Fundamentals of Nursing Practice Quiz 11

Answer: B – Demonstrate equipment before using it.

Explanation: The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. The nurse should allow a preschooler to help with the examination when possible, but not usually a school-age child. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group.

Answer: B – Semi-Fowler’s

Explanation: If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient’s legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. The patient in S

Answer: C – Bowel sounds

Explanation: The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen.

Answer: D – Underweight

Explanation: For adults, BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered obese.

Answer: A – Bathe the patient’s entire body using 8 to 10 washcloths.

Explanation: A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub.

Answer: B – Keep the linens wrinkle free.

Explanation: Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence.

Answer: B – Intact skin

Explanation: Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.

Answer: A – A clean gown and gloves must be worn when in contact with the client.

Explanation: A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections.

Answer: A – admitted with unstable diabetes mellitus.

Explanation: The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer, or with a client who has a urinary tract infection.

Answer: D – Reaching 1 foot over the sterile field

Explanation: Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape.