Foundations Exam 1 Clinical Essentials Questions (SELECTIVE)

Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient?

Gown, gloves, mask, and eye protection

What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation?

perform hand hygiene

The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse?

"I really dislike wearing a mask, so it's the first thing I take off."

When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown?

To prevent touching contaminated material with unprotected hands

When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first?

Review the patient's need for a specific isolation precaution

The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure?

Follow sterile technique during the procedure

While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained?

Ask the assistant who has been helping with the procedure to bring the necessary supplies

What direction would the nurse provide to nursing assistive personnel (NAP) while establishing and maintaining a sterile field?

"Remember, reaching over the sterile field constitutes a break in sterile technique."

While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient's gown. Which action is most appropriate in this situation?

Collect the supplies necessary and establish a new sterile field

Why might the nurse offer the patient a bedpan before establishing a sterile field?

Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement.

The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field?

Placing the needed supplies near the back of the sterile field

Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field?

Do not allow the wrapper to touch the sterile field.

Which action would the nurse perform first when preparing to apply sterile gloves?

Assess the glove packaging for wetness or tears

Which patient is at the greatest risk for hospital-acquired infection (HAI)?

A. A middle-age female patient receiving chemotherapy for lung cancer

B. An older adult male patient who experienced a myocardial infarction 3 days ago

C. A young man recovering from bilateral femur fractures and a mild concussion sustained in a car accident

D. A young woman with abdominal pain who is scheduled for exploratory surgery in the morning

A

Inadequate oxygenation to the body will cause the radial pulse to become:

tachycardic

During the admissions process, the nurse initially assesses the patient's radial pulse primarily for what purpose?

Establishment of a baseline as part of the patient's vital signs

What is the major health problem resulting from a pulse deficit?

decreases cardiac output

When measuring a patient's respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?

the number of inspirations and expirations per minute

Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?

Assess respiration after measuring the pulse.

Which of the following is a risk factor for decreased oxygen saturation level in a patient?

chest wall injury

The nurse is preparing to assess a patient's blood pressure. What would cause the blood pressure reading to be inaccurately high?

Blood pressure cuff is too loose around the arm

What would cause the nurse to delay the assessment of a patient's blood pressure?

patient just finished having a cigarette

The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?

Ensure that your diet has an adequate daily intake of calcium.

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?

The patient rates his pain a 7 on a scale of 0 to 10.

Which observation indicates that a patient's analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention?

The patient rates her current pain as 3 out of 10 on the pain rating scale.

The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw?

The absence of physiological signs and symptoms is associated with chronic pain

Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed?

To provide the correct amount of oxygen to the patient

What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy?

Observing the six rights of medication administration.

What is the primary purpose of initially assessing an apical pulse?

Establishment of a baseline as part of the patient's vital signs

Which action would take priority if a patient's apical pulse has an irregular rhythm?

Reassess the pulse for 1 full minute