front 1 The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection? | back 1 Skin and mucous membranes |
front 2 A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections? | back 2 Auditing staff members hand hygiene practices |
front 3 A student nurse asks why brushing clients teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best? | back 3 It mechanically removes biofilm on teeth. |
front 4 A client is admitted with possible sepsis. Which action should the nurse perform first? | back 4 Obtain specified cultures. |
front 5 A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important? | back 5 Consult with the provider about obtaining stool cultures. |
front 6 A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a clients bed linens. What action by the UAP requires intervention by the nurse? | back 6 Shaking dirty linens and placing them on the floor |
front 7 A hospital unit is participating in a bioterrorism drill. A client is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the client? | back 7 Standard Precautions |
front 8 Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized? | back 8 Consistently using appropriate hand hygiene |
front 9 A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first? | back 9 Place the client on Airborne Precautions. |
front 10 A client has been placed on Contact Precautions. The clients family is very afraid to visit for fear of being contaminated by the client. What action by the nurse is best? | back 10 Inform them that the infection is the issue, not the client. |
front 11 A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? | back 11 Prepare to administer vancomycin (Vancocin). |
front 12 A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate? | back 12 Ensure that the radiology department is aware of the isolation precautions. |
front 13 A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)? | back 13 Elevate the arm above the level of the heart |
front 14 A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important? | back 14 Notify the provider and request antibiotics. |
front 15 A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best? | back 15 Assess the client frequently for worsening of his or her condition. |
front 16 The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) | back 16 Host Mode of transmission Portal of entry Reservoir |
front 17 Which statements are true regarding Standard Precautions? (Select all that apply.) | back 17 Use personal protective equipment as needed for client care. Wear gloves when touching client excretions or secretions. |
front 18 The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) | back 18 Appropriate drug Proper route of administration Sufficient dose Sufficient length of treatment |
front 19 A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.) | back 19 Admit the client to a negative-airflow room. Order specialized masks/respirators for caregiving |
front 20 A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.) | back 20 Age-related decrease in immune function Decreased cough and gag reflexes Diminished acidity of gastric secretions Thinning skin that is less protective |
front 21 A client with an infection has a fever. What actions by the nurse help increase the clients comfort? (Select all that apply.) | back 21 Change the clients gown and linens when damp. Offer cool fluids to the client frequently. |
front 22 While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next? | back 22 Use pulse oximetry to assess the clients oxygen saturation |
front 23 A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? | back 23 What do you do for a living? |
front 24 A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? | back 24 What medications are you taking? |
front 25 After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition? | back 25 I can use powder to keep this area dry. |
front 26 A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions? | back 26 Two 2-cm hyperpigmented patches |
front 27 While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? | back 27 Palpate the clients pedal pulses bilaterally. |
front 28 A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond? | back 28 Tell me more about your concerns related to your skin. |
front 29 A nurse assesses a client who has open lesions. Which action should the nurse take first? | back 29 Put on gloves. |
front 30 A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder | back 30 Clean hair and nails |
front 31 A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? | back 31 Hemoglobin and hematocrit |
front 32 During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations? | back 32 Linear and circinate |
front 33 A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding? | back 33 Petechiae |
front 34 A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.) | back 34 Lesion with various colors Asymmetric 6-mm dark lesion on forehead |
front 35 A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.) | back 35 Height Alcohol use Prealbumin laboratory results |
front 36 A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.) | back 36 Look for asymmetry of shape and irregular borders. Assess for color variation within each lesion |