EXAM 1 Chapter 28, 29, 39, 40, 48 (Infection Control, Hygiene, Activity & Exercise, Immobility, Skin Integrity & Wound Care)

EXAM 1 Chapter 28, 29, 39, 40, 48 (Infection Control, Hygiene, Activity & Exercise, Immobility, Skin Integrity & Wound Care) 1- A 26 year old is being admitted from the recovery room and is identified as at risk for falls. Which of the following best describes the rationale for this nursing diagnosis? Select one: a. Depression b. Surgical tooth extraction c. Pain medication d. History of asthma 2- A cognitively intact bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? Select one: a. Bag bath b. Partial bed bath c. Complete bed bath d. Sponge bath 3- A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? Select one: a. Review the medication list that the patient brought from home. b. Position the patient comfortably on the stretcher. c. Don gloves and other appropriate personal protective equipment. d. Explain the procedure for dressing change to the patient. 4- After providing perineal hygiene an intact male patient, the nurse ensures: Select one: a. The foreskin remains retracted for the glans to dry b. The patient knows to replace the foreskin back over the glans in 15-20 minutes after drying c. The patient knows to use soap and water with hygiene to the glans going forward d. The foreskin is replaced back over the glans 5- A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? Select one: a. All of the above b. Race c. Pregnancy status d. Emotional factors Question 6 A nurse is assessing a patients skin. Which patient is most at risk for skin breakdown? Select one: a. A patient who is diaphoretic b. A patient who is afebrile c. A patient with adequate skin turgor d. A patient with strong pedal pulses 7- A nurse is assessing a patients wound. Which nursing observation will the nurse anticipate in a wound healing by secondary intention? Select one: a. Scarring that may be severe b. Minimal loss of tissue function c. Minimal scar tissue d. Permanent dark redness at site 8- A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? Select one: a. Blood pressure sitting 120/64; blood pressure 140/70 standing b. Blood pressure sitting 140/60; blood pressure 130/54 standing c. Blood pressure sitting 130/60; blood pressure 110/60 standing d. Blood pressure sitting 126/64; blood pressure 120/58 standing 9- ulcer open to air and does not apply a dressing. To which patient did the nurse provide care? Select one: a. A patient with a clean Stage I b. A patient with a clean Stage IV c. A patient with a clean Stage II d. A patient with a clean Stage III 11- A nurse is assisting the patient to perform exercises. Which action will the nurse take? Select one: a. Set the pace for the exercise session. b. Force muscles or joints to go just beyond resistance. c. Stop the exercise if pain is experienced. d. Encourage wearing tight shoes. 12- A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient? Select one: a. Increased diarrhea b. Increased metabolic rate c. Increased appetite d. Altered nutrient metabolism 13- A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? Select one: a. The patient is moaning softly and frowning, with a pinched expression on his face. b. The patient rates his pain a 7 on a scale of 0 to 10. c. The patient winces and guards the area as the nurse gently palpates the abdomen. d. The patient is having trouble sleeping and has become irritable. 14- A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? Select one: a. Sleep assessment b. Muscular strength assessment c. Pulse oximetry assessment d. Sensation assessment 15- A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? Select one: a. Chronic drainage of fluid through the incision site b. Drainage that is odorous and purulent c. Report by patient that something has given way d. Protrusion of visceral organs through a wound opening 16- A nurse is inserting an indwelling urinary catheter on a female patient. Which is the most important first step in maintaining a sterile field? Select one: a. Unfold the sterile drape away from your body b. Never turn your back to the sterile field c. When adding sterile supplies, hold 10 to 12 inches above the field and allow them to drop d. Inspect the sterile kit for package integrity, contamination or moisture 17- A nurse is performing passive range of motion (ROM) and splinting on an immobile patient. What is the desired outcome of this intervention? Select one: a. Prevention of atelectasis b. Prevention of joint contractures c. Prevention of pressure ulcers d. Prevention of renal calculi 18- A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? Select one: a. Performing patient hygiene requires a physician order b. During hygiene care do not take the time to learn about patient needs. c. Hygiene care is always routine and expected. d. No two individuals perform hygiene in the same manner. 19- A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel? Select one: a. Identifying immobility hazards b. Determining the level of comfort c. Making an occupied bed d. Assessing circulation 20- A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area?1. Face2. Eyes3. Perineum4. Arm and chest5. Hands and nails6. Back and buttocks7. Abdomen and legs Select one: a. 1, 2, 4, 5, 3, 7, 6 b. 2, 1, 4, 5, 7, 3, 6 c. 2, 1, 5, 4, 6, 7, 3 d. 1, 2, 5, 4, 7, 6, 3 21- A nurse is providing care to a group of patients. Which patient will the nurse see first? Select one: a. A patient on bed rest who has renal calculi and needs to go to the bathroom b. A patient after knee surgery who needs range of motion exercises c. A bedridden patient who has a reddened area on the buttocks who needs to be turned d. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea A nurse is providing oral care to an elderly patient with dentures who has a restricted diet and is receiving nothing by mouth. Which of the following is an appropriate action? Select one: a. Brush dentures and remaining teeth in mouth using toothbrush or swab b. Place your finger in the mouth of the unconscious patient to open the mouth c. Provide oral care daily and as needed to prevent nosocomial pneumonia d. Position patient in Trendelenburg or side-lying position A nurse is providing passive ROM to a patient’s left lower extremity when he encounters resistance in the ankle. What should the nurse do first? Select one: a. Continue slow ROM activity to gently increase mobility b. Stop movement to prevent injury c. Notify the physician d. Assess the ankle for swelling A nurse is providing skin care for a morbidly obese patient. Which of the following interventions are essential to prevent skin breakdown in bariatric patients? Select one: a. Cleansing the back b. Elevating heels from bed c. Drying beneath the pannus d. Assessing behind the ears when using a nasal cannula A patient develops a urinary tract infection after having an indwelling foley catheter. How is this infection categorized? Select one: a. Adverse reaction b. Treatment related complication c. Nosocomial infection d. Community acquired infection A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? Select one: a. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. b. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? Select one: a. Pulse b. Blood pressure c. Temperature d. Respirations A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? Select one: a. Albumin b. Potassium c. Vitamin E d. Sodium A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement? Select one: a. Contractures developed. b. Muscle strength improved. c. Heart rate decreased. d. Joint mobility maintained A patient with a diabetic foot ulcer is placed on bed rest with the affected foot elevated. Which rationale best supports this intervention? Select one: a. To support a weak patient b. To reduce edema c. To avoid dislodging a DVT d. To decrease metabolic needs A patient with pneumonia is identified as having elevated white blood cell count, elevated temperature, low blood pressure and increase heart rate. Which of the following is the nurse concerned that the patient is developing? Select one: a. Respiratory failure b. Sepsis c. Leukopenia d. Opportunistic infection During the following task, identify whether the situation calls for medical or surgical asepsis: The nurse is suctioning the tracheostomy of a hospitalized patient. Select one: a. Medical b. Surgical During the following task, identify whether the situation calls for medical or surgical asepsis: The nurse is preparing medications for oral administration Select one: a. Medical b. Surgical During the following task, identify whether the situation calls for medical or surgical asepsis: The nurse is caring for a central intravenous access device line Select one: a. Surgical b. Medical The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? Select one: a. Ineffective peripheral tissue perfusion b. Imbalanced nutrition: less than body requirements c. Acute pain d. Risk for infection The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient’s susceptibility to this infectious process? Select one: a. Do you have religious preferences that may impact your care? b. Do you have any children living in the home? c. Do you have a spouse? d. Do you have an chronic health problems? The nurse is bathing a patient and notices movement in the patients hair. What is the best first action for the nurse to take? Select one: a. Use gloves to inspect the hair. b. Implement advanced contact precaution isolation. c. Ignore the movement and continue. d. Apply a lindane-based shampoo immediately. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? Select one: a. A patient who is in observation for chest pain b. A patient who has been admitted for stabilization of heart problems c. A patient who is recovering from a right total hip surgery d. A patient who has been admitted with dehydration The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? Select one: a. Applying an elastic bandage to a medical-surgical patient b. Treating a pressure ulcer on the buttocks of a medical patient c. Assessing a surgical patient for risk of pressure ulcers d. Implementing negative-pressure wound therapy on a stable patient