Deck 29: Basic Procedures

Question 1

When a nurse will be in direct contact with a client's body fluids,which of these statements about use of protective equipment is TRUE?

A)Gloves are optional,but a gown is required.
B)Hands should be cleansed before and after gloves are applied.
C)Gown,mask,and goggles are required.
D)Sterile gloves are required for any client contact.

Answer 1

Hands should be cleansed before and after gloves are applied.

Question 2

A nurse maintains constant release of pressure in the blood pressure cuff to identify the five phases of the Korotkoff sounds.At which of these points is the systolic reading obtained?

A)when a faint,clear tapping sound that increases in intensity is heard
B)when a swishing sound is heard
C)when an intense sound is heard
D)when an abrupt,distinct muffled sound is heard

Answer 2

when a faint,clear tapping sound that increases in intensity is heard

Question 3

According to Centers for Disease Control and Prevention (CDC)protocol,which statement about hand hygiene is TRUE?

A)When hands are visibly dirty,wash them with water and antimicrobial soap only.
B)An antiseptic hand rub with antimicrobial soap destroys any resident hand flora.
C)If hands are visibly soiled,an alcohol-based hand rub may be used.
D)Use of plain soap is preferred for all types of hand hygiene.

Answer 3

When hands are visibly dirty,wash them with water and antimicrobial soap only.

Question 4

The nurse is taking a client's tympanic temperature.Which of the following is the MOST appropriate position for the client to be placed?

A)Sims'
B)high Fowler's
C)Trendelenburg
D)orthopneic

Question 5

For hand hygiene to remove transient flora from the hands,the nurse is aware that hand hygiene must be performed for at least:

A)10 to 15 seconds
B)20 to 30 seconds
C)60 seconds
D)90 seconds

Question 6

While the preferred site for obtaining a client's blood pressure measurement is over the brachial artery,what artery is the next measurement site of choice?

A)dorsalis pedis
B)posterior tibial
C)popliteal
D)radial

Question 7

Which of the essential elements of hand hygiene is MOST important?

A)soap
B)chemical substance
C)water
D)friction

Question 8

When a nurse is working in an area of the hospital where the hair must be covered,such as the operating room,which item of protective equipment is donned first?

A)gloves
B)gown
C)cap
D)mask

Question 9

A client is to be weighed on a sling scale.When should the scale be calibrated to zero?

A)before the sling is applied
B)when the legs of the scale are underneath the bed
C)after the sling is hooked onto the scale
D)when the sling is off the bed

Question 10

What does assessment of a client's pulse measure?

A)quality of cardiac function
B)pressure impulse created with cardiac contraction and ejection of blood into the aorta
C)peripheral resistance of vascular system
D)length and caliber of cardiac cycle

Question 11

A nurse checks the radial pulse of a client and notes an irregular rhythm.The MOST appropriate action would be to:

A)count pulse rate for 15 seconds,then multiply by 4
B)count pulse rate for 30 seconds,then multiply by 2
C)count pulse rate for 60 seconds
D)count pulse rate for 90 seconds

Question 12

In selecting a blood pressure cuff of appropriate size for a client,the nurse should remember that the bladder inside the cuff should encircle what percentage of the adult client's arm for accurate measurement?

A)50
B)60
C)70
D)80

Question 13

When taking a client's oral temperature,which of these facts contribute to the accuracy of the results?

A)The client is sitting in an upright position.
B)The client has no allergies to the protective sheath material.
C)The client has not consumed any hot or cold food or beverages for the previous 15 minutes.
D)The client has no company at the bedside.

Question 14

When a nurse is engaged in hand hygiene,in which of these positions should the hands be placed?

A)hands and forearms kept down with elbows straight
B)hands kept at waist level with elbows at 45-degree angle
C)hands held at chest level with elbows bent
D)no preferred position as long as the hands are cleansed thoroughly

Question 15

Before actually counting a client's respirations,the nurse should FIRST determine which of the following?

A)The client is fully aware that the respiratory rate is being measured.
B)There is bilateral movement of the client's chest wall or any irregularity in movement.
C)The client is lying on either side.
D)There is evidence of cyanosis.

Question 16

For nurses caring for clients in high-risk areas such as newborn nurseries,visitor teaching should include a minimum time required for hand hygiene of:

A)30 seconds
B)60 seconds
C)90 seconds
D)2 minutes

Question 17

Which of the following interventions provide the MOST important technique for infection control?

A)hand hygiene
B)Standard Precautions
C)universal precautions
D)surgical asepsis

Question 18

A nurse is preparing to take a client's apical pulse.The nurse places the stethoscope at the point of maximal impulse (PMI)at the:

A)sternum
B)suprasternal notch
C)right of the midclavicular line
D)fifth intercostal space

Question 19

A nurse is preparing to perform a urinary catheterization and would use the MOST appropriate method for gloves and glove technique of:

A)sterile gloves,closed technique
B)sterile gloves,open technique
C)clean gloves,closed technique
D)clean gloves,open technique

Question 20

To assess circulation in a client's legs,the nurse would take pulses at which of these locations?

A)temporal
B)apical
C)radial
D)popliteal

Question 21

A nurse is repositioning a client who cannot do this without assistance and observes an area of redness on the right hip.The redness is not resolved within 30 minutes of the position change.Which of these actions should the nurse take next?

A)Document the reddened area in the client's chart.
B)Call the supervisor.
C)Call the health care provider.
D)Plan to reposition the client more frequently.

Question 22

When a nurse is teaching assistive personnel to perform routine catheter care,they should be instructed to do which of the following?

A)Wear sterile gloves for the procedure.
B)Cleanse the catheter from the end toward the meatus.
C)Repeat catheter care at least three times per shift.
D)Perform perineal care before cleansing the meatus.

Question 23

A client is to be transferred from bed to stretcher,and maximum assistance is required.Which of these steps is essential when two nurses are performing this transfer?

A)Place a lift sheet under the client's back,trunk,and upper legs after logrolling the client to one side.
B)Have both nurses on the same side of the bed at all times.
C)Place pillows on the stretcher before the client is transferred.
D)Clamp any drainage tubes to prevent spills.

Question 24

When assisting a client who is at risk for bleeding from the gums to perform oral care,the nurse should take which of these actions?

A)Inspect the oral cavity for signs of bleeding before beginning the procedure.
B)Cleanse the mouth with gauze sponges soaked in hydrogen peroxide.
C)Floss the teeth carefully.
D)Use a medicated mouthwash to cleanse the mouth before and after the procedure.

Question 25

A nurse is ambulating a client who suddenly feels faint and starts to fall.Which of these actions should the nurse take FIRST?

A)Check the client's blood pressure.
B)Call for help.
C)Ease the client to the floor.
D)Hold the client upright until a chair is available.

Question 26

A client in semi-Fowler's position has slipped down in bed and needs to be moved up.Which of these actions should the nurse take FIRST?

A)Ensure the bed is below waist level,and lower the head of the bed.
B)Lower the side rails on the side where the nurse is standing.
C)Ask the client to bend the knees,and place the feet flat on the bed.
D)Change the bed linens.

Question 27

To move a client from a supine to a side-lying position,which of these actions should the nurse take first?

A)Lift the client's body.
B)Place the client's inside arm next to the body with the palm of the hand against the hip.
C)Slide hands under the client's body in a secure manner.
D)Place pillows at the client's back to stabilize the new position.

Question 28

When a nurse is teaching assistive personnel how to make an unoccupied bed,they should be instructed to place which item on the top when fresh linen is gathered?

A)bottom sheet
B)top sheet
C)draw sheet
D)pillowcase

Question 29

When giving a client a back rub,the nurse should apply firm,continuous pressure beginning at which point?

A)the upper back
B)the sacral area
C)the lower buttocks
D)wherever the client prefers

Question 30

When a nurse is making an occupied bed,the client should be placed in which position as the nurse begins the procedure?

A)on the side facing the nurse
B)on the side facing away from the nurse
C)on the back
D)at the top of the bed

Question 31

Which of these statements is TRUE about the care of a client who has an ocular prosthesis?

A)The eye socket should be cleansed before and after removal of the artificial eye.
B)The artificial eye is washed with soap and water,and then dried before reinsertion.
C)Removal of an artificial eye for daily cleansing is not always necessary.
D)Cover the eye socket with an eye pad while the artificial eye is being cleansed.

Question 32

As a nurse is performing passive range of motion (PROM)exercises with a client,it is important for the nurse to do which of the following?

A)Keep the bed rails up at all times.
B)Describe the PROM to be performed for each joint.
C)Start at the client's feet and legs,and work upward.
D)Repeat each PROM exercise at least 10 times.

Question 33

A nurse is teaching assistive personnel how to bathe a client in bed.Effective teaching would include instructions to begin the bath at the:

A)feet
B)arms
C)legs
D)face

Question 34

Which of these statements about logrolling a client is TRUE?

A)It is a less painful way for a client to be moved.
B)The client is able to assist the nurse in the move.
C)It requires the assistance of three nurses.
D)It reduces pressure ulcer development.

Question 35

When a nurse is transferring a client with left-sided weakness from the bed to a wheelchair,the client should be transferred in which direction?

A)from left to right
B)the direction of convenience for the nurse
C)from right to left
D)no preferred direction

Question 36

When a nurse is providing perineal care to a client,regardless of gender,it is essential that the nurse do which of the following?

A)Use plenty of soap and water to cleanse the area.
B)Apply a barrier ointment to the area.
C)Place the client at ease with a professional approach.
D)Wear two pairs of gloves during the procedure.

Question 37

When a nurse is assisting a client who has a urinary catheter in place to ambulate,the drainage bag should be:

A)disconnected temporarily for the period of ambulation
B)carried by the client
C)carried by the nurse
D)kept below the level of the bladder

Question 38

Which of the following is one of the MOST important rules of body mechanics for lifting?

A)Relax the abdominal muscles.
B)Twist the body to better secure the load.
C)Ask for help.
D)Keep the legs straight.

Question 39

When a nurse is pushing or pulling a client,which of these positions should the nurse assume?

A)Stand near the client with both feet firmly planted.
B)Stand near the client,and place one foot partially ahead of the other.
C)Lean into the client,and move the client with a swift motion.
D)Lean away from the client,and apply maximum pressure.

Question 40

When assisting a self-care client with denture care,which of these actions is MOST important for the nurse to take?

A)Help the client choose a toothpaste containing fluoride.
B)Pad the sink with a towel.
C)Encourage the client to brush the dentures from top to bottom.
D)Remove the top denture before the bottom denture.

Question 41

The nurse is completing the client's intake and output record.Which of the following foods would NOT be included in the calculation of a client's fluid intake?

A)ice cream
B)pudding
C)mashed potatoes
D)gelatin

Question 42

Which of these statements about obtaining a stool specimen for occult blood is TRUE?

A)The client must use a bedpan for specimen collection.
B)If possible,the client should void before and after specimen collection.
C)Only a representative sample of stool is required.
D)The entire stool is placed in the appropriate collection cup.

Question 43

A nurse is to obtain a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter connected to a closed drainage system.The specimen should be collected from:

A)the collection bag
B)the catheter
C)the collecting tubing
D)the tubing and the collection bag

Question 44

When placing a client on a bedpan,the nurse should instruct the client to move to a side-lying position and:

A)take several deep breaths before sitting on the bedpan
B)raise the hips as far as possible
C)pin the call light cord on the gown
D)roll onto the back while the bedpan is held

Question 45

Which of these statements about obtaining a clean-catch urine specimen is TRUE?

A)It is a sterile procedure.
B)Only the first portion of the voiding stream is saved.
C)The client cleanses him- or herself first and places a sterile collection cup after voiding is initiated.
D)Only the end portion of the voiding stream is saved.

Question 46

If an infant's airway becomes obstructed with a foreign body,the rescuer should place the infant with the head lower than the trunk.Which of the following actions should be taken NEXT?

A)Deliver five back blows between the shoulder blades.
B)Give the infant five cardiac blows.
C)Do a finger sweep of the mouth.
D)Initiate oxygen therapy.

Question 47

A nurse is applying a condom catheter to a client who is incontinent,when the client has an erection.Which of these actions should the nurse take?

A)Discontinue the procedure.
B)Discuss the situation with a colleague.
C)Continue with the catheter application.
D)Wait until the erection ends before applying the catheter.

Question 48

When performing cardiopulmonary resuscitation on an adult client,what compression-to-ventilation rate should be maintained?

A)1 compression and 1 ventilation
B)5 compressions and 1 ventilation
C)10 compressions and 2 ventilations
D)15 compressions and 2 ventilations

Question 49

A nurse is to obtain a throat culture from a client.Which of these sequences should the nurse follow before placing the swab in the culture tube?

A)Swab the cheeks and throat completely,and withdraw.
B)Swab the tonsillar area from side to side,and withdraw without touching adjacent structures.
C)Swab the anterior portion of the tongue only.
D)Ask the client to cough;then swab the mouth and throat.

Question 50

When performing the Heimlich maneuver on an adult client who is choking,the rescuer should stand behind the client,wrap the arms around the client's waist,and then:

A)make a fist and gently punch the abdomen
B)give the client a firm hug
C)call for help before initiating the process
D)place fists below the xiphoid process and give a quick upward thrust

Question 51

When completing the client's intake and output record,which of the following is the largest component of clients' fluid volume output?

A)gastric secretions
B)diaphoresis
C)wound drainage
D)urine

Question 52

A client is becoming increasingly restless,and the nurse is concerned that the client may fall out of bed.After obtaining a health care provider's order for a chest restraint,the nurse applies the restraint to the client.What MUST the nurse document concerning this situation?

A)client age,diagnosis,and time restraint is applied
B)generic name of restraint,where applied,and estimated time it will remain in place
C)reason for restraint,type of restraint used,time of placement,and condition of skin
D)name of prescribing health care provider,type of restraint,and time applied

Question 53

What is the first step in performing cardiopulmonary resuscitation (CPR)on an adult?

A)Place the client on a firm surface.
B)Open the airway.
C)Assess for responsiveness.
D)Activate the local emergency response system.

Question 54

After giving two breaths to an adult client who is not breathing,the rescuer should assess the client for:

A)return of consciousness
B)rise and fall of the chest
C)strength of carotid pulse
D)tolerance of rescue breathing

Question 55

Regardless of the type of facility involved,it is MOST important for an admitting nurse to introduce him- or herself to the client and family and determine the client's:

A)immediate reaction to the assigned room
B)understanding of why admission is necessary
C)willingness to follow agency policies
D)readiness to wear designated hospital gown

Question 56

When a male client is unable to shave himself,the nurse should prepare to shave the client by first:

A)applying shaving cream
B)placing a warm,wet washcloth over the face
C)using short,firm strokes to begin
D)pulling the skin taut

Question 57

To determine the correct size of below-the-knee antiembolic stockings for a client,the nurse should measure the distance from the:

A)Achilles tendon to the gluteal fold and midthigh circumference
B)knee to the ankle
C)Achilles tendon to the popliteal fold and the midcalf circumference
D)knee to the toes

Question 58

A client has a large abdominal dressing following abdominal surgery.Which of the following binders would be MOST appropriate for the nurse to apply?

A)Velcro
B)single T
C)double T
D)stretch net

Question 59

To administer a large-volume enema to a client,the nurse should place the client in which of these positions?

A)position of comfort for the client
B)prone,with legs extended
C)left lateral with right leg sharply flexed
D)right lateral with left leg sharply flexed

Question 60

An adult client is to have a large-volume cleansing enema.The nurse is aware that the MOST appropriate temperature of the solution to be administered should be:

A)100 degrees Fahrenheit
B)105 to 110 degrees Fahrenheit
C)115 to 120 degrees Fahrenheit
D)125 degrees Fahrenheit

Question 61

When a client's condition warrants transfer to another unit,which of these actions by the nurse will facilitate continuity of care?

A)introducing the client and family to personnel on the new unit
B)giving the client's personal effects to the family for safekeeping
C)allowing the client and family to say good-bye to personnel on the unit being left
D)promising that the nurse will visit the client frequently on the new unit

Question 62

A client is to be discharged home.Which of these aspects is MOST important for the nurse to review with the client before discharge?

A)reason for discharge
B)understanding of self-care required,including medications
C)satisfaction with care received
D)date of next physical exam

Question 63

A nurse has completed morning care for a client in strict isolation,including taking the client's vital signs.Which of these approaches should the nurse use in recording vital signs and other assessment data?

A)Repeat data to oneself and record them on the client's chart after leaving the room.
B)Open the door and request that another nurse write down the data.
C)Record data on a piece of paper without making contact with articles in the client's room.
D)Keep a running record of data on a tablet in the client's room.

Question 64

Before leaving the room of a client in strict isolation,it is MOST important for the nurse to:

A)remove protective barrier items and place them in an impermeable bag
B)ensure that the client's television set is working properly
C)place the call light so that it is easily accessible for the client
D)replenish supplies by having a staff member bring clean items and transfer items at the door

Question 65

When a client is placed in strict isolation,barrier protective equipment must be applied before any client care is provided.Additionally,which of these actions is part of this procedure?

A)All linens and trash are double-bagged prior to removal from the client's room.
B)Plates and utensils used for food service are washed in the client's room for reuse.
C)Any item,such as books and newspapers,must remain in the client's room.
D)Visitors are prohibited from seeing the client.