Mr. C. has just been admitted for acute asthma exacerbation and placed in a high Fowler's position. The nurse knows this position is best because it

1. is required for the aerosol treatments to work.

2. is the position for the chest X-ray.

3. facilitates maximal ventilation.

4. allows for chest physiotherapy.

Ms. L. is to go home with her family. The nurse is evaluating that the family members can correctly move Ms. L. from the bed to a chair. Which of the following should be seen?

1. The transfer belt is placed loosely around the waist.

2. The family member leans forward from the waist.

3. The client has one foot slightly in front of the other.

4. There is no pause while the client is standing.

Ms. F. suffered a stroke and has right-sided hemiparesis. The nurse is going to transfer her from bed to wheelchair. Which of the following is the best method?

1. Have the client put her arms around the nurse's neck.

2. Place the wheelchair about a foot away from the bed.

3. Put the wheelchair at a 45° angle to the bed.

4. Position the wheelchair closer to the weaker foot.

The nurse knows which of the following is the proper technique for medical asepsis?

1. Gloving for all client contact.

2. Using your hands to turn off the faucet after handwashing.

3. Gowning to care for a one-year-old child with infectious diarrhea.

4. Changing hospital linen weekly.

The nurse is conducting a class on aseptic technique and universal precautions. Which of the following statements is correct and should be included in the discussion?

1. Medical asepsis is designed to confine microorganisms to a specific area, limiting the number, growth, and transmission of microorganisms.

2. Medical asepsis is designed to decrease exposure to bloodborne pathogens.

3. Universal precautions are designed to reduce the number of potentially infectious agents.

4. The term universal precautions is synonymous with disease or category-specific isolation precautions.

The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap?

1. Toward the nurse.

2. To the nurse's left or right.

3. It does not matter as long as the nurse only touches the outside edge.

4. Away from the nurse.

For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile technique?

1. Aseptic technique for changing the client's linen and sterile technique for placing a central line.

2. Aseptic technique for urinary catheterization in the hospital and sterile technique for cleaning surgical wounds.

3. Aseptic technique for a spinal tap and sterile technique for surgery.

4. Aseptic technique for food preparation and sterile technique for starting an IV line.

Ms. W. has a draining pressure ulcer on her sacrum and is to be discharged to her daughter's care. The nurse has taught Ms. W.'s daughter to perform dressing changes. Which observation by the nurse indicates the daughter's technique is done correctly? The daughter

1. washes her hands before each gloving and after the procedure is done.

2. uses only sterile gloves to remove the old dressing.

3. irrigates the wound from the bottom up.

4. places the forceps used to remove the old dressing on the sterile field.

Ms. P. is transferred to a skilled nursing facility from the hospital because she is unable to ambulate due to a left femoral fracture. The nurse knows Ms. P.'s greatest risk factor for developing a pressure ulcer is that she

1. has slightly limited mobility and needs assistance to move from bed to chair.

2. is 5 ft 4 in tall, 130 lb, and eats more than half of most meals.

3. is apathetic but oriented to person, place, and time.

4. has good skin turgor, no edema, and her capillary refill is less than three seconds.

An elderly male client is transferred to a skilled nursing facility from the hospital because he is unable to ambulate due to a left femoral fracture. When doing a skin assessment, the nurse notices a 3-cm, round area partial thickness skin loss that looks like a blister on the client's sacrum. The nurse knows this is a

1. stage II pressure ulcer.

2. stage I pressure ulcer.

3. stage III pressure ulcer.

4. stage IV pressure ulcer.

When planning for the care of a client with a pressure ulcer on the sacrum, the nurse would include which of the following?

1. Positioning the client with a donut around the area to relieve pressure on the ulcer.

2. Using a heat lamp twice a day to dry the wound.

3. Having a pressure-relieving device such as an egg crate mattress or gel flotation pad.

4. Massaging the sacrum, concentrating on the bony prominences and reddened areas.

The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressings is best?

1. Moisture-vapor permeable dressing.

2. Wet gauze dressing.

3. Dry gauze dressing.

4. Wet to dry dressing.

When evaluating a client with a pressure ulcer, the nurse understands that the best response to treatment of the sacral pressure ulcer on a client with a hip fracture would be indicated by

1. the client's nutritional status including adequate protein; carbohydrates; fats; vitamins A, B, C, and K; and minerals including copper, iron, and zinc.

2. absence of clinical signs of infection including redness, warmth, swelling, pain, odor, and exudate.

3. the client's skin status including length, width, depth, condition of the wound margins, and stage of the ulcer as well as the integrity of the surrounding skin.

4. increased mobility including the ability to reposition self in bed or wheelchair and walking with assistance.

Mr. D. has a disorder of the hypothalamus and is on a hypothermia blanket. The nurse should make which of the following assessments?

1. Document the client's ability to sweat.

2. Confirm that the client is alert and oriented.

3. Record baseline vital signs, neurologic status, and skin integrity.

4. Ensure the client's skin is warm and dry.

When Mr. C. is placed on a hypothermia blanket, which of the following should be included in the nursing care plan?

1. Taking frequent vital signs, and doing skin assessments.

2. Placing the client directly on the blanket.

3. Ensuring the hypothermia blanket continues to cool until the client's temperature reaches 98.6° F.

4. Monitoring Mr. C.'s temperature through the hypothermia machine's rectal probe.

The physician's orders for Mr. C. include warm compresses to the left leg three times a day for treatment of an open wound. The nurse should

1. use medical aseptic techniques throughout the procedure.

2. remove the compress after about five minutes.

3. place both a dry covering and waterproof material over the compress.

4. wet the compress and apply it directly to the area.

Ms. H. is receiving a hot soak to her right arm. What assessments would the nurse make?

1. The water temperature at the start of the treatment is 120° F (48° C).

2. The client's baseline and after-treatment temperature.

3. Throughout the treatment, the water remains at approximately the same temperature.

4. That the water basin is placed at shoulder height.

Mr. H. has chronic lower back pain and receives hot packs three times a week. The nurse knows the treatment is given for which of the following reasons?

1. To relieve muscle spasm and promote muscle relaxation.

2. To keep the client warm and raise his temperature.

3. To help remove debris from the wound.

4. To improve the client's general circulation.

While giving an adult a tepid sponge bath to reduce his temperature, the nurse notes that the client is shivering. The nurse correctly interprets this to mean that the

1. client has a decreased metabolic demand.

2. temperature of the water is below 90° F (32° C).

3. body is trying to warm itself.

4. sponge bath is being given too slowly.

Ms. B. is giving a tepid sponge bath to her invalid mother who has a fever. When evaluating Ms. B. to ensure the procedure is being given correctly, the nurse would note which of the following? That Ms. B.

1. rubs her mother's skin dry after each area is sponged.

2. sponges one part of the body, and then another.

3. tests the water temperature on the inside of her wrist.

4. rubs each area with the wet sponge.

Mr. S. is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?

1. 90° F (32° C).

2. 65° F (18° C).

3. 110° F (43° C).

4. 105° F (40.5° C).

Mr. A. has sprained his ankle. The physician would order cold applied to the injured area to

1. reduce the body's temperature.

2. increase circulation to the area.

3. aid in reabsorbing the edema.

4. relieve pain and control bleeding.

Mr. A. is going home from the emergency room with directions to apply a cold pack to his ankle sprain. He asks how he will know if the cold pack has worked. The nurse tells him

1. he will notice the red-blue bruises will turn purple.

2. that the skin will be blanched and numb afterward.

3. there should be less pain after applying the cold pack.

4. after the first application, the swelling will be decreased.