215: Exam 2

Which finding indicates that a client has a systemic infection?

• Redness and warmth at the wound site

• Positive blood cultures and chills

• Purulent drainage from the wound

• Localized swelling

What is the most effective method to prevent the spread of infection in healthcare settings?

• Wearing gloves

• Using personal protective equipment (PPE)

• Proper hand hygiene

• Using sterile equipment

Which PPE should a nurse wear when entering the room of a client with MRSA in an abdominal wound?

• Mask and gloves

• Gown and gloves

• Gown, gloves, and face shield

• N95 respirator only

Educating children not to share personal items prevents infection at which link of the chain of infection?

• Portal of entry

• Portal of exit

• Mode of transmission

• Infectious agent

Which assessment is most important when providing foot care to a client with diabetes?

• Skin color

• Capillary refill

• Sensation between the toes

• Ankle circumference

What is the best pain assessment tool for a nonverbal client?

• Numeric rating scale

• Wong-Baker FACES Pain Scale

• PAINAD scale

• Revised FLACC scale

Referred pain is best described as pain:

• Felt only at the site of injury

• That spreads along a nerve pathway

• Felt in an area other than its source

• Caused by psychological factors

How should a client use a walker?

• Move walker forward, step forward with strong leg first

• Move walker forward, step forward with weak leg first

• Keep walker stationary, move both legs forward

• Lift walker completely off the floor

Which gait pattern is used when no weight is placed on the affected leg?

• Two-point gait

• Three-point gait

• Four-point gait

• Swing-through gait

What should the nurse assess first to reduce fall risk?

• Client’s vision

• Client’s blood pressure

• Client’s ability to reposition

• Client’s BMI