NUR 164 EXAM 2 Textbook Questions Latest

NUR 164 EXAM 2 (Textbook Questions) Latest Update - 160 Questions with 100% Verified Correct Answers with Rationale Guaranteed A+ Verified by Professor

A charge nurse working on a medical-surgical unit stops the AP from taking rectal temperatures on patients with which problems? Select all that apply.

• Hypothermia
• Pneumonia
• Bradycardia
• Leukemia
• Thrombocytopenia
• Pancreatitis - CORRECT ANSWER: c, d, e. The rectal site should not be used in

newborns, children with diarrhea, and in patients who have undergone rectal or vaginal surgery. Inserting a rectal thermometer can stimulate the vagus nerve causing or worsening bradycardia; this route may be contraindicated in certain cardiac patients.The rectal route is also contraindicated in patients who have neutropenia (low white blood cell counts, such as in leukemia or those receiving chemotherapy), thrombocytopenia (low platelet counts), and certain neurologic disorders.

A home health nurse teaches a patient to a change the dressing for a chronic venous stasis ulcer using clean technique. Which principle of asepsis will the nurse consider when preparing the teaching plan?

• The nurse chooses clean or sterile technique based on personal preference.
• The use of clean technique is considered safe in the home setting.
• Surgical asepsis is the safest method to use in a home setting.

D.The patient can use clean technique; their partner must wear sterile gloves. - CORRECT ANSWER: b. Medical asepsis, or clean technique, involves procedures and 1 / 3

practices that reduce the number and transfer of pathogens. This is usually recommended in the home setting, where the patient's environment is more controlled.Injections require surgical asepsis. The patient and partner share the same home; medical asepsis is appropriate.

A new graduate nurse tells the preceptor they want to obtain recognition in wound care, a specialty area of nursing. What credential will this nurse need to seek?

• Accreditation
• Licensure
• Certification

D. Board approval - CORRECT ANSWER: C. Certification is the process by which a

person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

A nurse administering an injection to a patient who tested positive for HIV sustains a needlestick. What action should the nurse take first?

• Report the incident to the nurse manager and file an injury report
• Wash the exposed area with warm water and soap
• Consent to postexposure prophylaxis (PEP) at the appropriate time
• Set up counseling sessions regarding safe practice to protect self - CORRECT

ANSWER: b. When a needlestick injury occurs, the nurse should wash the affected

area immediately with warm water and soap, report the incident to the nurse manager or appropriate person and complete an injury report, consent to and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe practice to protect self and others. 2 / 3

A nurse and health care provider are preparing for insertion of a central venous catheter when the patient accidentally touches the sterile field. What action will the nurse take next?

• Ask another nurse to hold the patient's hand and continue setting up the field
• Remove any objects the patient touched and resume setting up the sterile field
• Have someone hold the patient's hand, discard the supplies, and prepare a new

sterile field

• No action since the patient has touched their own sterile field - CORRECT ANSWER:
• If a patient touches a sterile field, the nurse should discard all supplies and prepare a

new sterile field. If the patient is restless or confused, the nurse obtains an assistant to hold the patient's hands and explain what is happening.

A nurse answers a call light and finds the patient on the floor. After the health care provider examines the patient and finds no injury, the nurse returns the patient to bed and fills out an incident report. What statements are true about incident reports? Select all that apply.

• They can be used as disciplinary action against staff members.
• They can be used as a means of identifying risks.
• They can be used for quality control.
• They must be completed by the facility manager.
• They make facts available in litigation cases.

F. They should be documented in the patient record. - CORRECT ANSWER: B, C, E.

Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

• / 3