Review

The nurse is performing a dressing change on a client. Which of the following warrants correction by the charge nurse?

• • The nurse dons sterile gloves to apply to new dressing.

• • The nurse keeps hands at waist level to maintain sight on hands at all times.

• • The nurse dons sterile gloves and removes the old dressing.

• • The nurse washes hands before and after the procedure.

The nurse is reviewing methods to prevent the spread of infection to other clients and family. Which of the following methods are most effective? Select all that apply.

• • Wear a clean uniform daily.

• • Avoid wearing rings and bracelets.

• • Keep nursing shoes clean and stored away.

• • Clean stethoscope between clients.

• • Perform hand hygiene.

Which of the following is a reservoir for infection?

• • Human

• • Droplets

• • Bacteria

• • Animal

• • Water

Hypertension, heart disease, and stroke are common illnesses in which age group?

• • Adolescents

• • Young adults

• • Middle-aged adults

• • Older adults

The nurse is developing a plan of care for a middle-aged male client with multiple sclerosis. The client has been able to maintain full-time employment while his spouse stayed home with the children. Now the client’s spouse had to re-enter the work force with considerably lower pay than her husband. Both client and wife are verbalizing frustration with the role change. What is an appropriate nursing diagnosis for this situation?

• • Ineffective role performance

• • Caregiver role strain

• • Disturbed body image

• • Powerlessness

The nurse is evaluating the planned outcome for the caregiver of an elderly client with Alzheimer's disease. The evaluation revealed caregiver role strain. As the client has begun to wander in the house at night, the caregiver stated that it is stressful to be awakened several times a night. The caregiver has installed deadbolt locks on the exit doors and an alarm on the windows but must continuously check on the client's safety throughout the night. What are some actions the caregiver can implement to obtain quality sleep while the client wanders in the house?

• • Remove the knobs on the stove and lock up the knives and other utensils that can cause harm to the client.

• • Alert the authorities of the possibility that the client may exit the house at night and to contact the caregiver.

• • Medicate the client with a sleeping pill prior to bed so both client and caregiver can sleep all night.

  
  

• • Place the client in a day center for activities to help readjust the client’s sleep-wake cycle.

• Place the client in a day center for activities to help readjust the client’s sleep-wake cycle.

• • Advocacy

• • Paternalism

• • Autonomy

• • Veracity

The LPN/LVN notices on a client’s plan of care the following nursing diagnosis: Ineffective airway clearance related to decreased energy and fatigue as evidenced by a weak cough and inability to cough up sputum. Which part of the nursing diagnosis does the LPN/LVN identify as the etiology?

• • Ineffective airway clearance

• • Decreased energy and fatigue

• • Weak cough

• • Inability to cough up sputum

The nurse is using the WHAT’S UP method to help gather client data. Which question would the nurse ask to determine the “S” in WHAT’S UP?

• “How does the pain feel?

• • “How bad is the pain?”

• • “Where is your pain?”

• • “When did your pain start?”

The nurse is preparing a class on prevention of sexually transmitted infections (STIs). Which of the following should the nurse include in the presentation? Select all that apply.

• • Limit sexual partners to people you know well.

• • Use a new condom with each sexual encounter.

• • Practice oral sex instead of vaginal intercourse.

• • Know what clinical manifestations of STIs to report.

• • Avoid alcohol in situations where sex may occur.