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Nursing Competencies
A 1-month old baby is having a wellness exam. Which approach indicates that the nurse correctly measured the client's abdomen? - Recorded the measurement to the nearest 1/4 inch The support person of a new pediatric client asks why the child's blood pressure was measured twice. Which response will the nurse make to the support person? - The first measurement was to help determine how high to pump the blood pressure cuff A neonate receiving phototherapy is prescribed pulse ox measurements every 2 hours. Which nursing action ensures that the measurement will be accurate? - covers the sensor with a blanket A client who consumed breakfast at 0800 hours has loud and frequent bowel sounds at 1330 hours. In which way will the nurse interpret this assessment finding? - Normal expected bowel sounds During an assessment, the nurse notes that a preschool child is able to read the 10th line on the HOTV eye chart with the right eye and the 5th line with the left eye. Which treatment should the nurse expect to be prescribed for this client? - Corrective eye glasses The nurse suspects that a client in ICU is experiencing a reaction to a carotid sinus massage. Which finding did the nurse observe to make this clinical determination? - cardiac monitor alarmed "low pulse" A client is able to shrug the shoulders at the level of normal movement against gravity. In which way should the nurse make to document this finding? - Trapezius muscles grade 3 The nurse is assessing a client's neck with the chin bent down over the chest. Which approach should be used to palpate the client's supraclavicular nodes? - With client's head forward move the fingertips in a forward circular motion against the sternocleidomastoid and trapezius muscles A client is unable to feel the nurse lightly touching the lower legs. In which way should the nurse document this finding - Anesthesia bilateral lower legs The nurse suspects that an older client has chronic venous insufficiency. What did the nurse assess to make this clinical determination - Dark skin tones of the lower legs and edema of the ankles
The nurse auscultates a clients breath sounds. which sounds should the nurse report to the healthcare provider? - Low=pitched, continuous snoring over the trachea The nurse is reviewing tasks that need to be completed over the next shift. Which peripheral assessment should the nurse delegate to the UAP to complete? - Brachial A client having a knee replacement is returning to the care area. Which technique should the nurse use when making this clients bed - Create a triangle, and fanfold the top linens to one side of the bed The nurse instructs a client with diabetes on conducting foot care at home. which client statement indicates teaching has been effective? - I should file my toenails The nurse prepares to provide mouth care to a 20-month old client. Which action should the nurse take when completing this care - use a soft bristled brush moistened with water The nurse asks another nurse to do a double check on a med before providing it to a client. What med is the nurse most likely preparing to administer? - Insulin The nurse prepares to administer an oral dose of med to an adult. Which info does the nurse need to calculate the amount of med given to this client - dose desired The nurse prepares an injection from two vials of medication. If following the traditional method, which action should the nurse do after withdrawing the required amount of medication from the second vial - Remove the needle and attach a sterile needle to the syringe A client with a gastrostomy needs to receive 3 meds at 1000 hours Which volume of water should the nurse have avail to provide these meds correctly - 60 mL The nurse evaluates a client's ability to use a metered dose inhaler with a spacer Which observation indicates that additional teaching is required - Holds the breath for 2 seconds The nurse prepares to apply a transdermal patch med to a client. Which approach should the nurse take when applying this med - select a skin area that is clean, dry, hairless, and intact
The nurse reviews intake and output measures collected by a UAP. Which measurement should the nurse investigate prior to reporting to the healthcare professional - Client weighing 121 IB with an 8 hour urine output of 110mL While changing the transparent semipermeable membrane dressings on a client's central line the nurse measures the catheter length as being 10.75 cm. This is a change from the previous measurement of 11.5 cm. Which action should the nurse take - complete the dressing change The nurse observes a new grad nurse changing the intravenous fluid tubing for a clients central line infusion. For which action should the nurse intervene - Flushes the catheter with a 3 mL syringe The nurse prepares to administer an IV med through the middle port of a clients central venous catheter/ Which action should the nurse take before administering the med? - Flushing the port with 5mL normal saline The nurse inserts a Huber needle into a client's vascular access device in order to draw blood samples. In which receptable should the nurse place the first 10 mL of blood withdrawn from the device - Biohazard waste container An older clients Iv infusion dressing is wet. Which action should the nurse take - clamp the infusion tubing A client is prescribed to receive 3 mL of Iv fluid over the next 12 hours. Which action should the nurse take to ensure that the correct amount is infused as prescribed - Use an IV catheter with a larger diameter A client's IV fluid infusion was changed to keep vein open rate at 1400 hours. At which time should the nurse change the client's fluid container and tubing - 1400 hours the next day A client receiving IV fluids reports burning pain along the vein being used for the infusion. Which action should the nurse take first - Clamp the infusion The nurse turns off the smart pump and removes a client's Iv catheter. Which assessment finding caused the nurse to make this clinical decision - Erythema and swelling at the site
The nurse assists in preparing a client for placement of a percutaneous central vascular catheter in the right subclavian vein. Which action should the nurse complete before the procedure begins - Place a rolled towel between the clients shoulder blades The nurse cleanses the site of a peripherally inserted central catheter with antimicrobial soaked swabs. Which action should the nurse perform next - Wait 30 seconds for the solution to dry Ch. 6 The nurse completes cleaning the perineum of a client who just had a bowel movement. Afterward, which approach should the nurse use to cleanse the hands? - Remove the gloves and wash the hands with soap and water. Ch. 6 The nurse observes a UAP provide care to a client in enteric contact precautions. For which UAP action should the nurse intervene? - Leaves the room with the stethoscope draped around the neck Ch. 6 The nurse cares for a client with bacterial meningitis. At which time should the nurse remove the face mask when doffing PPE? - After removing the gown Ch. 6 During a home visit, the nurse notes that a client's infected leg wound is draining purulent and serosanguineous fluid onto the bed sheets. Which information should the nurse instruct the primary caregiver about the care of the client's bed linens? - Wash separately with very hot water, detergent, and bleach. Ch. 6 The nurse irrigates and changes a client's abdominal wound dressing. Which item should the nurse flush down the commode? - Wound drainage Ch. 6 A sputum sample is collected from a client in airborne precautions. Which action should the nurse take before sending this specimen to the laboratory? - Place specimen container in plastic biohazard bag outside the room. Ch. 6 While transferring a client with a norovirus from the transportation cart to the bed, the nurse notes stool has seeped through the blankets that were covering the mattress. Which action should be taken to disinfect the mattress on the cart appropriately? - Wipe down the mattress with an antimicrobial solution. Ch. 6 The nurse enters the room of a client with seeping skin wounds. At which time should the nurse don gloves? - After washing the hands
Ch. 7 The nurse assesses a saturated dressing over the site of a lumbar puncture completed an hour ago on an adult client. Which treatment should the nurse anticipate being prescribed for this client?
- Trendelenburg position (If leaking after a lumbar puncture persists, the healthcare provider may prescribe that the client be placed in the Trendelenburg position to prevent a headache. A pressure dressing will not stop the flow of cerebral spinal fluid after a lumbar puncture. The semi-Fowler position may encourage the development of a headache after a lumbar puncture. Intravenous fluid replacement is not indicated for leaking from a lumbar puncture site.) Ch. 7 A client being prepared for a lumbar puncture asks why the fetal position is used. Which response should the nurse make to this client? - "It helps spread the vertebrae apart so that the needle can be inserted more easily." (The fetal position is used during an adult lumbar puncture because in this position, the back is arched, increasing the spaces between the vertebrae so that the spinal needle can be inserted readily. Spreading the vertebrae apart prior to a lumbar puncture eases the placement of the needle; however, the client may still experience pain when the needle is inserted. Spreading the vertebrae apart for a lumbar puncture will not help the procedure to be completed faster. Spreading the vertebrae apart for a lumbar puncture will not affect the results of the procedure.) Ch. 8 After assessing a client, the nurse reschedules serum thyroid tests for the following week. Which information caused the nurse to make this clinical decision? - Client ate crab cakes for dinner the previous day. (For serum thyroid tests, the client should avoid eating shellfish for several days before the test. Smoking cigarettes does not affect the results of serum thyroid tests. Lying supine for 1 hour does not affect the results of serum thyroid tests. Fasting does not need to be done before serum thyroid tests.) Ch. 8 The nurse provides a schedule of beginning yoga classes for a client. Which health problem is this client most likely attempting to manage? - Addison disease (Yoga is identified as a complementary and alternative therapy approach for Addison disease. Yoga is not identified as a complementary and alternative therapy approach for myxedema coma, Cushing syndrome, or Hashimoto thyroiditis.) CH. 8 During a paracentesis, 1500 mL of fluid was removed from a client's abdomen over 10 minutes. Which assessment finding indicates the client is experiencing an adverse effect from this procedure?
- Blood pressure 88/58 mmHg
(Normally about 1500 mL is the maximum amount of fluid drained at one time and it is drained very slowly. Limiting the amount and speed of fluid withdrawal prevents hypovolemic shock; a low blood pressure could indicate that the client is experiencing an adverse effect from the procedure. Warm, dry skin does not indicate an adverse effect from this procedure. A heart rate of 94 bpm is within normal limits and does not indicate an adverse effect from this procedure. A respiratory rate of 18/min and unlabored could indicate an improvement in respiratory functioning after this procedure, not an adverse effect.) Ch. 8 The laboratory report from a paracentesis sample indicates the presence of urate crystals. In which way should the nurse interpret this information? - The bladder was punctured during the procedure. (Urate crystals are found in urine and are precursors to the development of gout. If these crystals were present in a paracentesis sample, the bladder was most likely punctured. Urate crystals are not found in paracentesis fluid. Urate crystals do not indicate an electrolyte imbalance. Urate crystals do not indicate an insufficient amount of fluid was sent as a sample for testing.) Ch. 8 The UAP reports that a client's capillary blood glucose level could not be measured at 1600 hours because of "insufficient sample size." Which action should the nurse take? - Observe the UAP perform the skill to determine competency. (f the UAP received a reading of insufficient sample size, it is possible that the skill is not being performed correctly. The best way to evaluate competency and obtain an accurate reading would be for the nurse to observe the UAP perform the skill on the client again. Having another UAP perform the skill does not help evaluate the original UAP's competency to perform capillary blood glucose measuring. The nurse is responsible for the assessment, interpretation of abnormal findings, and determination of appropriate responses for the capillary glucose measurement. The nurse needs to investigate why an insufficient sample was obtained. It could be due to the UAP's technique. The nurse needs to obtain an accurate capillary blood glucose measurement prior to contacting the healthcare provider for the insulin dose.) Ch. 8 The nurse reviews the process of measuring capillary blood glucose with a client newly diagnosed with type 2 diabetes mellitus. Which client statement indicates additional teaching is required? - I should press on the puncture site to make the blood flow better. (The client should be instructed to gently squeeze proximal to, but not to touch, the puncture site until a large drop of blood forms. The site should be cleansed with an antiseptic swab and allowed to dry completely; alcohol can affect accuracy, and the site burns when punctured if wet with alcohol. The skin should be punctured with a lancet using a darting motion. Wrapping the finger in a warm
(Because the client is starting to fall forward, the nurse should first widen own stance to increase the base of support. Separating the feet allows the nurse to rock backward and use the femoral muscles when supporting the client's weight. It also lowers the center of gravity to prevent back strain. Pulling on the client's arm could cause an injury to both the client and the nurse. Tightening the grip on the gait belt will not be sufficient if the client is falling forward. Having the client look down at the floor may cause the client to fall forward faster.) CH. 9 The nurse observes the UAP logroll a client. For which action should the nurse intervene? - Client's upper body moved, followed by the lower body (The client's entire body should be moved in unison to the side of the bed. Moving the upper body then the lower body does not keep the spine in alignment. The client's arms are crossed over the chest to ensure that the arms are not injured or trapped under the body when the client is turned. Pillows between the legs prevent adduction of the upper leg and keep the legs parallel and aligned. Placing a pillow where it will support the client's head after the turn prevents lateral flexion of the neck and ensures alignment of the cervical spine.) CH. 9 A client needs to be moved up in bed. Which action should the nurse take once a draw sheet is placed under the client? - Grasp the draw sheet at the shoulders and hips (After the draw sheet is in place, it should be grasped at the shoulders and hips because it draws the client's weight closer to the nurse's center of gravity for balance and stability. Lowering the head of the bed is the first action the nurse should take; it would be done before placing the draw sheet. Raising the height of the bed is the second action that the nurse should take; it would be done before placing the draw sheet. A pillow should be placed against the head of the bed after the bed is flat and raised to the appropriate height; this would also be done before placing the draw sheet.) Ch. 9 A client with a left lower leg wound needs to be transferred to a wheelchair. In which position should the nurse place the wheelchair? - Parallel to the bed on client's right side (The client has a left leg injury, so the chair should be parallel to the bed on the client's right (unaffected) side. If the wheelchair is facing the bed, the client would have to turn around completely to sit. The wheelchair should be placed so the client can move toward the uninjured lower extremity. Placing the wheelchair at a 45-degree angle is appropriate for the client who has difficulty walking. This is not the case for this client situation.) Ch. 9 A client who was placed in the prone position is located near the left side rail. Which action should the nurse take to ensure proper positioning of this client? - Reverse the turn and start over.
(Because the client should never be pulled across the bed in the prone position, the best way to ensure proper positioning is to start over. Placing pillows against the left raised side rail does not ensure proper positioning. This could also be unsafe. Never pull a client across the bed while the client is in the prone position. Doing so can injure a client's breasts or genitals. Moving the body in segments toward the center of the bed could be harmful and cause injury to the client.) CH. 9 The nurse is ambulating a client who is using a newly prescribed cane. Which action should the nurse instruct the client to do after moving the cane forward? - Move the weak leg to the level of the cane (After moving the cane forward, the client should move the weak leg to the level of the cane. Moving the weak leg ahead of the cane can throw the client off balance and precipitate a fall. The weak leg should be moved first.) CH. 9 The nurse observes a client use crutches to walk down a set of stairs. Which action indicates that the nurse needs to review the process for safety? - Moves crutches and unaffected leg to the lower step (When moving down a step, the crutches and the affected leg should be moved together. Then the unaffected leg is moved down to the step. The elbows should be flexed at a 30-degree angle. The client's body weight should be supported by the hands on the hand bar. The client should start by assuming the tripod position at the top of the stairs.) Ch. 9 A client with right leg weakness is prescribed to use a walker. Which direction should the nurse provide when instructing on the use of this device? - Move the right foot and walker together (If one leg is weaker than the other, the walker and the weak leg should be moved ahead together. The walker should be moved ahead first before moving either of the feet. Moving the right leg up to the walker first would be appropriate if both legs are equally weak. Moving the strong leg and the walker together could cause the client to become unstable and fall.) Ch. 9 Two hours after the application of a fiberglass cast, the client complains of severe pain. Which action should the nurse take? - Apply ice to the limb (Complaints of severe pain could indicate compartment syndrome. The first thing that the nurse should do is apply ice to reduce inflammation. The nurse needs to apply ice and notify the healthcare provider before providing pain medication. The healthcare provider should be notified after ice is applied to the limb and the limb is placed in a neutral position. Elevating the limb on two
(For the client with dysphagia, swallowing takes concentration; talking increases risk of aspiration. For the client with dysphagia, sitting upright assists with proper bolus movement to the stomach. A towel under the tray stabilizes it for eating or feeding. The use of a straw increases the risk of aspiration because the client with dysphagia has less control over the amount of fluid intake.) CH. 10 The nurse provides 240 mL of feeding through a client's gastrostomy tube. Which action should the nurse take to ensure that the tube remains patent? - Follow the last amount of feeding with 30 mL of water (After the feeding, the tube should be flushed with water to maintain patency. Clamping the feeding tube will not ensure that it remains patent. Sterile normal saline is not used to flush a gastrostomy tube. Maintaining an upright position for 30 minutes after the feeding prevents aspiration; it does not guarantee patency.) CH. 10 The nurse aspirates 200 mL of formula through the nasogastric tube of an older client receiving a continuous feeding. Which health problem should the nurse consider might be affecting the absorption of this client's feeding? - Diabetes mellitus (Diabetes mellitus, as well as physiological changes associated with aging, may result in increased amount of time to empty the stomach. Heart failure is not identified as a health problem that adversely affects absorption of enteral feedings. Diverticulitis is not identified as a health problem that adversely affects absorption of enteral feedings. Parkinson disease is not identified as a health problem that adversely affects absorption of enteral feedings.) Ch. 10 After inserting a nasogastric tube, the client is not coughing despite the nurse not being able to auscultate sounds over the epigastric area. Which action should the nurse take? - Advance the tube another 5 cm (2 in.). (If the signs do not indicate placement in the lungs or the stomach, advance the tube 5 cm (2 in.) and repeat the test. The client would be gagging and coughing if the tube is coiled in the throat. Placing the end of the tube in a container of water is not an appropriate method to assess for placement. There is no reason to remove the tube. It might not be advanced enough to reach the stomach.) Ch. 10 While removing a nasogastric tube, the client begins to cough. Which nursing action could have prevented the client's response? - Having the client take a deep breath and hold it
(Having the client take a deep breath and hold it closes the glottis and prevents accidental aspiration of gastric contents. Instilling air into the tube clears the tube of contents and prevents dragging drainage through the esophagus and nasopharynx. It does not prevent coughing. Flushing the tube will not prevent the client from coughing. The side-lying position is not recommended when removing a nasogastric tube. This position may encourage aspiration of tube contents.) Ch. 10 An adult client is prescribed 500 mL of intralipids to be infused at 1 mL/min for 15 min and then 2 mL/min for the remainder of the infusion. If the infusion is started at 1000 hours, at which time should the nurse expect to discontinue the infusion? - 1400 hours (For 500 mL, first subtract 15 mL for the first 15 min of the infusion. Then divide the remaining amount of 485 mL by 2 because the rate will increase to 2 mL/min. Take this value of 242.5 and divide it by 60 minutes (60 minutes = 1 hour). It will take approximately 4 hours for the intralipids to infuse. If the infusion started at 1000 hours, it should conclude at 1400 hours. Two hours is not enough time to infuse the intralipids properly. Six hours is too much time to infuse the intralipids properly. Eight hours is too much time to infuse the intralipids properly.) Ch. 10 The nurse notices that a client's infusion of total parenteral nutrition (TPN) has less than 100 mL remaining even though the pump was programmed to infuse at a much slower rate. Which action should the nurse take? - Measure capillary blood glucose (Capillary blood glucose should be measured to determine if the excess infusion has had an adverse effect on the client's metabolism of glucose. Never interrupt or discontinue a TPN infusion abruptly because the client could develop rebound hypoglycemia. A change in weight would reflect fluid volume; however, weighing the client is not the first action that the nurse should take. If the prescribed TPN solution is temporarily unavailable, a solution containing at least 5-10% dextrose would be infused. An infusion of normal saline could cause rebound hypoglycemia.) Ch. 11 While taking oral medications, the client begins to cough. Which action should the nurse take? - Wait to determine if the client is able to clear the airway (Coughing could indicate that the airway is partially occluded. The nurse should wait and permit the client to cough to see if the airway can be cleared. Water is not provided until the client clears the airway. There is no reason to call for help yet. Rescue breathing would not be required while the client is coughing.) Ch. 11 The nurse observes a client use an incentive spirometer. Which action indicates that the client would benefit from additional instruction about the use of the device? - Takes a brisk low-volume breath
(When removing the endotracheal tube, have the client take a deep breath to dilate the vocal cords and make removal easier and less traumatic. Then apply suction while removing catheter and airway at the same time. The client does not need to take a deep breath before deflating the cuff. A deep breath is not required before preparing the suction catheter. A deep breath is not required before untying the endotracheal tube ties.) Ch. 11 After connecting a sterile suction catheter to the suction tubing in preparation for performing nasopharyngeal suctioning, the sterile catheter tip accidentally touches the client's chin. Which action should the nurse take? - Obtain another sterile catheter (The tip of the catheter became contaminated when it touched the client's chin. The catheter is contaminated and cannot be used. The nurse needs to obtain another sterile catheter. Placing a contaminated tip into sterile lubricant will contaminate the lubricant. Hyperoxygenating the client is not part of the procedure when suctioning a client's nasopharyngeal airway. Placing a contaminated tip in sterile water will contaminate the sterile water.) Ch. 11 While the nurse is suctioning an endotracheal tube, the client begins to cough. Which action should the nurse take? - Stop suctioning until the client stops coughing (The nurse should withdraw the catheter and permit the client to cough. After coughing has stopped, the nurse can resume suctioning to remove the secretions loosened by coughing. Hyperoxygenation should occur before suctioning and between each pass of the catheter to suction. Nothing should be instilled into the tube to loosen secretions. Continuing to suction could dramatically reduce the client's oxygen level.) Ch. 11 The nurse observes the spouse of a client with a 2-month-old permanent tracheostomy performing care of the site at home. Which observation indicates that additional teaching is required? - Used full-strength hydrogen peroxide to cleanse around the stoma (Half-strength, not full-strength, hydrogen peroxide may be used to remove crusty secretions around the tracheostomy site. Hydrogen peroxide can be irritating to the skin and may inhibit healing if not thoroughly removed. The client should flex the neck before tying the ties to ensure that the ties are not too tight. Tap water may be used for rinsing the inner cannula. The hands should be washed before applying gloves and after removing gloves.) Ch. 11 After turning and repositioning a client with a chest tube, the nurse notes that the fluid in the container is not fluctuating. Which action should the nurse take? - Check the tube for kinks
Ch. 11 The nurse reports a moderate amount of cloudy drainage in a client's chest tube collection container. Which treatment should the nurse expect to be prescribed for this client? - Culture the drainage (Cloudy chest tube drainage is associated with infection or inflammation. A culture would be needed before starting antibiotics. Anticoagulants would be held if the drainage were blood-tinged. Airborne precautions would be appropriate if it is suspected that the client has tuberculosis. Nothing by mouth status would be appropriate if food particles were present in the drainage.) Ch. 11 The nurse auscultates diminished breath sounds in a client who had a chest tube removed 30 minutes ago. Which intervention should the nurse expect to be prescribed for this client? - Chest x- ray (Because the client is demonstrating signs of poor lung inflation after the removal of the chest tube, a chest x-ray is needed to determine the best course of action. Incentive spirometry might be prescribed; however, it would occur after confirmation with a chest x-ray. A chest x-ray is needed before determining if the chest tube needs to be reinserted. Deep breathing and coughing would most likely be prescribed, but only after a chest x-ray is done to determine the best course of action for the client.) Ch. 12 A client receiving a unit of packed red blood cells begins to vomit 15 minutes into the transfusion. Which action should the nurse take first? - Stop the transfusion. (Vomiting is an indication of a transfusion reaction. The first thing to do is to stop the transfusion. After the transfusion is stopped and the intravenous tubing changed to infuse normal saline, the nurse should call for help. Although the client is uncomfortable and vomiting, an emesis basin in not a priority. The transfusion needs to be stopped and the client's hemodynamic status needs to be supported first. The saline infusion should continue, not be increased; however, new tubing is required.) Ch. 12 The nurse assigns the UAP to complete morning care for a client with a sequential compression device. Which information should the nurse instruct the UAP to report to the nurse? - Condition of the skin under the devices (Because the UAP will be removing the devices for bathing, it is appropriate for the UAP to report the condition of the skin under the devices. The UAP is not responsible for assessing pulses in the feet of a client with sequential compression devices. This is the nurse's responsibility to assess. Although the devices should not be off for an extended period of time, it is not essential for the UAP to report the length of time the devices were turned off for bathing. Sensorimotor function
(The client should be informed of electromagnetic interference restrictions, which include not placing a cell phone over the generator. It is wise for the client to wear a medical alert band/bracelet at all times. Many clients use telephone transmission of the generator's pulse rate to determine status of pacemaker function. Special equipment is used to transmit information concerning function of the pacemaker over the telephone to a receiving system in a pacemaker clinic. The client should carry a pacemaker information ID card in the wallet.) CH. 12 A new graduate reports that a client's arterial blood pressure monitor reading is 20 mmHg higher than the measurement from the previous shift. Which factor should the nurse assess first to determine the reason for the change in measurement? - Angle of the head of the bed (When leveling and calibrating the monitoring system, the first action is to adjust the head of the bed to be between flat to up to a 45-degree angle. Then the calibration process is completed. Readings will be inaccurately high or low if the stopcock above the transducer is not level with the client's phlebostatic axis, which is done when calibrating the monitor. However, calibration is done after the head of the bed is adjusted. The pressure bag setting has no impact on the monitor reading. The arterial site dressing has no impact on the monitor reading.) The nurse schedules preoperative teaching sessions for an older client having bowel surgery. Which information should the nurse reinforce during every teaching session with this client? - Use of a splint for breathing exercises The nurse performs surgical hand scrub antisepsis prior to entering the operating room. Which action should the nurse take next after cleaning the broad surfaces of the hands, wrists, and forearms with circular movements? - Interlace the fingers and thumbs and move the hands back and forth The nurses prepares the site for a client's surgery. Which action should the nurse take first after removing the hair from the surgical area? - Apply antiseptic solution in circular strokes The charge nurse observes a new graduate opening a sterile package for a procedure to be conducted at a client's bedside. For which action should the charge nurse intervene? - Opens the closest flap first While preparing a sterile field on a client's over-the-bed table, a small amount of sterile water splashes on the sterile field. Which action should the nurse take? - Consider the field contaminated and start over
During a bedside surgical procedure, the tip of a sterile catheter brushes the cuff of the nurse's sterile gown. Which action should the nurse take? - Ask someone to bring another sterile catheter to the bedside A surgical time out occurs for a client having lumbar spinal fusion surgery. Which aspect of the verification is waived for this client? - Surgical site and side A client scheduled for surgery refuses to remove the wedding band on the left ring finger. Which action should the nurse take? - Apply a piece of tape the covers the entire ring on the finger The nurse determines that a client is at a high risk for falling. Which information in the health history did the nurse use to make this clinical determination? - Walks with a cane A new graduate nurse prepares the room for a client with a known seizure disorder. Which item should the nurse discuss with the graduate before the client arrives from the emergency department? - Padded tongue blade The nurse arrives to visit the home of a client recovering from knee replacement surgery. Which environmental issue should the nurse address to reduce the client's risk of injury in the home? - Throw rug on the floor next to the bed The nurse manager examines client rooms in anticipation of a regulatory body visit over the next few days. Which stimulation should the manager address to reduce the risk of a fire? - Suction machine plugged into an extension cord A client with confusion has a safety monitoring device with a leg band. Which action should the nurse take after receiving a report on the status of this client? - Test the battery and alarm system A client demonstrating aggressive behavior is prescribed wrist restraints. Which action should the nurse take to ensure this client's safety? - Perform range of motion to each wrist every 2 hr A client with severe confusion is prescribed a vest restraint. Which area should the nurse affix the ties of the restraint when the client is in bed? - The bed frame The nurse notes that the hand of a client in wrist restraints is edematous. Which action should the nurse take first? - Remove the restraint
