Fundementals

A new grad nurse is preparing to perform oral care for a client who is sedated and unconscious. Which of the following actions indicates that the nurse understands how to safely perform this care? 

 

The nurse vigorously scrubs teeth and mucosa

 

The nurse positions the patient supine

 

The nurse positions the client on their side for care

 

The nurse ensures to use a lot of water to rinse the oral cavity

The nurse positions the client on their side for care

A student nurse is working with a co-assigned nurse on a medical surgical unit. For which of the following actions by the student should the nurse intervene when changing bed linens?

 

The student raises the bed to a workable height before changing linens

 

The student nurse places the soiled linens on the floor while changing the sheets

 

The student nurse holds soiled linens away from their body while carrying

 

The student nurse places linens in the soiled linen hamper

The student nurse places the soiled linens on the floor while changing the sheets

A nurse is preparing to assist a client with foot care. Which of the following are appropriate actions for this care? select all that apply 

Washing the feet with warm water

 

Use dry towels to ensure that feet and toes are completely dry

 

Trimming toenails with a rounded angle

 

Applying lotion in between toes

 

Allowing feet to air dry

Washing the feet with warm water

Use dry towels to ensure that feet and toes are completely dry

Which of the following are considered health care associated infections? select all that apply. 

UTI after catheter insertion

 

Client with a central line has cellulitis at the insertion site

 

Pneumonia after being on a ventilator

 

Surgical site infection

 

Tuberculosis

UTI after catheter insertion

Client with a central line has cellulitis at the insertion site

Pneumonia after being on a ventilator

Surgical site infection

A new grad nurse is working with physical therapy during orientation to review body mechanics/ergonomics. Which of the following should the new grad nurse recall to ensure safety while moving/lifting/carrying/transferring?  select all that apply 

 

Keeping the back straight to maintain good spine alignment

 

Bending at the hips when lifting an item

 

Keep feet close together when lifting an item

 

Stand close to the object being moved

 

Bending at the knees when lifting an item

Keeping the back straight to maintain good spine alignment

Stand close to the object being moved

Bending at the knees when lifting an item

A nurse is teaching a client about safe ambulation with assistance of a cane. Which of the following should the nurse include in the teaching? 

 

Advance the cane 12-18 inches forward when walking

 

When starting to walk, move the affected leg first

 

When going up stairs, ensure the cane and the affected leg are at the same level for support

 

Hold the cane on the same side as the affected leg

When going up stairs, ensure the cane and the affected leg are at the same level for support

When preparing to transfer a client from bed to a chair, if the client has a weak side the chair should be placed at the clients strong side. True of False

True

A nurse is admitting a client with dehydration related to excessive diarrhea x3 days. The client reports prior to experiencing diarrhea, they had just had a terrible sinus infection requiring 10 days of antibiotics, which the client  completed as ordered. What infection control measures should the nurse institute based on this information? select all that apply

 

Ensure the client is in a single occupancy room

 

Wear an N95 mask when caring for the patient

 

Ensure to wear a protective gown and gloves when caring for the patient

 

Wash hands with soap and water after caring for the client

Ensure the client is in a single occupancy room

Ensure to wear a protective gown and gloves

wash hands with soap and water after caring for the client

Which of the following are considered principles of sterility? select all that apply 

 

Open flaps of a package one side at a time, opening away from the body first

 

Items can be below waist level

 

If there is ever a doubt of contamination, the provider should stop and set up a new sterile field

 

0.5inch border of a sterile field is considered nonsterile

 

1 inch border of a sterile field is considered non sterile

 

Inspect packages/kits for holes, punctures, and expiration dates

Open flaps of a package one side at a time, opening away from the body first

If there is ever a doubt of contamination, the provider should stop and set up a new sterile field

1 inch border of a sterile field is considered non sterile

 Inspect packages/kits for holes, punctures, and expiration dates

Prodromal

start of immune response, has vague and mild symptoms

Incubation

pathogens are multiplying, host does not have any symptoms at this point

Acute illness

pathogens are at peak concentration, symptoms will be characteristics of illness

Convalescence

Body in recovery

Airborne

Infected host coughs, exhales, talks.. micro particles then stay suspended in the air for a while

Droplet

infected host coughs, sneezes, etc… small particles (larger than micro) travel in air but may land on surfaces

Vector

disease occurs after being bit by a tick

Indirect contact

touching inanimate contaminated items (door handles, towels, etc)

Which of the following is true regarding safe application of soft wrist restraints?

 

Only utilize a quick release knot when securing

 

3 or 4 fingers should easily slide under the restraint

 

Secure the restraint to the moveable bed rail

 

Restraints should be removed q 6 hours

Only utilize a quick release knot when securing

Crackles

bubbling, popping, or rice crispies

Ronchi

low pitch, like snoring or gurgling

Friction rub

grating sound or like a creaking old wood floor

Strior

high pitch, “barking” like a seal

Wheeze

high-pitch, musical or whistle tone

A nurse is planning care for a client on a neuro ICU floor. The clients most recent GCS was 7. The nurse anticipates what support for care? 

 

The client may need some assistance here and there as they are sleepy

 

The client is likely independent

 

The client will require full assistance with all care

 

The client may need some cueing

The client will require full assistance with all care

Olfactory

have the client ID smell

oculomotor

PERRLA

Facial

have the client smile, frown, puff out cheeks

Accessory

shrugs shoulders

hypoglossal

controls tongue movement

Trochlear & Abducens

cardinal fields of gaze

A new nurse is assessing a clients GI system. Which of the following sequences is correct for GI assessment? 

 

Inspection, palpation, auscultation, percussion

 

Inspection, auscultation, percussion, palpation

 

Auscultation, inspection, palpation

 

Auscultation, inspection, percussion, palpation

Inspection, auscultation, percussion, palpation

Which of the following findings are considered 'abnormal' ? select all that apply 

 

GI: 5-30 clicks or gurgles per minute

 

Neuro: AAOx1

 

GU: Bladder palpable, distended

 

GI: <5 clicks or gurgles per minute

 

GCS: 15

 

CV: +4 pitting edema bilateral lower extremities

 

CV: cap refill >3 seconds

 

Neuro: PERRLA intact

 

Integ: Petechiae and purpura to upper extremities

 

Integ: Skin clean, dry, and intact

 

Mucous membranes pink and moist

Neuro: AAOx1

GU: Bladder palpable, distended

GI: <5 clicks or gurgles per minute

CV: +4 pitting edema bilateral lower extremities

CV: cap refill >3 seconds

Integ: Petechiae and purpura to upper extremities

A client has a newly placed cast to right lower leg. Your clinical instructor asks that you assess CMSTs. What will you assess for? select all that apply 

 

Movement

 

Contractures

 

Sensation

 

Temperature

 

Circulation (color, cap refill..)

 

Sores

Movement

Sensation

Temperature

Circulation

A student nurse is performing a focused CV assessment for a patient. For which of the following actions does the instructor intervene? 

 

The student listens to the apical for 1 full minute for an irregular rhythm

 

The student palpates dorsalis pedis pulses simultaneously

 

The student attempts to palpate bilateral carotid arteries simultaneously

 

The student notes a weak/thready pulse at +1 and a bounding pulse at +4

The student attempts to palpate bilateral carotid arteries simultaneously