Free LVN Safe and Effective Care Environment Test 1
A nurse is cleaning the wound of a 33-year-old client. The nurse cleans the wound from the center of the incision and then outward, followed by lateral motions. Which of the following best identifies this type of wound cleansing?
Horizontal wound cleansing involves the cleaning of the wound from the center starting at the incision site, then moving outward and laterally. Other cleansing methods are vertical and drain/stab wound.
Which of the following is NOT true of delegation?
A nurse should never delegate tasks such as patient teaching, assessment, or evaluation. Choices B, C, and D are true.
Which of the following best represents the steps of the chain of infection?
Etiologic agent, reservoir, portal of exit, method of transmission, portal of entry to the susceptible host, susceptible host. The chain of infection has six components that makeup how an infection forms and is spread. These components are the etiologic agent, which is the microorganism, reservoir, which is the source of the microorganism, portal of exit where the microorganism leaves the source and is spread, method of transmission, which is how the microorganism is passed on to others people such as through direct contact, airborne, portal of entry to the susceptible host and susceptible host.
There are several areas of regulation of nursing practice. Which of the following is NOT an accurate statement regarding the various methods and guidelines that regulate nursing practice?
Institutional policies are employee guidelines set by a facility and are NOT laws. Courts do, however, generally rule against nurses who violate policies. Written policies and procedures of the employing institution detail how nurses are to perform their duties.
The nurse applies an external electronic fetal monitor (EFM) to assess a client's uterine contractions and evaluate the fetal heart rate (FHR). However, the client is uncomfortable and changes positions frequently, making FHR hard to assess. Consequently, the physician decides to switch to an internal EFM. Before internal monitoring can begin, which of the following must occur?
Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm, and when the presenting part is at least at 1 station. Anesthesia is not required for internal EFM.
A 23-year-old female has kidney stones. She is scheduled for an intravenous pyelogram. Which of the following client statements should stand out as a concern to the nurse?
The client’s statement should alert the nurse of a potential allergy to iodine. And, the nurse should report the client’s reaction to crab meat to the physician immediately before the client undergoes the procedure. If the client proceeds and has the intravenous pyelogram performed, then the client may have an allergic reaction to the contrast material. The intravenous pyelogram’s contrast material contains iodine. This contrast is injected into the client’s veins where it is transported through the bloodstream to the kidneys, ureter, and bladder. This dye highlights these areas on the x-ray so the physician can see where the kidney stones are located in the client’s body.
The nurse should instruct a client who is self-administering Atropine (Atropisol) to wait how long between instilling the first drop and instilling the second drop:
The client should wait 2 to 3 minutes before instilling a second drop of atropine to avoid losing a drop from tearing or blinking. Waiting 5 minutes is not necessary.