Nursing Chapter 31 Rationale Urinary Retention Would Cause The Urine

Question 17

Type: MCSA

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a client’s

room. What action should the nurse take first for this puncture wound?

1. Complete an injury report.

2. Encourage bleeding.

3. Initiate first aid.

4. Wash the area with soap and water.

Question 18

Type: MCSA

The nurse is preparing to leave a client’s isolation room. Which action should the nurse take first when removing

a grossly soiled gown?

1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand.

2. Release the neck ties of the gown and allow the gown to fall forward.

3. Untie the strings at the neck first.

4. Untie the strings at the waist first.

Question 19

Type: MCSA

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the

presentation?

1. Cut the needle off a syringe after using it to give a client an injection.

2. Dispose of blood-contaminated materials in a biohazard container.

3. Gloves should not be worn for client care unless body fluids are seen.

4. Wear a mask when in direct contact with all clients.

Question 20

Type: MCSA

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the

transmission of the disease?

1. Have the client wear a mask when coming from admission.

2. Stock the supply cart at the beginning of each shift.

3. Wash the hands only after leaving the room.

4. Wear a mask when exiting the room.

Question 21

Type: MCMA

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this

clinical decision?

Standard Text: Select all that apply.

1. Client is receiving intravenous fluids.

2. Client has an indwelling urinary catheter.

3. Client is recovering from surgery.

4. Client is receiving pain medication.

5. Client is ambulating twice a day with assistance.

Question 22

Type: MCMA

A client diagnosed with an infectious disease asks the nurse how the infection “got inside” her body. Which

responses would be appropriate for the nurse to make?

Standard Text: Select all that apply.

1. “It depends on the number of organisms present to cause a disease.”

2. “It depends on how aggressive the organisms are to cause a disease.”

3. “It depends upon how the organisms get inside the body to cause a disease.”

4. “It depends upon where the person is at the time the disease is present.”

5. “It depends upon where the person works.”

Question 23

Type: MCMA

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What

did the nurse assess in this client?

Standard Text: Select all that apply.

1. Intact and dry skin

2. Intact oral mucous membranes

3. Bowel sounds present in all four quadrants

4. Nasal congestion

5. Urinary retention

Question 24

Type: MCSA

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify

which diagnosis as a priority for this client?

1. Social Isolation

2. Anxiety

3. Acute Pain

4. Imbalanced Nutrition: Less Than Body Requirements

Question 25

Type: MCSA

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and

causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client?

1. Anxiety

2. Acute Pain

3. Social Isolation

4. Low Self-Esteem

Question 26

Type: MCMA

A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the

risk of infection?

Standard Text: Select all that apply.

1. Hand-washing technique

2. The importance of adequate nutrition

3. Covering the mouth and nose when coughing or sneezing

4. Increasing contact with others

5. Restricting rest period

Question 27

Type: MCSA

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed

assistive personnel do?

1. Assist the client with hand washing.

2. Assist the client back to bed.

3. Change the client’s bed.

4. Leave the client’s room.

Question 28

Type: MCSA

While irrigating a client’s abdominal wound, the irrigate splashes into the nurse’s nose and eyes. What should the

nurse do?

1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.

2. Begin HIV high-risk exposure prophylaxis within 24 hours.

3. Wash the areas with soap and water.

4. Have blood drawn for hepatitis B antibodies.

Question 29

Type: MCMA

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should

the nurse consider using?

Standard Text: Select all that apply.

1. Triclosan

2. Chlorine (bleach)

3. Isopropyl alcohol

4. Hydrogen peroxide

5. Chlorhexidine gluconate

Question 30

Type: SEQ

The nurse needs to apply personal protective equipment before entering a client’s room. In which order should the

nurse perform the following actions?