Western Governors University

NURSING BS C471

Quiz 3

1)To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What does the nurse do next?

1. Clamp another section of the tube to create a fixed sample section for retrieval.
2. Insert a syringe into the injection port and aspirate the quantity of urine required.
3. Clean the injection port cap of the drainage tubing with povidone-iodine solution.
4. Withdraw 10 mL of urine and discard it; then withdraw 10 mL more for the sample.

2. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

1. Asks the client to both say and spell his or her full name before starting the blood transfusion
2. Ensures that another qualified health care professional checks the unit before administering
3. Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed
4. Makes certain that an IV solution of 0.9% normal saline is infusing into the client before starting the unit

3. After an infection control in-service, which statement by the nurse demonstrates an accurate understanding of the mode of transmission of influenza?

1. “I will not develop the infection unless I have physical contact with the client.”
2. “I should wear an N95 respirator to provide care for the client with influenza.”
3. “I should try to stay at least 3 feet away from the client, if at all possible.”
4. “The infection is spread through droplets suspended in the air and inhaled.”

4. The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client? (Select all that apply.)

1. Use sterile gloves and gowns whenever the nursing staff is in contact with the client.
2. Provide an incentive spirometer to encourage coughing and deep breathing by the client.
3. Keep a blood pressure cuff, thermometer, and stethoscope in the client’s room for his or her use only.
4. Use N95 respirators (all nursing staff) when in the client’s room.
5. Request that the family take home the fresh flowers that are at the client’s bedside.
6. Assist the client with meticulous oral care after meals and at bedtime.

5. A female client with deteriorating neurologic function states, “I am worried I will not be able to care for my young children.” How does the nurse respond?

1. “Caring for your children is a priority. You may not want to ask for help, but you have to.”

2. “Our community has resources that may help you with some household tasks so you have energy to care for your children.”
3. “You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?”
4. “Give me more information about what worries you, so we can see if we can do something to make adjustments.”

6. A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer?                       mL

6. A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?

1. Tenting of skin on the back of the hand
2. Increased urine osmolarity
3. Weight loss of 10 pounds
4. Pulse rate of 115 beats/min

7. Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

1. “I am often cold and need to wear a sweater.”
2. “I seem to urinate more when I drink coffee.”
3. “In the summer, I feel thirsty more often.”
4. “My rings seem to be tighter this week.”

8. A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective?

1. Chinese take-out, including steamed rice
2. A grilled cheese sandwich with tomato soup
3. Slices of ham and cheese on whole grain crackers
4. A chicken leg, one slice of bread with butter, and steamed carrots

9. The nurse is planning care for a client who has a spinal cord injury. Which interdisciplinary team member does the nurse consult with to assist the client with activities of daily living?

1. Social worker
2. Physical therapist