Download NRSG 327 Exam Questions: Infection Control and Pain Management and more Exams Nursing in PDF only on Docsity!
NRSG 327 EXAM QUESTIONS WITH ACCURATE ANSWERS.
Which precaution should the nurse use when setting up a client's food tray? Transmission Based (Tier 2) Handwashing only Standard (Tier 1) -- Correct Answer ✔✔ Handwashing only Setting up a client's food tray is not an infection control concern if the client does not have symptoms of an infection. Gloves may be used when clearing a food tray, which is a greater health concern. Which precautions should the nurse take when giving a shot? Transmission Based (Tier 2) Handwashing only Standard (Tier 1) -- Correct Answer ✔✔ Standard (Tier 1) The primary concern when giving a shot, starting an IV, or performing any other procedure using sharp objects is the prevention of blood transmission to the nurse. Standard precautions are used to minimize an incident. Which precaution should the nurse use when starting an IV for a client with a high fever and productive cough of unknown origin?
Transmission Based (Tier 2) Handwashing only Standard (Tier 1) -- Correct Answer ✔✔ Transmission based (Tier 2) When a client has signs of an unknown infection, it is safest for the nurse to implement transmission-based precautions. When the infection is localized to a wound or urine, contact precautions are sufficient. If the client is coughing, sneezing, or expectorating, the infection can be found on the droplets distributed throughout the room. In this case, droplet precautions are needed. Airborne precautions are utilized when the organism is small and known to exist in the air rather than on surfaces. Examples include tuberculosis, chickenpox, severe acute respiratory syndrome (SARS), and measles. The client has a reddened area around their IV site. It is tender to touch. Which type of infection is this? Localized Systemic Endogenous Healthcare-Related Infection -- Correct Answer ✔✔ Localized A localized infection occurs and stays in a specific part of the body. If an infection becomes systemic, the pathogen will invade the blood or lymph and spread throughout the body, perhaps causing septicemia. When an infected IV site is not treated promptly, a systemic infection is probable. An endogenous healthcare-related infection is a secondary infection that results from treatments that lower the body's normal immune responses.
pathogens are eliminated, but it significantly prevents transmission. A nurse using a cleaning solution to wipe down an IV pole before moving it to another patient's room is disinfecting it. Sterilizing is the elimination of all microorganisms with the use of autoclaving with moist heat, ethylene oxide gas, or dry heat. Equipment used in the operating room is sterilized using these processes. Which example of personal protective equipment is unique to transmission-based precautions? Surgical Mask' Face Mask Respirator Mask -- Correct Answer ✔✔ Respirator Mask The respirator mask (N-95) is used for airborne precautions. It is specially designed to protect the healthcare worker from small airborne organisms. Special training is needed to confirm that the mask is worn properly and fitted tightly enough for protection. Which type of environment best protects a client who is immunosuppressed and at high risk for acquiring an infection? Protective Isolation Contact Isolation Airborne Isolation -- Correct Answer ✔✔ Protective Isolation Protective isolation is used when a severely immune-compromised client is at high risk of acquiring an infection. Additional steps must be taken to clean equipment and the environment and restrict visitors. The nurse must wear a mask, gown, and gloves when providing patient care.
A client is admitted to the hospital with bloody sputum and night sweats, signs of tuberculosis. Which precautions must the nurse institute immediately? Droplet Airborne Contact Protective -- Correct Answer ✔✔ Airborne The client has developed kidney and blood infection following a bladder infection from the urinary catheter. How would the nurse describe this infection? Select all that apply. Local Systemic Primary Secondary Healthcare related -- Correct Answer ✔✔ Systemic Secondary Healthcare related How should the nurse deliver the breakfast tray to the bedside of a client in protective isolation? Place the tray on the table just inside the clients door Apply gloves and place the tray on the clients nightstand Apply respirator mask, gown, gloves, then place the tray in the clients room Set the tray outside the clients room -- Correct Answer ✔✔ Apply respirator mask, gown, gloves, then place the tray in the clients room
Physiological Pain Response Behavioral Pain Response Psychological Pain Response -- Correct Answer ✔✔ Behavioral Pain Behavioral pain response is considered voluntary and assessments include withdrawing from painful stimuli, moaning, facial grimacing, crying, agitation, and guarding the painful area. A client has degenerative joint disease and experiences pain with any physical activity, including walking. The client is irritable and wants to be left alone to sleep all the time. Which nonverbal response is being demonstrated? Physiological Pain Response Behavioral Pain Response Psychological Pain Response -- Correct Answer ✔✔ Psychological Pain response Psychological or affective responses are a result of the mental impact of the pain. These can include anxiety, depression, anger, fear, exhaustion, hopelessness, and irritability. A client is experiencing chest pain and shortness of breath with tachycardia, hypertension, and tachypnea. Which nonverbal response is demonstrated? Physiological Pain Response Behavioral Pain Response Psychological Pain Response -- Correct Answer ✔✔ Physiological Pain Response The physiological pain response is involuntary and includes both sympathetic and parasympathetic responses. The sympathetic responses are seen in acute pain and include increased systolic blood pressure, heart rate, respiratory rate, dilated blood vessels to the brain, increased alertness, dilated pupils, and rapid speech.
The parasympathetic responses are a result of deep or prolonged pain and include decreased diastolic blood pressure, syncope, decreased heart rate, changeable breathing patterns, withdrawal, constricted pupils, and slow, monotonous speech. A client is experiencing signs of appendicitis with right lower quadrant pain and is being prepared for surgery. What type of pain is this client experiencing? Acute Pain Chronic Pain Intractable Pain -- Correct Answer ✔✔ Acute pain Acute pain is of rapid onset and short duration, usually only a few months. It is usually associated with injury or surgery and may be indicative of a more significant injury. A client has rheumatoid arthritis. The pain impairs their ability to be physically active. The client describes that there are bad days and worse days, but the pain is always there. Acute Pain Chronic Pain Intractable Pain -- Correct Answer ✔✔ Chronic Pain Chronic pain lasts several months or longer and may interfere with activities of daily living. It is often a result of a progressive disorder and can come and go with remission and exacerbation. It often is accompanied by a psychological pain response. A client experienced a back injury at work. The pain shoots down the left leg and it is impossible to find a comfortable position that relieves the distress. The client has tried every pain management suggestion and multiple prescription pain medications with minimal relief.
Pain intensity words (adjectives) are used to describe pain. Which type of pain scale is this? The Wong-Baker FACES Pain Rating Scale The Simple Descriptor Scale The Intensity Word Scale -- Correct Answer ✔✔ The simple descriptor scale. The simple descriptor scale uses words such as mild, moderate, and severe to explain pain level. Nurses should use a few descriptive words to prevent confusion. Which type of pain scale uses illustrations to help describe pain? The Simple Descriptor Scale The Numerical Rating Scale The Wong-Baker FACES Pain Rating Scale -- Correct Answer ✔✔ The Wong-Baker FACES Pain Rating Scale The Wong-Baker FACES pain rating scale was originally designed for children but is now used in many settings, especially for those with communication or cognitive impairments. This scale is also helpful if the client speaks a different language from that of the healthcare providers. Which factors impact a persons perception of pain? Select all that apply. Developmental stage Developmental age Location Culture and environment
Cognitive impairment -- Correct Answer ✔✔ Developmental stage Developmental age Culture and environment Cognitive impairment *NOT LOCATION Which pain scales are used to determine a client's level of pain? Select all that apply. OPQRST-AAA FACES Visual analog scale Numeric rating scale The intensity word scale -- Correct Answer ✔✔ FACES Visual analog scale Numeric rating scale An older adult who lives alone has fallen and fractured the left hip. The client cannot get to the phone to call for help. The pain worsens as time passes and the client becomes confused waiting for someone to come. What factors are exacerbating the situation? Select all that apply. Fear Helplessness Cognitive impairment Need to be independent Hunger -- Correct Answer ✔✔ Fear
Esther puts on her call light during the night, telling the nurse that her back aches from being in bed so long and she cannot sleep. Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing -- Correct Answer ✔✔ Massage Massage is effective in relaxing muscles, reducing pain, and promoting sleep. The nurse should use slow, long strokes for the best level of relaxation, especially in the laboring and bed-bound client. The nurse should obtain verbal consent first because some people are uncomfortable being touched. I’m, a teenager, lands on his knee during a basketball game and it begins to swell. The nurse in the audience comes to assist with his discomfort. Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing -- Correct Answer ✔✔ Application of cold
Cold application causes vasoconstriction and can help prevent swelling and bleeding. It is especially effective in reducing pain as a result of procedures. Cold devices should never be in direct contact with the skin as this can cause frostbite and superficial tissue damage. Take a break at least every 15 minutes. Ron is experiencing phantom pain after a left below-the-knee amputation. Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing -- Correct Answer ✔✔ Contralateral Stimulation Phantom pain occurs when a limb has been amputated. The client will continue to feel pain as though the extremity were still present. Doctors once believed this postamputation phenomenon was psychological, but experts now recognize that these real sensations originate in the spinal cord and brain. Contralateral stimulation is the stimulation of the skin in an area opposite to the painful site by scratching, rubbing, or applying heat or cold. In this case, the stimulation would occur to the right lower leg. Sarah fell while downhill skiing and fractured her tibia. The bone has a compound fracture and has broken through the skin. Which pain intervention would be most beneficial? Contralateral stimulation
The nurse just gave an immunization to Jonathan, a 2-year-old.Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing -- Correct Answer ✔✔ Distraction Distraction allows the nurse to pull the patient's attention away from the pain by focusing on toys, videos, or sound. It is most effective with children for mild to moderate pain and for brief periods of time. Michael experiences chronic low back pain. The pain is especially significant while bending to put on his socks and shoes. Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing -- Correct Answer ✔✔ Relaxation Techniques
Relaxation techniques are useful for reducing chronic pain. For Michael, knowing that bending exacerbates the pain will make it worse with anticipation. Relaxation techniques would help minimize the discomfort. Donna would like a way to manage her pain on a long-term basis. She struggles with the emotions that come from living with chronic pain. Which pain intervention would be most beneficial? Contralateral stimulation Massage Application of cold Immobilization Application of heat Distraction Relaxed Techniques Expressive writing -- Correct Answer ✔✔ Expressive Writing Expressive writing helps reduce chronic pain by allowing for an outlet of emotions, fear, and frustration common when dealing with pain on a daily basis. The nurse is caring for a client after a large abdominal surgery. He is restless and uncomfortable. Which positioning change could be most beneficial? Select all that apply. Trendelenburg Side-lying Head of bed flat Fetal position Head elevation -- Correct Answer ✔✔ Side-lying Head elevation
Heat/cold devices are safe to use for all clients Heat/cold devices should be in place for 30 minutes at a time -- Correct Answer ✔✔ Heat/cold devices can cause superficial tissue damage Heat/cold devices should never come in direct contact with the skin Heat/cold devices should be used intermittently The nurse is teaching a family about phantom pain. Which statement is correct? Phantom pain occurs before an amputation The pain is deadened from surgery Phantom pain is a psychological condition Phantom pain is real and should be treated as such -- Correct Answer ✔✔ Phantom pain is real and should be treated as such Philip and Emma are a young married couple expecting twins. They have spent years trying to conceive and were finally able to do so with artificial insemination. Both babies, a boy and a girl, were born small but healthy. The night after delivery, Emma suffers a significant brain hemorrhage and is placed on life support. In the next few days, her family is told she is brain dead and only being kept alive by the machines. They are asked to consider withdrawing life support, allowing her to die. What factors will impact Philip's grieving process? Select all that apply. His attachment to his wife
Support of family and friends Previous experiences with loss Cost of the hospitalization Spiritual beliefs -- Correct Answer ✔✔ His attachment to his wife Support of family and friends Previous experiences with loss Spiritual beliefs Many things impact a person's grief process, including the significance of the loss, support systems, conflicts occurring at the time of death, circumstances of the loss, previous loss experience, spiritual and cultural beliefs, and the timing of death. Having two babies to care for could make Philip's grief process easier or more difficult. For some people, the "busyness" of twins will keep the mind occupied and delay the grieving process; for others, the twins will be a constant reminder of the lost spouse, which could have a positive or negative impact. The healthcare providers said that Emma has experienced brain death. What does that mean for her physical functions? Select all that apply. Her heart is beating without artificial means. Breathing requires a ventilator. Cognitive functioning is intact.
