1. Which of the following is an appropriate nursing action when implementing standard precautions?
A. Consider all body substances potentially infectious
B. wear gloves whenever in contact with patient
C wear gown and gloves when caring for a client in droplet precaution
D. place a body substance isolation sign on the client's door
2. Which of the following clients would qualify for hospice care?
A. a client with metastatic
cancer
B. a client with left-side after a stroke
C. a client who had coronary artery bypass surgery 1 week ago
D. a client who is undergoing treatment for heroin addiction
3. For a hospitalized client, which statement reflects appropriate documentation in the client's medical record?
A. "client had a good day"
B. "seems to be mad at the physician"
C. "small pressure ulcer noted at the lower back"
D. "skin moist and cool"
4. The nurse will administer the client's 9 A.M. medications. The client is away from his room for ultrasound of the liver. Which nursing action is appropriate ?
A. have the client skip that
dose of medication
B. ask the client's relatives to keep the medications for the client until he returns
C. lock the medications in the medicine preparation area until the client returns
D. leave the medications on the drawer of the client's bedside table
5. The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true?
A. the PCA pump cant' infuse opioids continuously
B. pain relief is initiated by the client as needed
C. no complications related to opioid delivery by the pump exist
D. the nurse prescribes the dosage of opioid for delivery
6. Which assessment sequence should the nurse follow when examining abdomen?
A. Inspection, percussion, auscultation, palpation
B. auscultation, inspection, percussion, palpation
C. inspection, auscultation, percussion, palpation
D. auscultation, inspection, palpation, percussion
7. Which of the following instructions given to an elderly client who had undergone total hip replacement would prevent post-operative constipation?
A. "take metamucil regularly"
B. "walk 50 feet daily"
C. "eat a soft diet"
D. "drink 6 to 8 glasses of water a day"
8. Which action by the nurse is essential when cleaning the area around a Jackson Pratt wound drain?
A. clean from the center, out in a circular motion
B. remove the drain before cleaning the skin
C. clean briskly around the site with alcohol
D. wear sterile gloves and mask
9. An obese client comes to the physician's office for a routine physical examination. The nurse chooses a standard
blood pressure cuff to auscultate the client's
blood pressure. If the blood pressure cuff is too small for the client, blood pressure reading taken with such cuff may do which of the following?
A. fail to show changes in
blood pressure
B. produce a false-high measurement
C. cause sciatic nerve damage
D. produce false-low measurement
10. Before administering a medication through a
nasogastric tube (NGT), which action should the nurse take first?
A. instruct the client to cough
B. give the client a sip of water through a straw
C. observe and test the
pH of the aspirate
D. inject 10ml of water into the
NGT
ANSWERS AND RATIONALE
1) A- standard precautions are based on the concepts that all body substances are potentially infectious. The nurse should wear gloves when contact with body substances is potential, not when in contact with intact skin. Mask should be used as a barrier to prevent transmission of droplet infections. Signs on door are unnecessary for standard precaution.
2) A
- hospices provide supportive, palliative care to terminally ill clients and their families
3) D
- documentation should be factual and accurate, what are heard, seen, smelled, or felt. Documentation of ulcer should include exact size and location. Interpretations, conclusions, opinions should not be documented.
4) C
- the nurse must put the medicines in the secured area. She should not leave the medications at the bedside. The nurse should not omit doses of medications without physician's order
5) B
- the client pushes a button to self-administer narcotic analgesic. The PCA pump also allows for continuous infusions of the medication. The client may still experience complications of the medication. It is the physician who prescribes the medication order
6) C
- the sequence of inspection, auscultation, percussion and palpation ensures that bowel sounds are not altered or stimulated by percussion and palpation (IAPP)
7) D
- Water is needed to promote peristalsis. Regular use of laxative may create dependence and cause dehydration. A
high fiber diet, not soft diet prevents constipation. Walking 50 feet a day may not be enough to increase motility
8) A
- cleaning from the center, out in a circular motion around a wound drain prevents contamination of wound. The skin near the drain is more contaminated.
Alcohol is never used to clean around the drain because it is irritating. The nurse should wear sterile gloves to prevent contamination but a mask in not necessary
9) B
- using too small blood pressure cuff produces a false-high measurement because the cuff can't measure brachial artery pressure unless it's excessively inflated
10) C
- NGT placement must be verified before administering a medication to prevent introducing the medication into the airway. Placement may be checked by assessing the pH of gastric contents. The pH should be less than 5.
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