Use alcohol-based hand sanitizer when leaving the client's room.
The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does
not kill
Clostridium difficile spores.
Clean contaminated surfaces in the client's room with a phenol solution.
The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi.
However, phenol
does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills
spores.
Have family members wear a gown and gloves when visiting.
Nurses are responsible for ensuring that family members wear a gown and gloves to prevent
the transmission of
Clostridium difficile spores. Staff must also wear gowns and gloves.
2. A nurse is giving change of shift report about a client they admitted earlier that day who has
pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Admitting diagnosis
Knowing the client's admitting diagnosis is essential for planning care and following critical
pathways; however,
other information is the nurse's priority to provide.
Breath sounds
When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority
information to provide is the current status of the client's breath sounds.
Body temperature
Knowing the client's current body temperature is essential for planning care and following critical
pathways;
however, other information is the nurse's priority to provide.
Diagnostic test results
Knowing diagnostic test results is essential for planning care and following critical pathways;
however, other
information is the nurse's priority to provide.
3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate?
Ambulating a client who is postoperative
Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to
the AP that do not
require special skills, assessment, or teaching.
Inserting an indwelling urinary catheter for a client
Indwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This
task is
outside the range of function of an AP.
Demonstrating the use of an incentive spirometer to a client
Client education requires advanced nursing knowledge and is outside the range of function of an AP.
Confirming that a client's pain has decreased after receiving an analgesic
Evaluating a client's pain level requires advanced nursing judgment and is outside the range of
function of an AP.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the
client was trying to get out of bed and fell over the side rail onto the floor. Which of the following
statements should the nurse document about this incident?
"Incident report completed."
An incident report is an internal document that is part of a facility's risk management system. The
nurse should not
document completion of an incident report in the client's medical record for the facility's protection
in the event of litigation.
"Client climbed over the side rails."
Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an
objective account
of the nurse's findings.
"Client found lying on floor."
The nurse should include documentation of information that is descriptive and objective
, concerning what the
nurse actually observed, without including any opinions or judgments about motives or
cause. “client found lying on floor” is correct
"Client was trying to get out of bed."
Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective
account of the
nurse’s findings.
, 5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following
actions should the nurse take?
Wear sterile gloves when removing the old dressing.
The nurse should wear clean gloves to remove the old dressing.
Warm the irrigation solution to 40.5° C (105° F).
The nurse should warm the irrigation solution to body temperature.
Cleanse the wound from the center outward.
The nurse should clean the wound from the center outward to prevent introduction of micro-
organisms from the
outer skin surface.
Use a 20-mL syringe to irrigate the wound.
The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid
create a safe
but effective amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types of transmission based
precautions should the nurse initiate?
Droplet
Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that
are larger
than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal
pharyngitis.
Airborne
Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei
that are
smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
Contact
Contact precautions are a requirement for clients who have infections that spread via direct contact
with another
person or contact with the environment, including vancomycin-resistant enterococci, methicillin-
resistant
Staphylococcus aureus, and scabies.
Protective environment
Pts who have compromised immune system, such as those who have an allogeneic hematopoietic
stem cell
transplant, req a protective environment
7. A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen
concentrator. Which of the following instructions should the nurse provide to the client and his
family? (SATA)
Check the cord routinely for frays or tearing.
Keep the unit at least 1.2 m (4 feet) away from a gas
stove. Consider purchasing a generator for power
backup.
Observe for signs of hypoxia.
Select synthetic clothing and bedding.
Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of
this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the
client to routinely check the condition of the cord.
Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment
includes keeping the unit at least
m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away
from other heat sources. Consider purchasing a generator for power backup is correct. Loss of electricity
prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse
should also instruct the family to have the client placed on their municipality's priority list for restoring power after
an outage occurs.
Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of
hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with
supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.
Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and
bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to
select materials made from cotton.
, 8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following items should
the nurse plan to document on the client’s intake and output record as 120 mL of fluid?
• 2 cups of soup
o The nurse should understand that 2 cups of soup are equivalent to 480 mL of fluid.
• 1 quart of water
o The nurse should understand that 1 quart of water is equivalent to 960 to 1,000 mL of fluid.
• 8 oz of ice chips
o The nurse should document half of the volume of ice chips when calculating fluid intake to
account for the air in
between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of
fluid.
• 6 oz of tea
o The nurse should understand that 6 oz of tea is equal to 180 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse
take? (SATA)
Place the client in a room with negative-
pressure airflow
Wear gloves when assisting the client with oral
care.
Limit each visitor to 2-hr increments.
Wear a surgical mask when providing client care.
difficile infection. which of the following information should the nurse include in the teaching?
Assign the client to a room with a negative airflow system.
A client who has a Clostridium difficile infection requires a private room, but a negative airflow
system is not
necessary.
Use alcohol-based hand sanitizer when leaving the client's room.
The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does
not kill
Clostridium difficile spores.
Clean contaminated surfaces in the client's room with a phenol solution.
The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi.
However, phenol
does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills
spores.
Have family members wear a gown and gloves when visiting.
Nurses are responsible for ensuring that family members wear a gown and gloves to prevent
the transmission of
Clostridium difficile spores. Staff must also wear gowns and gloves.
2. A nurse is giving change of shift report about a client they admitted earlier that day who has
pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Admitting diagnosis
Knowing the client's admitting diagnosis is essential for planning care and following critical
pathways; however,
other information is the nurse's priority to provide.
Breath sounds
When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority
information to provide is the current status of the client's breath sounds.
Body temperature
Knowing the client's current body temperature is essential for planning care and following critical
pathways;
however, other information is the nurse's priority to provide.
Diagnostic test results
Knowing diagnostic test results is essential for planning care and following critical pathways;
however, other
information is the nurse's priority to provide.
3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate?
Ambulating a client who is postoperative
Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to
the AP that do not
require special skills, assessment, or teaching.
Inserting an indwelling urinary catheter for a client
Indwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This
task is
outside the range of function of an AP.
Demonstrating the use of an incentive spirometer to a client
Client education requires advanced nursing knowledge and is outside the range of function of an AP.
Confirming that a client's pain has decreased after receiving an analgesic
Evaluating a client's pain level requires advanced nursing judgment and is outside the range of
function of an AP.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the
client was trying to get out of bed and fell over the side rail onto the floor. Which of the following
statements should the nurse document about this incident?
"Incident report completed."
An incident report is an internal document that is part of a facility's risk management system. The
nurse should not
document completion of an incident report in the client's medical record for the facility's protection
in the event of litigation.
"Client climbed over the side rails."
Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an
objective account
of the nurse's findings.
"Client found lying on floor."
The nurse should include documentation of information that is descriptive and objective
, concerning what the
nurse actually observed, without including any opinions or judgments about motives or
cause. “client found lying on floor” is correct
"Client was trying to get out of bed."
Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective
account of the
nurse’s findings.
, 5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following
actions should the nurse take?
Wear sterile gloves when removing the old dressing.
The nurse should wear clean gloves to remove the old dressing.
Warm the irrigation solution to 40.5° C (105° F).
The nurse should warm the irrigation solution to body temperature.
Cleanse the wound from the center outward.
The nurse should clean the wound from the center outward to prevent introduction of micro-
organisms from the
outer skin surface.
Use a 20-mL syringe to irrigate the wound.
The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid
create a safe
but effective amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types of transmission based
precautions should the nurse initiate?
Droplet
Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that
are larger
than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal
pharyngitis.
Airborne
Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei
that are
smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
Contact
Contact precautions are a requirement for clients who have infections that spread via direct contact
with another
person or contact with the environment, including vancomycin-resistant enterococci, methicillin-
resistant
Staphylococcus aureus, and scabies.
Protective environment
Pts who have compromised immune system, such as those who have an allogeneic hematopoietic
stem cell
transplant, req a protective environment
7. A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen
concentrator. Which of the following instructions should the nurse provide to the client and his
family? (SATA)
Check the cord routinely for frays or tearing.
Keep the unit at least 1.2 m (4 feet) away from a gas
stove. Consider purchasing a generator for power
backup.
Observe for signs of hypoxia.
Select synthetic clothing and bedding.
Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of
this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the
client to routinely check the condition of the cord.
Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment
includes keeping the unit at least
m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away
from other heat sources. Consider purchasing a generator for power backup is correct. Loss of electricity
prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse
should also instruct the family to have the client placed on their municipality's priority list for restoring power after
an outage occurs.
Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of
hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with
supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.
Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and
bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to
select materials made from cotton.
, 8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following items should
the nurse plan to document on the client’s intake and output record as 120 mL of fluid?
• 2 cups of soup
o The nurse should understand that 2 cups of soup are equivalent to 480 mL of fluid.
• 1 quart of water
o The nurse should understand that 1 quart of water is equivalent to 960 to 1,000 mL of fluid.
• 8 oz of ice chips
o The nurse should document half of the volume of ice chips when calculating fluid intake to
account for the air in
between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of
fluid.
• 6 oz of tea
o The nurse should understand that 6 oz of tea is equal to 180 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse
take? (SATA)
Place the client in a room with negative-
pressure airflow
Wear gloves when assisting the client with oral
care.
Limit each visitor to 2-hr increments.
Wear a surgical mask when providing client care.
