226 exam 2 study

1. The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis?

1. Disinfecting an item before adding it to a sterile field

2. Allowing sterile gloved hands to fall below the waist

3. Suctioning the oral cavity of an unconscious client

4. Touching only the inside surface of the first glove while pulling it onto the hand

4. Touching only the inside surface of the first glove while pulling it onto the hand

2. The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate?

1. Administering parenteral medications

2. Changing a dressing

3. Performing a urinary catheterization

4. Using personal protective equipment

4. Using personal protective equipment

3. The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection?

1. A client in the emergency department with abdominal pain

2. A 19-year-old woman in her first trimester of pregnancy

3. A 72-year-old male client with COPD

4. An 86-year-old female client on steroid therapy

4. An 86-year-old female client on steroid therapy

4. The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound?

1. Adjust the diet so it contains more fruits and vegetables.

2. Apply lubricating lotion to the edges of the wound.

3. Notify the physician of any edema, heat, or tenderness at the wound site.

4. Thoroughly irrigate the wound with hydrogen peroxide.

3. Notify the physician of any edema, heat, or tenderness at the wound site.

5. A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client?

1. Edema, rubor, heat, and pain

2. Fever, malaise, anorexia, nausea, and vomiting

3. Palpitations, irritability, and heat intolerance

4. Tingling, numbness, and cramping of the extremities

2. Fever, malaise, anorexia, nausea, and vomiting

6. An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client?

1. Active bowel sounds

2. Dry intact skin

3. Intact mucous membranes

4. Susceptibility of the client

4. Susceptibility of the client

7. The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms?

1. Heavy smoking

2. Moisturizing the skin

3. Breakdown of skin

4. Voiding quantity sufficient

4. Voiding quantity sufficient

8. The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity?

1. Becoming ill with tetanus and receiving tetanus toxoid

2. Having chickenpox

3. Receiving a rabies shot after being bitten by a rabid dog

4. Receiving an injection of gamma globulin

2. Having chickenpox

9. A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client?

1. A tetanus toxoid injection

2. An immunization for rabies

3. An injection of immunoglobulin

4. Mothers breast milk with antibodies in it

2. An immunization for rabies

10. The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection?

1. Assess vital signs only once daily.

2. Raise the temperature in the clients room.

3. Wash hands.

4. Wear a mask for all client care.

3. Wash hands.

11. The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection?

1. Cover the mouth and nose when sneezing.

2. Place contaminated linens in a paper bag.

3. Use personal protective equipment (PPE) sparingly.

4. Wear gloves at all times.

1. Cover the mouth and nose when sneezing.

12. The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client?

1. Allow the water to splatter forcibly when it is turned on.

2. Clean the faucet after use.

3. Hold the hands upward under the faucet.

4. Use approximately a teaspoon of soap.

4. Use approximately a teaspoon of soap.

13. The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask?

1. Bend the strip at the top of the mask.

2. Loop the ties over the ears.

3. Tie the strings in a bow.

4. Touch the mask by the strings only.

4. Touch the mask by the strings only.

14. The nurse is preparing to remove soiled gloves. What action should the nurse take first?

1. Drop the gloves into the appropriate waste receptacle.

2. Ease the fingers into the gloves.

3. Grasp the outside of the nondominant glove.

4. Hook the bare thumb inside the other glove.

3. Grasp the outside of the nondominant glove.

15. The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break?

1. Grasping the edge of the outermost flap and opening it away from oneself

2. Keeping objects on the field 1 inch from the edge

3. Keeping the sterile field in eyesight

4. Transferring a sterile object to a sterile field with a clean gloved hand

4. Transferring a sterile object to a sterile field with a clean gloved hand

16. A client needs to be placed in contact isolation. What items should the nurse ensure are included in this clients room?

1. Cabinet stocked with gloves and gowns

2. Cards and records

3. Paper towels, sink, and blood pressure cuff

4. Sign on the door

3. Paper towels, sink, and blood pressure cuff

17. The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a clients room. What action should the nurse take first for this puncture wound?

1. Complete an injury report.

2. Encourage bleeding.

3. Initiate first aid.

4. Wash the area with soap and water.

2. Encourage bleeding.

18. The nurse is preparing to leave a clients isolation room. Which action should the nurse take first when removing a grossly soiled gown?

1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand.

2. Release the neck ties of the gown and allow the gown to fall forward.

3. Untie the strings at the neck first.

4. Untie the strings at the waist first.

4. Untie the strings at the waist first.

19. The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation?

1. Cut the needle off a syringe after using it to give a client an injection.

2. Dispose of blood-contaminated materials in a biohazard container.

3. Gloves should not be worn for client care unless body fluids are seen.

4. Wear a mask when in direct contact with all clients.

2. Dispose of blood-contaminated materials in a biohazard container.

20. A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease?

1. Have the client wear a mask when coming from admission.

2. Stock the supply cart at the beginning of each shift.

3. Wash the hands only after leaving the room.

4. Wear a mask when exiting the room.

1. Have the client wear a mask when coming from admission.

21. The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision?

Standard Text: Select all that apply.

1. Client is receiving intravenous fluids.

2. Client has an indwelling urinary catheter.

3. Client is recovering from surgery.

4. Client is receiving pain medication.

5. Client is ambulating twice a day with assistance.

1, 2, 3

22. A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make?

Standard Text: Select all that apply.

1. It depends on the number of organisms present to cause a disease.

2. It depends on how aggressive the organisms are to cause a disease.

3. It depends upon how the organisms get inside the body to cause a disease.

4. It depends upon where the person is at the time the disease is present.

5. It depends upon where the person works.

1, 2, 3, 4

23. The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Intact and dry skin

2. Intact oral mucous membranes

3. Bowel sounds present in all four quadrants

4. Nasal congestion

5. Urinary retention

1. Intact and dry skin

2. Intact oral mucous membranes

3. Bowel sounds present in all four quadrants

24. A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client?

1. Social Isolation

2. Anxiety

3. Acute Pain

4. Imbalanced Nutrition: Less Than Body Requirements

1. Social Isolation

25. A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client?

1. Anxiety

2. Acute Pain

3. Social Isolation

4. Low Self-Esteem

1. Anxiety

26. A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection?

Standard Text: Select all that apply.

1. Hand-washing technique

2. The importance of adequate nutrition

3. Covering the mouth and nose when coughing or sneezing

4. Increasing contact with others

5. Restricting rest period

1. Hand-washing technique

2. The importance of adequate nutrition

3. Covering the mouth and nose when coughing or sneezing

27. A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do?

1. Assist the client with hand washing.

2. Assist the client back to bed.

3. Change the clients bed.

4. Leave the clients room.

1. Assist the client with hand washing.

28. While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose and eyes. What should the nurse do?

1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.

2. Begin HIV high-risk exposure prophylaxis within 24 hours.

3. Wash the areas with soap and water.

4. Have blood drawn for hepatitis B antibodies.

1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.

29. The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using?

Standard Text: Select all that apply.

1. Triclosan

2. Chlorine (bleach)

3. Isopropyl alcohol

4. Hydrogen peroxide

5. Chlorhexidine gluconate

1, 3, 5

30. The nurse needs to apply personal protective equipment before entering a clients room. In which order should the nurse perform the following actions?

Standard Text: Place the steps in the order in which they should be performed.

1. Apply gloves.

2. Apply eyewear.

3. Apply the gown.

4. Apply the face mask.

5. Perform hand hygiene.

5, 3, 4, 2, 1

Rationale for Question 30

Rationale 1: Gloves are applied last.

Rationale 2: Protective eyewear is applied after the face mask.

Rationale 3: The gown is applied after hand hygiene.

Rationale 4: The face mask is applied after the gown.

Rationale 5: Before applying personal protective equipment, hand hygiene should be performed.

Rationale for question 29

Rationale 1: Triclosan is an agent that can be used on the hands as a disinfectant.

Rationale 2: Chlorine bleach is used to clean blood spills.

Rationale 3: Isopropyl alcohol is an agent that can be used on the hands as a disinfectant.

Rationale 4: Hydrogen peroxide is used to clean surfaces.

Rationale 5: Chlorhexidine gluconate is an agent that can be used on the hands as a disinfectant.

Rationale for question 28

Rationale 1: After an exposure to the mucous membranes, the area should be flushed for 5 to 10 minutes with saline or water.

Rationale 2: The client was not identified as being HIV-positive.

Rationale 3: Washing the area with soap and water would be appropriate for a puncture or laceration.

Rationale 4: Being tested for hepatitis B would be appropriate after a puncture or laceration but not for a splash to the mucous membranes.

Rationale for question 27

Rationale 1: The client should utilize good hand washing after going to the bathroom. The unlicensed assistive personnel should assist the client with hand washing.

Rationale 2: After handwashing, the unlicensed assistive personnel should assist the client back to bed.

Rationale 3: The clients bed can be changed at any time.

Rationale 4: The unlicensed assistive personnel should not leave the clients room until the client has washed her hands and has been assisted back to bed.

Rationale for question 26

Rationale 1: The nurse should instruct the client on the correct hand-washing technique to reduce the risk of infection.

Rationale 2: The nurse should instruct the client on the importance of adequate nutrition to reduce the risk of infection.

Rationale 3: The nurse should instruct the client to cover the mouth and nose when coughing or sneezing to reduce the risk of infection.

Rationale 4: The nurse should instruct the client to minimize exposure to others when recovering from surgery to reduce the risk of infection.

Rationale 5: The nurse should instruct the client to get adequate rest and sleep when recovering from surgery to reduce the risk of infection.

Rationale for question 25

Rationale 1: Anxiety is appropriate because the client is discussing the impact of the communicable disease on work and home life.

Rationale 2: Acute Pain is not appropriate, as the client is not experiencing discomfort.

Rationale 3: Social Isolation is not appropriate, as the client has not been placed in transmission precaution at this time.

Rationale 4: Low Self-Esteem is incorrect because the client is not expressing negative comments about himself.

Rationale for question 24

Rationale 1: Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.

Rationale 2: Anxiety would be appropriate if the client were demonstrating apprehension regarding a change in life activities because of the communicable disease.

Rationale 3: Acute Pain would be appropriate if the client were experiencing discomfort.

Rationale 4: Imbalanced Nutrition: Less Than Body Requirements would be appropriate if the client were too ill to eat adequately.

Rationale for question 23

Rationale 1: Intact skin is the bodys first line of defense against microorganisms.

Rationale 2: Intact mucous membranes are the bodys first line of defense against microorganisms.

Rationale 3: Peristalsis tends to move microbes out of the body.

Rationale 4: Nasal congestion would mean that the nasal passages would be ineffective in filtering microorganisms from inspired air.

Rationale 5: Urinary retention would cause the urine to remain in the body, possibly leading to an infection.

Rationale for question 22

Rationale 1: It depends on the number of organisms present to cause a disease addresses the number of microorganisms present.

Rationale 2: It depends on how aggressive the organisms are to cause a disease addresses the virulence and potency of the microorganisms.

Rationale 3: It depends upon how the organisms get inside the body to cause a disease addresses the ability of the microorganisms to enter the body.

Rationale 4: It depends upon where the person is at the time the disease is present addresses the susceptibility of the host and the ability of the microorganisms to live in the hosts body.

Rationale 5: It depends upon where the person works does not explain a factor for the development of an infection.

Rationale for question 21

Rationale 1: Bacteremia can occur from an intravascular line.

Rationale 2: The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter.

Rationale 3: After surgery, the clients health status is compromised, lowering the clients defenses to fight infection.

Rationale 4: Receiving pain medication does not increase the clients risk for developing a nosocomial infection.

Rationale 5: Ambulation does not increase the clients risk for developing a nosocomial infection.

Rationale for question 20

Rationale 1: When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask.

Rationale 2: Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health care provider.

Rationale 3: Hands should be washed before and after client care.

Rationale 4: The mask should be removed just as the staff leaves the clients room, not when coming out of the room.

Rationale for question 19

Rationale 1: Needles should never be cut, bent, or altered in any way, as this would place the health care provider at risk of being stuck.

Rationale 2: Disposal of blood-contaminated materials in a biohazard container is a standard precaution.

Rationale 3: Gloves should be worn when providing client care whether body secretions are seen or not.

Rationale 4: Masks need not be worn when giving routine direct client care unless the clients condition so warrants.

Rationale for question 18

Rationale 1: Gloves are not left on while taking off a soiled gown.

Rationale 2: The neck ties are untied after the ties at the waist are untied.

Rationale 3: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck.

Rationale 4: To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. After the neck ties are untied, the gown is allowed to fall forward.

Rationale for question 17

Rationale 1: This is not the first step. It can be done later.

Rationale 2: Encouraging bleeding is the first step.

Rationale 3: Initiating first aid is not the first step.

Rationale 4: Washing the area with soap and water is not the first step.

Rationale for question 16

Rationale 1: A cabinet stocked with gloves and gowns would be on the outside of the room.

Rationale 2: Cards and records should never be taken into an isolation room.

Rationale 3: Paper towels and a sink for hand washing should be in the clients room so they can be used before the staff leaves the room. A blood pressure cuff needs to stay in the clients room to prevent cross contamination.

Rationale 4: The sign explaining the kind of isolation should be on the outside of the door to alert the staff of what is needed to enter.

Rationale for question 15

Rationale 1: Grasping the edge of the outermost flap and opening it away from oneself will maintain the sterility of a field.

Rationale 2: Keeping objects on the field 1 inch from the edge will maintain the sterility of a field.

Rationale 3: Keeping the sterile field in eyesight will maintain the sterility of a field.

Rationale 4: Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile.

Rationale for question 14

Rationale 1: Dropping the gloves in the appropriate waste receptacle occurs after the gloves are removed.

Rationale 2: Easing the fingers into the glove is done when applying gloves.

Rationale 3: In order to remove gloves after use, one must grasp the outside of the nondominant glove.

Rationale 4: Hooking the bare thumb inside the other glove is done after the gloves are removed.

Rationale for question 13

Rationale 1: Bending the strip at the top of the mask is done when applying a mask.

Rationale 2: Looping the ties over the ears is done when applying a mask.

Rationale 3: Tying the strings in a bow under the chin is done when applying a mask.

Rationale 4: Touching the mask by the strings is the appropriate intervention because the mask is considered contaminated.

Rationale for question 12

Rationale 1: When the water is turned on, it should be adjusted so it does not splatter even if the flow is not very forceful.

Rationale 2: Cleaning the faucet after use would defeat the whole purpose of washing the hands. If the sink needs cleaning, clean it before washing the hands.

Rationale 3: Holding the hands upward under the faucet is incorrect. They should be held downward so the soap, germs, and water are washed downward from the hands and down the sink.

Rationale 4: Approximately 1 teaspoon of soap should be used when performing proper hand-washing technique.

Rationale for question 11

Rationale 1: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection.

Rationale 2: Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a fomite, thus allowing the chain to continue.

Rationale 3: PPE, according to OSHA standards, has to be used whenever the situation dictates, not sparingly.

Rationale 4: Gloves have to be worn but are to be changed between clients and hands washed.

Rationale for question 10

Rationale 1: Assessing vital signs is important but should occur more frequently than once daily.

Rationale 2: Raising the temperature in a clients room would contribute to the growth of microorganisms.

Rationale 3: Washing hands is always the first and best way to stop the spread of microorganisms, which cause infections.

Rationale 4: Wearing a mask for all clients is not practical and is unnecessary unless a microorganism is airborne and the client is in isolation.

Rationale for question 9

Rationale 1: A tetanus toxoid injection is not specific for rabies.

Rationale 2: Receiving an immunization for rabies is an example of artificially acquired passive immunity.

Rationale 3: An injection of immunoglobulin is not specific for rabies.

Rationale 4: Mothers breast milk is another example of passive immunity, but not for rabies.

Rationale for question 8

Rationale 1: Receiving an injection for tetanus is an example of acquired passive immunity.

Rationale 2: When the client has the disease, the body stimulates the process of acquired active immunity.

Rationale 3: Receiving an injection for rabies is an example of artificially acquired passive immunity.

Rationale 4: Receiving an injection of gamma globulin is an example of artificially acquired passive immunity.

Rationale for question 7

Rationale 1: Heavy smoking does not defend the body from microorganisms; it destroys the cilia in the nose that help to filter organisms.

Rationale 2: Moisturizing the skin can allow microorganisms to enter the body.

Rationale 3: Breakdown of the skin can allow microorganisms to enter the body.

Rationale 4: Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus.

Rationale for question 6

Rationale 1: Active bowel sounds would indicate the body is able to defend itself against an infection.

Rationale 2: Dry intact skin is a factor that would help the body defend against an infection.

Rationale 3: Intact mucous membranes is a factor that would help the body defend against infection.

Rationale 4: How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact.

Rationale for question 5

Rationale 1: Edema, rubor, heat, and pain are symptoms of a local infection.

Rationale 2: Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection.

Rationale 3: Palpitations, irritability, and heat intolerance are symptoms of a thyroid condition.

Rationale 4: Tingling, numbness, and cramping of the extremities are symptoms of hypocalcemia.

Rationale for question 4

Rationale 1: Increasing intake of fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice.

Rationale 2: Applying lubricating lotion to the edges of a wound would impede the healing process.

Rationale 3: A client being discharged with an open surgical wound has to be instructed on the detection of infection because the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection.

Rationale 4: Irrigating with hydrogen peroxide would break down good granulating tissue, so this would not increase healing.

Rationale for question 3

Rationale 1: A client in the emergency department with abdominal pain has just arrived in the facility, and not enough time has elapsed for this client to be considered to have a nosocomial infection. If this client has an infection, it would be community acquired.

Rationale 2: The 19-year-old female who is pregnant is at a low risk.

Rationale 3: The 72-year-old male with COPD is at a lower risk for infection than the 82-year-old because the older client has a weakened immune system because of taking steroids.

Rationale 4: The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system.

Rationale for question 2

Rationale 1: Administering parenteral medications requires surgical asepsis.

Rationale 2: Changing a dressing requires surgical asepsis.

Rationale 3: Performing a urinary catheterization requires surgical asepsis.

Rationale 4: Using personal protective equipment demonstrates medical asepsis.

Rationale for question 1

Rationale 1: Disinfecting an item is an example of medical asepsis, not surgical asepsis.

Rationale 2: If sterile gloved hands fall below the waist, they are considered to be unsterile.

Rationale 3: Suctioning the oral cavity of a client is considered contaminating.

Rationale 4: Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile.

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding?

a) an irregularly shaped lesion

b) a small papule with a dry, rough scale

c) a firm, nodular lesion topped with crust

d) a pearly papule with a central crater and a waxy border

a) an irregularly shaped lesion

rationale:

-a melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue toned color.

-actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale

-squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration

-basal cell carcinoma appears as a pearly papule with a central crater rolled waxy border

A client arriving at the ER has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

a) a pink, edematous hand

b) a fiery red skin with edema in the nail beds

c) black fingertips surrounded by an erythematous rash

d) a white color to the skin, which is insensitive to touch

d) a white color to the skin, which is insensitive to touch

rationale:

assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs or tissue edema appears. Options A, B, C are incorrect

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

a) coma

b) flushing

c) dizziness

d) tachycardia

b) flushing

Carbon monoxide produces a bright cherry red in face and upper torso because it has a higher affinity to hemoglobin than oxygen

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.

a) sunscreen should be applied every 8 hours

b) use sunscreen when participating in outdoor activities

c) wear a hat, opaque clothing, and sunglasses when in the sun

d) avoid sun exposure in the late afternoon and early evening hours

e) examine your body monthly for any lesions that may be suspicious

b) use sunscreen when participating in outdoor activities

c) wear a hat, opaque clothing, and sunglasses when in the sun

e) examine your body monthly for any lesions that may be suspicious

rationale:

-client should be instructed to avoid sun exposure between the hours of 10a-4p

-sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities

-the client should be instructed to examine the body monthly for appearance of any possible cancerous or precancerous lesions

-sunscreen should be reapplied every 2-3 hours and after swimming or sweating; otherwise, the duration of protection is reduced

test-taking strategy: noting the time frames in options A and D will assist in eliminating these options

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

a) a pink-colored tympanic membrane

b) a pearly colored tympanic membrane

c) a transparent and clear tympanic membrane

d) a red, dull, thick, and immobile tympanic membrane

D) a red, dull, thick, and immobile tympanic membrane

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

a) pruritus

b) tinnitus

c) hearing loss

d) burning in the ear

b) tinnitus

rational:

-tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span.

-options A, C, D are not associated specifically with disorders of the inner ear

the clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

a) the right eye is tested, followed by the left eye, and then both eyes are tested.

b) both eyes are assessed together, followed by an assessment of the right eye and then the left eye.

c) the client is asked to stand at a distance of 40 feet from the chart and is asked to read the largest line on the chart.

d) the client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.

a) the right eye is tested, followed by the left eye, and then both eyes are tested

rationale:

-visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting.

-the right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together.

-visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet from the chart.

Test-taking strategy:

-remember that normal visual acuity as measured by a Snellen chart is 20/20 vision. This should assist in eliminating options C and D because they are comparable or alike in that they indicate standing at a distance of 40 feet.

-from the remaining options, remember it is best to test each eye separately and then test bath eyes together. This method assesses visual acuity most accurately.

A client's vision is tested with the Snellen chart. The results of the tests are documented as 20/60. How should the nurse interpret this finding?

a) the client is legally blind.

b) the client's vision is normal.

c) the client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.

d) the client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

d) the client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.

rationale:

-vision that is 20/20 is normal--that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet.

-A client with a visual acuity of 20/60 cannily read at a distance of 20 feet what a person with normal vision can read at 60 feet.

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

a) Speak loudly.

b) speak frequently

c) speak at a normal volume

d) speak directly into the impaired ear.

C) speak at a normal volume

rationale:

-speaking in a normal tone to the client with impaired hearing and not shouting are important.

-the nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently.

-Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear,

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

a) tests the corneal reflexes

b) tests the six cardinal positions of gaze

c) tests visual acuity, using a Snellen eye chart

d) tests sensory function by asking the client to close eyes and then lightly touching the forehead, cheeks, and chin

B) tests the six cardinal positions of gaze

rationale:

-testing the six cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes.

-A Snellen eye chart assesses visual acuity and cranial nerve II (optic).

-Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assesses cranial nerve V (trigeminal)

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?

A. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it.

B. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations.

C. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it

D. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

C. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

A.Decreased fluid volume

B. Increased cardiac output

C.Narrowing of jugular veins

D. Elevated pressure related to heart failure

D. Elevated pressure related to heart failure.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

A. Palpate the artery in the upper one third of the neck.

B. Listen with the bell of the stethoscope to assess for bruits

C. Simultaneously palpate both arteries to compare amplitude.

D. Instruct the patient to take slow deep breaths during auscultation.

B. listen with the bell of the stethoscope to assess for bruits.

When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are

A. Mitral and tricuspid.

B. Tricuspid and aortic.

C. Aortic and pulmonic.

D. Mitral and pulmonic

C. aortic and pulmonic

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs

A. Roll toward the left side

B. Roll toward the right side

C. Trendelenburg position

D. Recumbent position

A. Roll toward the left side.

During a cardiovascular assessment, the nurse knows that a thrill is:

A. Vibration that is palpable

B. Palpated in the right epigastric area.

C.Associated with ventricular hypertrophy.

D. Murmur auscultated at the third intercostal space

A. vibration that is palpable

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

A. Third left intercostal space at the midclavicular line

B. Fourth left intercostal space at the sternal border

C. Fourth left intercostal space at the anterior axillary line

D. Fifth left intercostal space at the midclavicular line

D. fifth left intercostal space at the midclavicular line.

Which of the following guidelines may be used to identify which heart sound is S1?

A. S1 is louder than S2 at the base of the heart

B. S1 coincides with the A wave of the jugular venous pulse wave.

C. S1 coincides with the carotid artery pulse.

D. S1 coincides with the Q wave of the QRS electrocardiogram complex.

C. S1 coincides with the carotid artery pulse.

The first heart sound (S1) is produced by the:

A. Closure of the semilunar valves

B. Closure of the AV valves

C. Opening of the semilunar valves

D. Opening of the AV valves.

B. Closure of the AV valves.

During a client examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?

A) Using gentle pressure, palpate with both hands to compare the two sides.

B) Using strong pressure, palpate with both hands to compare the two sides.

C) Gently pinch each node between one's thumb and forefinger and move down the neck muscle.

D)Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

A) Using gentle pressure, palpate with both hands to compare the two sides.

The nurse is palpating a client's temporomandibular joint (TMJ) which is located just below the temporal artery and anterior to the tragus. Which of the following would be a normal finding?

A) Nontender to palpation

B) Crepitus

C) The jaw locking

D) Painful palpation

A) Nontender to palpation

Which of the following subjective data would the nurse want to collect for the client when performing a Head, Face and Neck Exam? (Select all that apply)

A. If they have unusually frequent or severe headaches

B. If they have any dizziness

C. If they have any neck pain

D. If they have any chest pain

E. If they have any history of neck injury or surgery

A, B, C, E

A client's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope

A)Low gurgling; bell

B) Loud, whooshing, blowing; diaphragm

C) Soft, whooshing, pulsatile; bell

D)High-pitched tinkling; diaphragm

C) Soft, whooshing, pulsatile; bell

The nurse is assessing the client's trachea. Which of the following would be a normal finding?

A. The trachea rising to midline when the client swallows

B. The trachea deviating to the left when the client swallows

C. The trachea deviating to the right when the client swallows

D. The trachea not moving when the client swallows

A. The trachea rising to midline when the client swallows

The nurse is assessing a client's neck ROM. The nurse would correctly expect the client to be able to perform which movements with the neck?

A. Flexion, hyperextension, rotation and lateral bending

B. Rotation, supination, inversion, flexion

C. Lateral bending, abduction, adduction, forward flexion

D. Eversion, pronation, external rotation, hyperextension

A. Flexion, hyperextension, rotation and lateral bending

The nurse is performing the Diagnostic Positions test (Six Cardinal Fields of Gaze) to check the extraocular eye muscles. The nurse knows that a healthy finding would be:

A. Each eye moves in opposite directions from each other

B. There is parallel tracking of the object with both eyes.

C. A rapid eye blink is expected.

D. The light reflex of the eyes is located in the same position in each eye.

B. There is parallel tracking of the object with both eyes.

When assessing the pupillary light reflex, the nurse should use which technique?

A) Shine a penlight from directly in front of the patient and inspect for pupillary constriction.

B) Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction.

C) Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.

D) Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.

C) Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

A) consider this a normal finding.

B) refer the individual for further evaluation.

C) document this as an asymmetric light reflex.

D) perform the confrontation test to validate the findings.

A) consider this a normal finding.

The nurse is assessing the pupils of a client with a pen light. Which finding would be considered normal?

A)Both eyes cross when exposed to the light.

B)The patient's pupils are fixed and dilated in response to light.

C)Both pupils dilate in response to light.

D)Both pupils constrict in response to light.

D)Both pupils constrict in response to light.

In using the ophthalmoscope to assess a client's eyes, the nurse notices a red glow in the pupils. On the basis of this finding, the nurse would:

A) suspect that there is an opacity in the lens or cornea.

B) check the light source of the ophthalmoscope to verify that it is functioning.

C) consider this a normal reflection of the ophthalmoscope light off the inner retina.

D) continue with the ophthalmoscopic examination and refer the patient for further evaluation.

C) consider this a normal reflection of the ophthalmoscope light off the inner retina.

The nurse is charting on a client's eye assessment and notes PERRLA. What does this stand for?

A. Pupils Equal, Rigid, React to Light, and Accessible

B. Pupils Even, Right, React to Light, and Accomodation

C. Pupils Equal, Round, React to Light and Accomodation

D.Pupils Even, Rigid, Restrict from Light, and Accomodation

C. Pupils Equal, Round, React to Light and Accomodation

The nurse is assessing the client's pupillary response to light. The nurse moves the penlight in from the side of the client's face into the right eye. Both the right and left pupil constrict. How would these reflexes be described?

A) Right eye consensual response, left eye direct response

B) Right eye medial response, left eye lateral response

C) Right eye dilation response, left eye constricting response

D) Right eye direct response, left eye consensual response

D) Right eye direct response, left eye consensual response

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation?

1. The anxiety level of the client has increased.

2. Hormones have fluctuated in this client.

3. Muscle activity has increased during the clients therapy session.

4. Loss of subcutaneous fat is noted

4

The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading?

1. Assess that the equipment used is working properly.

2. Place the client in a position that is most comfortable for the health care provider.

3. Take the temperature with a chemical disposable thermometer when the client is perspiring.

4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

1

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use?

1. Axilla

2. Oral

3. Popliteal

4. Rectal

2

While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client?

1. Bathe the client with ice water.

2. Give the client an antipyretic.

3. Increase fluid intake.

4. Lower the room temperature.

3

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings?

1. A change in the clients health status has occurred.

2. The client has thrown a blood clot in that extremity.

3. The RNs watch has stopped working.

4. Too much pressure was applied over the pulse site.

4

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use?

1. Ask another nurse to assess the pulses.

2. Document the findings.

3. Obtain a Doppler ultrasound stethoscope.

4. Wait and try again later.

3

When assessing a clients peripheral pulse, the health care provider is also assessing which of the following?

1. Depth

2. Rhythm

3. Sound

4. Stress

2

The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision?

1. A forceful radial pulse is much too difficult to count correctly.

2. Both arteriole and venous sounds were heard simultaneously.

3. The pulse was bounding and easily obliterated.

4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

4