NUR3227C PPNC2 Exam 1 Questions and Answers Best rated A+ Guaranteed Success Latest Update, Exams of Nursing

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear. - CORRECT ANSWER-2. Initiate bowel or habit training program to promote continence. The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance - CORRECT ANSWER-4. Lactose intolerance

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NUR3227C PPNC2 Exam 1
What should the nurse teach family caregivers when a patient has fecal incontinence
because of cognitive impairment?
1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks.
2. Initiate bowel or habit training program to promote continence.
3. Help the patient to toilet once every hour.
4. Use sanitary pads in the patient's underwear. - CORRECT ANSWER-2. Initiate bowel
or habit training program to promote continence.
The patient states, "I have diarrhea and cramping every time I have ice cream. I am
sure this is because the food is cold." Based on this assessment data, which health
problem does the nurse suspect?
1. A food allergy
2. Irritable bowel syndrome
3. Increased peristalsis
4. Lactose intolerance - CORRECT ANSWER-4. Lactose intolerance
A nurse is taking a health history of a newly admied patient with a diagnosis of possible
fecal impaction. Which question is the priority to ask the patient or caregiver?
1. Have you eaten more high-fiber foods lately?
2. Have you taken antibiotics recently?
3. Do you have gluten intolerance?
4. Have you experienced frequent, small liquid stools recently? - CORRECT ANSWER-
4. Have you experienced frequent, small liquid stools recently?
When repositioning an immobile patient, the nurse notices redness over the hip bone.
What is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic
episode - CORRECT ANSWER-4. Blanching hyperemia, indicating the attempt by the
body to overcome the ischemic episode
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NUR3227C PPNC2 Exam 1

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment?

  1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks.
  2. Initiate bowel or habit training program to promote continence.
  3. Help the patient to toilet once every hour.
  4. Use sanitary pads in the patient's underwear. - CORRECT ANSWER-2. Initiate bowel or habit training program to promote continence. The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect?
  5. A food allergy
  6. Irritable bowel syndrome
  7. Increased peristalsis
  8. Lactose intolerance - CORRECT ANSWER-4. Lactose intolerance A nurse is taking a health history of a newly admied patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver?
  9. Have you eaten more high-fiber foods lately?
  10. Have you taken antibiotics recently?
  11. Do you have gluten intolerance?
  12. Have you experienced frequent, small liquid stools recently? - CORRECT ANSWER-
  13. Have you experienced frequent, small liquid stools recently? When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?
  14. A local skin infection requiring antibiotics
  15. Sensitive skin that requires special bed linen
  16. A stage 3 pressure injury needing the appropriate dressing
  17. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode - CORRECT ANSWER-4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first?

  1. Stop the instillation.
  2. Ask the patient to take deep breaths to decrease the pain.
  3. Tell the patient to bear down as he would when having a bowel movement.
  4. Continue the instillation; then administer a pain medication. - CORRECT ANSWER-1. Stop the instillation. Which instructions do you include when educating a person with chronic constipation? (Select all that apply.)
  5. Increase fiber and fluids in the diet.
  6. Use a low-volume enema daily.
  7. Avoid gluten in the diet.
  8. Take laxatives twice a day.
  9. Exercise for 30 minutes every day.
  10. Schedule time to use the toilet at the same time every day.
  11. Take probiotics 5 times a week. - CORRECT ANSWER-1. Increase fiber and fluids in the diet.
  12. Exercise for 30 minutes every day.
  13. Schedule time to use the toilet at the same time every day. Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.)
  14. How to change the pouch
  15. How to empty the pouch
  16. How to open and close the pouch
  17. How to irrigate the colostomy
  18. How to determine whether the ostomy is healing appropriately - CORRECT ANSWER-1. How to change the pouch
  19. How to empty the pouch
  20. How to open and close the pouch
  21. How to determine whether the ostomy is healing appropriately Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.)
  22. Lift the patient's hips off the bed and slide the bedpan under the patient.
  23. After positioning the patient on the bedpan, elevate the head of the bed to a 45- degree angle.
  24. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient.
  1. Get three fecal smears when you see blood in your bowel movement. - CORRECT ANSWER-3. Collect one fecal smear from three separate bowel movements. Match the pressure injury stages with the correct definition: Stage 1 Stage 2 Stage 3 Stage 4 a. partial thickness loss of skin with exposed dermis. the wound bed is viable, pink or red, most, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not viable, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and sheer in the skin over the pelvis and shear of the heel. This stage should not be used to describe moisture associated skin damage (MASD), including incontinent associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, Burns, abrasions) b. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in - CORRECT ANSWER-Stage 1- b Stage 2 - a Stage 3 - d Stage 4 - c After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the boom of the now- opened wound. Which are the priority nursing interventions? (Select all that apply.)
  2. Notify the health care provider.
  3. Allow the area to be exposed to air until all drainage has stopped.
  4. Place several cold packs over the area, protecting the skin around the wound.
  5. Cover the area with sterile, saline-soaked towels immediately.
  6. Cover the area with sterile gauze and apply an abdominal binder. - CORRECT ANSWER-1. Notify the health care provider.
  7. Cover the area with sterile, saline-soaked towels immediately. What is the correct sequence of steps when performing wound irrigation to a large open wound?
  8. Use slow, continuous pressure to irrigate wound.
  9. Attach 19-gauge angiocatheter to syringe.
  10. Fill syringe with irrigation fluid.
  11. Place biohazard bag near bed.
  1. Position angiocatheter over wound. - CORRECT ANSWER-4, 3, 2, 5, 1 Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)
  2. Frequent position changes
  3. Keeping the buttocks exposed to air at all times
  4. Using a large absorbent diaper, changing when saturated
  5. Using an incontinence cleaner
  6. Applying a moisture barrier ointment - CORRECT ANSWER-1. Frequent position changes
  7. Using an incontinence cleaner
  8. Applying a moisture barrier ointment Which of the following describes a hydrocolloid dressing?
  9. A seaweed derivative that is highly absorptive
  10. Premoistened gauze placed over a granulating wound
  11. A debriding enzyme that is used to remove necrotic tissue
  12. A dressing that forms a gel that interacts with the wound surface - CORRECT ANSWER-4. A dressing that forms a gel that interacts with the wound surface Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)
  13. Collection of wound drainage
  14. Providing support to abdominal tissues when coughing or walking
  15. Reduction of abdominal swelling
  16. Reduction of stress on the abdominal incision
  17. Stimulation of peristalsis (return of bowel function) from direct pressure - CORRECT ANSWER-2. Providing support to abdominal tissues when coughing or walking
  18. Reduction of stress on the abdominal incision When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.)
  19. To relieve edema
  20. To reduce shivering
  21. To improve blood flow to an injured part
  22. To protect bony prominences from pressure injuries
  23. To immobilize area - CORRECT ANSWER-1. To relieve edema
  24. To improve blood flow to an injured part What is the removal of devitalized tissue from a wound called?
  25. Debridement

When obtaining subjective data from a patient during assessment of the endocrine system, the nurse asks specifically about a. energy level. b. intake of vitamin C. c. employment history. d. frequency of sexual intercourse. - CORRECT ANSWER-a. energy level. An appropriate technique to use during physical assessment of the thyroid gland is a. asking the patient to hyperextend the neck during palpation. b. percussing the neck for dullness to define the size of the thyroid. c. having the patient swallow water during inspection and palpation of the gland. d. using deep palpation to determine the extent of a visibly enlarged thyroid gland. - CORRECT ANSWER-c. having the patient swallow water during inspection and palpation of the gland. Endocrine disorders often go unrecognized in the older adult because a. symptoms are often attributed to aging. b. older adults rarely have identifiable symptoms. c. endocrine disorders are relatively rare in the older adult. d. older adults usually have subclinical endocrine disorders that minimize symptoms. - CORRECT ANSWER-a. symptoms are often attributed to aging. Abnormal findings during an endocrine assessment include (select all that apply) a. excess facial hair on a woman. b. blood pressure of 100/70 mm Hg. c. soft, formed stool every other day. d. 3-lb weight gain over last 6 months. e. hyperpigmented coloration in lower legs. - CORRECT ANSWER-a. excess facial hair on a woman. e. hyperpigmented coloration in lower legs. A patient has a total serum calcium level of 3 mg/dL (1.5 mEq/L). If this finding reflects hypoparathyroidism, the nurse would expect further diagnostic testing to reveal a. decreased serum PTH. b. increased serum ACTH. c. increased serum glucose. d. decreased serum cortisol levels. - CORRECT ANSWER-a. decreased serum PTH. An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.)

  1. Infiltration at vascular access device (VAD) site
  2. Patient lying on tubing
  1. Roller clamp wide open
  2. Tubing kinked in bedrails
  3. Circulatory overload - CORRECT ANSWER-1. Infiltration at vascular access device (VAD) site
  4. Patient lying on tubing
  5. Tubing kinked in bedrails The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first?
  6. Apply a warm, moist compress.
  7. Aspirate the infusing fluid from the VAD.
  8. Report the situation to the health care provider.
  9. Discontinue the intravenous infusion. - CORRECT ANSWER-4. Discontinue the intravenous infusion. When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips?
  10. Two-thirds of the volume
  11. One-half of the volume
  12. One-quarter of the volume
  13. Two times the volume - CORRECT ANSWER-2. One-half of the volume What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.)
  14. Urine output
  15. Arterial blood gases
  16. Fullness of neck veins
  17. Serum potassium laboratory value in EHR
  18. Level of consciousness - CORRECT ANSWER-1. Urine output
  19. Serum potassium laboratory value in EHR The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump?
  20. 100 mL/hr
  21. 125 mL/hr
  22. 167 mL/hr
  23. 200 mL/hr - CORRECT ANSWER-2. 125 mL/hr An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action?
  24. Notify a health care provider.
  25. Decrease the IV flow rate.
  26. Lower the head of the bed.

tries to kick you away from his bed with a purposeful aim. - CORRECT ANSWER- Behavioral The nurse is inserting a Foley catheter for an elderly client with benign prostatic hypertrophy (BPH). The technique for this procedure is classified as ...? - CORRECT ANSWER-Sterile technique Procedures that are classified as aseptic techniques. - CORRECT ANSWER- Handwashing Emptying a full foley drainage bag Cleaning the ports of IV tubing prior to giving medications Wiping the bedside table prior to preparing a sterile field Match:

  1. Dehiscence
  2. Evisceration
  3. Approximated
  4. Slough a. Protrusion of visceral organs through a wound opening b. Partial or total separation of wound layers c. Tough stringy substance attached to the wound bed d. Wound edges are closed/ come together - CORRECT ANSWER-Dehiscence - b. Partial or total separation of wound layers Evisceration - a. Protrusion of visceral organs through a wound opening Approximated - d. Wound edges are closed/ come together Slough - c. Tough stringy substance attached to the wound bed What is the term for removal of devitalized tissue in a wound when appropriate for the patient's condition and consistent with the patient's goals? - CORRECT ANSWER- debridement Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? - CORRECT ANSWER-Drain and measure the output from the ostomy. A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. What information should be given to the patient? - CORRECT ANSWER-Soft, formed stool can be expected as drainage. A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? Select all that apply.

A. Use the patient's dominant arm B. Check for contraindications for using the extremity C. Select a vein with minimal curvature D. Avoid areas of flexion E. Choose a vein that feels rigid to touch F. Start proximally and move distally - CORRECT ANSWER- A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? SELECT ALL THAT APPLY a Use the patient's dominant arm b Check for contraindications for the site/extremity c Select a vein with minimal curvature d Avoid areas of flexion if possible e Choose a vein that feels rigid to touch — means they've used it a lot and there's scarring F Start proximally and move distally — opposite - CORRECT ANSWER-b Check for contraindications for the site/extremity c Select a vein with minimal curvature d Avoid areas of flexion if possible You're assigned to an 88yr. old female patient who needs a peripheral IV initiated. Her weight is 56kg and a height 5'2". Her skin is dry, fragile and her veins are visible. Which steps are necessary when inserting a peripheral IV line? SELECT ALL THAT APPLY a Apply tourniquet over her sleeve 10 to 15 cm (4 to 6 inches) above the intended insertion site. b. Clean skin using an approved antiseptic agent such as 70% isopropyl alcohol and allow to dry thoroughly. c Stabilize the vein by placing the thumb proximal to the insertion site while stretching the skin in the direction of insertion. d Use the smallest-gauge and shortest catheter available and insert with the bevel up at a 10- to 15-degree angle. e Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein. f Release the tourniquet once the catheter has been secured and the dressing has been applied - CORRECT ANSWER-a Apply tourniquet over her sleeve 10 to 15 cm (4 to 6 inches) above the intended insertion site. b. Clean skin using an approved antiseptic agent such as 70% isopropyl alcohol and allow to dry thoroughly. d Use the smallest-gauge and shortest catheter available and insert with the bevel up at a 10- to 15-degree angle. e Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein.

b Phlebitis c Hematoma d Infiltration e Pump malfunction - CORRECT ANSWER-d Infiltration The nurse goes in to provide discharge instructions for another client who has had surgery. The client has this finding at a previous IV site. The nurse concludes that which of the following complications has occurred? a Infection b Hematoma or bruising c Infiltration d Thrombophlebitis - CORRECT ANSWER-b Hematoma or bruising The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order.

  1. Apply suction.
  2. Assist patient to semi-Fowler's or high Fowler's position, if able.
  3. Advance catheter through nares and into trachea.
  4. Have patient take deep breaths.
  5. Lubricate catheter with water-soluble lubricant.
  6. Apply sterile gloves.
  7. Perform hand hygiene.
  8. Withdraw catheter. - CORRECT ANSWER-7, 2, 6, 4, 5, 3, 1, 8 Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.)
  9. Initiate oxygen therapy via nasal cannula.
  10. Perform nasotracheal suctioning of a patient.
  11. Educate the patient about the use of an incentive spirometer.
  12. Assist with care of an established tracheostomy tube.
  13. Reposition a patient with a chest tube. - CORRECT ANSWER-4. Assist with care of an established tracheostomy tube.
  14. Reposition a patient with a chest tube. The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?
  15. Start oxygen at 2 L/min via nasal cannula.
  16. Elevate the head of the bed to 45 degrees.
  17. Encourage the patient to use the incentive spirometer.
  18. Notify the health care provider. - CORRECT ANSWER-2. Elevate the head of the bed to 45 degrees.

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?

  1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles."
  2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus."
  3. "I will ensure that I receive an influenza vaccine every year, preferably in the fall."
  4. "I will look for a smoking-cessation support group in my neighborhood." - CORRECT ANSWER-2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.)
  5. SpO2 value of 95%
  6. Retractions
  7. Respiratory rate of 28 breaths per minute
  8. Nasal flaring
  9. Clubbing of fingers - CORRECT ANSWER-2. Retractions
  10. Respiratory rate of 28 breaths per minute
  11. Nasal flaring The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.)
  12. The patient has visible secretions in the airway.
  13. There is a sawtooth pattern on the patient's EtCO2 monitor.
  14. The patient has clear breath sounds.
  15. It has been 3 hours since the patient was last suctioned.
  16. The patient has excessive coughing. - CORRECT ANSWER-1. The patient has visible secretions in the airway.
  17. There is a sawtooth pattern on the patient's EtCO2 monitor.
  18. The patient has excessive coughing. The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?
  19. New, vigorous bubbling in the water seal chamber.
  20. Scant amount of sanguineous drainage noted on the dressing.
  21. Clear but slightly diminished breath sounds on the right side of the chest.
  22. Pain score of 2 one hour after the administration of the prescribed analgesic. - CORRECT ANSWER-1. New, vigorous bubbling in the water seal chamber.
  1. Instruct patient to stay in bed and use a urinal or bedpan. - CORRECT ANSWER-3. Report the time and amount of first voiding. A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.)
  2. Increase the rate of the CBI.
  3. Assess the patency of the drainage system.
  4. Measure urine output.
  5. Assess vital signs.
  6. Administer ordered pain medication. - CORRECT ANSWER-2. Assess the patency of the drainage system.
  7. Measure urine output. An ambulatory elderly woman with dementia is incontinent of urine. She has poor short- term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?
  8. Recommend that she be evaluated for an overactive bladder (OAB) medication.
  9. Establish a toileting schedule.
  10. Recommend that she be evaluated for an indwelling catheter.
  11. Start a bladder-retraining program. - CORRECT ANSWER-2. Establish a toileting schedule. What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.)
  12. Maintain regular bowel elimination.
  13. Limit water intake to 1 to 2 glasses a day.
  14. Wear coon underwear.
  15. Cleanse the perineum from front to back.
  16. Practice pelvic muscle exercise (Kegel) daily. - CORRECT ANSWER-1. Maintain regular bowel elimination.
  17. Wear coon underwear.
  18. Cleanse the perineum from front to back. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.
  19. Insert and advance catheter.
  20. Lubricate catheter.
  21. Inflate catheter balloon.
  22. Cleanse urethral meatus with antiseptic solution.
  23. Drape patient with the sterile square and fenestrated drapes.
  24. When urine appears, advance another 2.5 to 5 cm.
  1. Prepare sterile field and supplies.
  2. Gently pull catheter until resistance is felt.
  3. Attach drainage tubing. - CORRECT ANSWER-5, 7, 2, 4, 1, 6, 3, 8, 9 Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.)
  4. Attach a 3-mL syringe to the inflation port.
  5. Allow the balloon to drain into the syringe by gravity.
  6. Initiate a voiding record/bladder diary.
  7. Pull the catheter quickly.
  8. Clamp the catheter before removal. - CORRECT ANSWER-2. Allow the balloon to drain into the syringe by gravity.
  9. Initiate a voiding record/bladder diary. Which nursing intervention decreases the risk for catheter- associated urinary tract infection (CAUTI)?
  10. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution
  11. Hanging the urinary drainage bag below the level of the bladder
  12. Emptying the urinary drainage bag daily
  13. Irrigating the urinary catheter with sterile water - CORRECT ANSWER-2. Hanging the urinary drainage bag below the level of the bladder There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next?
  14. Remove the catheter and start all over with a new kit and catheter.
  15. Leave the catheter there and start over with a new catheter.
  16. Pull the catheter back and reinsert at a different angle.
  17. Ask the patient to bear down and insert the catheter farther. - CORRECT ANSWER-2. Leave the catheter there and start over with a new catheter. which action should the nurse take to maintain sterility when performing a dressing change? a. put the unopened sterile glove package carefully on the sterile field b. remove the sterile drape from its package by lifting it by the corners c. don sterile gloves before opening the package containing the field drape d. pour irrigation liquid from a height of at least 3inches (2.5 cm) above the sterile container - CORRECT ANSWER-b. remove the sterile drape from its package by lifting it by the corners outer 1 inch of the sterile field is considered contaminated; must pour from 4-6 inches

e. use a Y-type infusion set to initiate 0.9% normal saline - CORRECT ANSWER-a. obtain the client's vital signs d. determine typing and crossmatching of blood e. use a Y-type infusion set to initiate 0.9% normal saline which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? a. wound asepsis b. medical asepsis c. surgical asepsis d. concurrent asepsis - CORRECT ANSWER-b. medical asepsis the nurse is preparing to change a client's dressing. for which reason would the nurse use surgical asepsis? a. keeps the area free of microorganisms b. confines microorganisms to the surgical site c. protects self from microorganisms in the wound d. reduces the risk for growing opportunistic microorganisms - CORRECT ANSWER-a. keeps the area free of microorganisms which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion? a. stop the transfusion b. obtain the vital signs c. notify the health care provider d. maintain the flow with normal saline - CORRECT ANSWER-a. stop the transfusion acute hemolytic reaction which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? a. stop the blood transfusion and infuse saline b. administer the prescribed antipyretic c. obtain a prescription for an antihistamine d. notify the blood bank about the symptoms - CORRECT ANSWER-a. stop the blood transfusion and infuse saline acute hemolytic reaction which action should the nurse take to maintain sterility when performing a dressing change?

a. put the unopened sterile glove package carefully on the sterile field b. remove the sterile drape from its package by lifting it by the corners c. don sterile gloves before opening the package containing the field drape d. pour irrigation liquid from a height of at least 3 inches (2.5 cm) above the sterile container - CORRECT ANSWER-b. remove the sterile drape from its package by lifting it by the corners which technique would the nurse use to maintain surgical asepsis? a. change the sterile field after sterile water is spilled on it b. put a sterile gloves before opening a container of sterile saline c. place a sterile dressing no more than half an inch from the edge of the sterile field d. clean the surgical area with a circular motion, moving from the outer edge toward the center - CORRECT ANSWER-a. change the sterile field after sterile water is spilled on it which action by the fmaily member during a return demonstration indicates the need for additional tecahing after a home health nurse teaches a fmaily member to cleanse a client's wound and apply a sterile dressing? a. placing the old dressing in a plastic bag b. changing the dressing without wearing a mask c. donning non-sterile gloves for removing the old dressing d. using a back and forth motion with the same gauze while cleaning the wound - CORRECT ANSWER-d. using a back and forth motion with the same gauze while cleaning the wound why are the faucet handles on the sink in a client's room considered contaminated? a. they are not in sterile area b. they are touched by dirty hands when turning the water on c. large number of people use them each day d. water encourage bacterial growth - CORRECT ANSWER-b. they are touched by dirty hands when turning the water on which basic principles of surgical asepsis must the nurse consider when changing the dressing of a child with severe burns? a. a paper field must remain dry to be considered sterile b. sterile items held below the waist are considered sterile c. a 1-inch (2.5cm) border around a sterile field is considered contaminated d. sterile objects in contact with clean objects are considered contaminated e. a fenestrated drape is not considered sterile - CORRECT ANSWER-a. a paper field must remain dry to be considered sterile c. a 1-inch (2.5cm) border around a sterile field is considered contaminated d. sterile objects in contact with clean objects are considered contaminated