1 Basic Physical Care

The home health nurse is reviewing clients for hospice care. Which client would qualify for hospice care? a) a client with late-stage acquired immunodeficiency syndrome (AIDS) b) a client with left-sided paralysis resulting from a stroke c) a client who's undergoing treatment for heroin addiction d) a client who had a myocardial infarction 2 weeks previously

a client with late-stage acquired immunodeficiency syndrome (AIDS)

The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include? a) Encourage a high-calorie, high-protein diet. b) Restrict fluids to 1,500 ml per day. # encourage c) Limit salt intake to 2 g per day. # not restrict d) Encourage foods high in vitamin B water solunle. # vit A, D, E, K fat-soluble vitamins

Encourage a high-calorie, high-protein diet. cystic fibrosis # to digest fat, protein, and some sugars since the enzymes from the pancreas (lipase, trypsin, and amylase) become so thick that the ducts become plugged.

A nurse is preparing to administer a medication to a client. Which method is best for verifying the client's identity? 1. ask the client to state his or her name # maybe confused & give an incorrect answer 2. check the name posted outside the client's room 3. ask a family member the identity of the client 4. check the client's identification bracelet

4. check the client's identification bracelet

A registered nurse RN asks a licensed practical nurse LPN to change the colostomy bag on a client. Although having received in-service training for this procedure, the LPN has never performed it on a client. What action should the LPN expect the RN to take? a) Request that the LPN review the procedure in the hospital manual. b) Instruct the LPN to review the in-service materials prior to performing the procedure. c) Perform the procedure step by step with the LPN. d) Have another LPN observe the procedure when the assigned LPN performs it.

Perform the procedure step by step with the LPN.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) fresh orange slices. b) ground beef patties. c) steamed broccoli. d) ice cream # incomplete protein

ground beef patties.

The nurse is making rounds on a client in a vest restraint. Which should the nurse do if it has been 2 hours since a nurse last made rounds? 1. provide elimination care for the client 2. administer prescribed medications # should be administered at the scheduled time 3. discontinue the restraint # without a further assessment will endanger the client. 4. nothing needs to be done at this time

1. provide elimination care for the client

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions? a) Wear gloves for all contact with the client. b) Consider all body substances potentially infectious. c) Place a body substance isolation sign on the client's door. d) Wear gloves and a gown whenever caring for the client.

Consider all body substances potentially infectious.

A client has been admitted to the hospital with heart failure. On entering the room, the nurse notices that the client is having difficulty breathing. Which position would be most appropriate to help the client's breathing? a) flat in bed with feet elevated # promotes venous return to an already overloaded heart and restricts lung expansion. b) semi-Fowler position c) side-lying position # promotes venous return to an already overloaded heart and restricts lung expansion. d) high Fowler position

High Fowler's position facilitates adequate lung expansion by helping gravity to pull the organs away from the chest and by decreasing venous return to the heart.

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed? a) Apply the saturated fine-mesh gauze dressings over the wound. b) Apply an occlusive dressing over the saturated fine-mesh gauze dressings. c) Cover the saturated fine-mesh gauze dressings with an elastic bandage. d) Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

The nurse is performing tracheal suction for a client as indicated due to a "gurgling" sound with respirations. Which nursing action is correct for performing this procedure? a) Apply suction during insertion of the catheter. # trauma to the mucosa & fastly hypoxia b) Limit suctioning to 10 to 15 seconds' duration. c) Resterilize the suction catheter in alcohol after use. # diposed d) Repeat suctioning intervals every 15 minutes until clear.

Limit suctioning to 10 to 15 seconds' duration.

The nurse is caring for a client on the medical-surgical unit who has an acute attack of vertigo. What intervention should the nurse provide for safety of the client? a) Start an IV with lactated Ringers solution at 125 mL/h. b) Keep the client on bed rest with the side rails elevated. c) Place the client in a modified Trendelenburg position. # can further increase the dizziness associated with vertigo d) Administer meclizine 50 mg PO daily.

b) Keep the client on bed rest with the side rails elevated and the call light readily accessible

A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often? a) Once, to establish a baseline b) Once per year c) Every 2 years d) Twice per year

b) Once per year mammogram every year starting 1 at age 40 2 family history, genetic tendency, hx of breast cancer

Preoperatively, the health care practitioner orders antiembolism stockings for a client scheduled for open heart surgery. The client asks the nurse what is the purpose of antiembolism stockings. How does the nurse appropriately responds? a) "The stockings will decrease arterial blood circulation to your legs and feet." # increase b) "The stockings will decrease venous blood circulation from your legs and feet." # increase c) "The stockings will reduce or prevent edema in your legs and feet." d) "The stockings will maintain warmth in your legs and feet." # blanket

c) "The stockings will reduce or prevent edema in your legs and feet."

The nurse evaluates a client who is 36-hours postoperative. Which sign or symptom indicates to the nurse that the client is experiencing a complication? a) presence of dark colored urine # Not clear, culture urine b) oral temperature of 100° F (37.8° C) # normal c) a warm, erythematous tender incision d) white blood cell (WBC) count of 9.6 x 103/μl # normal

c) a warm, erythematous tender incision # postoperative infection

The nurse receives a call from the laboratory with lab values. Which lab value represents the highest priority for the nurse? a) potassium 3.5 mEq/L (3.5 mmol/L) b) sodium 148 mEq/L (148 mmol/L) c) calcium, total 32 mg/dL (8 mmol/L) d) magnesium 2.2 mEq/L (1.10 mmol/L)

c) calcium, total 32 mg/dL (8 mmol/L)

The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client? a) number scale from one to ten b) face rating scale c) body diagram d) questionnaire

face rating scale simple way of pain assessment

When inserting a urinary catheter on a male client, which action should the nurse take to facilitate the insertion? a) ask the client to urinate while inserting the catheter b) instruct the client to breathe deeply c) move the client close to the edge of the bed d) hold the shaft of the penis firmly

instruct the client to breathe deeply

A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client? a) oral antidiabetic agents b) nonsteroidal anti-inflammatory drugs (NSAIDs) c) beta-adrenergic blockers d) oral hormonal contraceptives

nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: Simultaneous use of NSAIDs and prednisone can increase the risk of peptic ulcers; therefore, NSAIDs should be administered 2 hours before or 2 hours after prednisone.

An LVN/LPN working on a busy unit decides to delegate some tasks to the unlicensed assistive personnel. Which client tasks can be delegated to the UAP? SATA a) positioning a client b) vital signs on critical clients c) pharyngeal suctioning d) intake and output measurement e) ambulation of a client

positioning a client intake and output measurement ambulation of a client

A nurse in a long-term care facility is delegating a task to the unlicensed assistive personnel UAP. Which task is appropriate to assign to the UAP? a) obtaining vital signs on a client with chest pain b) adjusting the weight on Buck's traction c) changing a dressing on an infected wound d) repositioning a client every 2 hours

repositioning a client every 2 hours

A nurse wants to use a waist restraint for a client who wanders at night. Which intervention should be considered before applying the restraint? a) the nurse's convenience b) the client's reason for getting out of bed c) a sleeping medication ordered as needed at bedtime d) the lack of unlicensed assistive personnel UAP on the night shift

the client's reason for getting out of bed e.g looking for a bathroom

A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics? a) straighten the knees and back # flex the knees and use arm and leg muscles instead of the back. b) use a wide stance for support c) lift the client to the proper position d) stand several feet from the client

use a wide stance for support Explanation: When repositioning a client in bed, the nurse should stand with the feet apart # one foot in front of the other, to establish a wide base of support and good body alignment. To reduce the energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull, rather than lift the client. To minimize stress, the nurse should stand as close to the client as possible.

A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, "When is the infectious period?" What statement made by the nurse is most accurate? 1 "The client is infectious from the time the rash appears until the rash dries up." 2 "The client is infectious before the rash appears." 3 "The client is infectious 1-2 days before the rash appears and until the blisters are crusted." 4 "The client is infectious up to 2 weeks after the blisters are dry and crusted

"The client is infectious 1-2 days before the rash appears and until the blisters are crusted."

A nurse is caring for a client on a mental health unit and receives a call asking to know if the client is admitted on that unit. What should the nurse do? 1. verify the identity of the caller 2. verify that the client is on that unit 3. refer the person to the unit clerk 4. put the call through to the client to answer the question

. verify the identity of the caller

The nurse is caring for multiple clients that have been determined to be at risk for falls. Which intervention(s) should the nurse institute to prevent falls? SATA a) Orient client to the nurse call system and encourage its use. b) Ensure the nurse call system is within reach. c) Keep hospital bed in low position. d) Keep all side rails up for ambulatory confused clients restraint e) Keep room dark to minimize noise.

Orient client to the nurse call system and encourage its use. Ensure the nurse call system is within reach. Keep hospital bed in low position.

Which client requires further data collection by the licensed practical nurse (LPN)? a) the client whose respiratory rate is 21 breaths/minute b) the client whose blood pressure is 129/78 mm Hg c) the client whose apical pulse rate is 84 beats/minute d) the client who is restless

the client who is restless Explanation: The LPN should collect further data on the client who is restless because restlessness is an early sign of hypoxia. A respiratory rate of 21 breaths/minute, blood pressure of 129/78 mm Hg, and an apical pulse rate of 84 beats/minute are within normal limits and don't require further data collection at this time.

A nurse is caring for a client with a history of falls. What is the first priority when caring for a client at risk for falls? 1. place the call light within the client's reach # 2nd steps of risk for fall 2. keep the bed in the lowest possible position 3. instruct the client not to get out of bed without assistance 4. keep the bedpan available so the client doesn't have to get out of bed

2. keep the bed in the lowest possible position # first priority of risk for falls

A nurse is performing a focused abdominal assessment. When can the nurse document that her client's bowel sounds are absent after listening for how long over each quadrant? 5 minutes 4 minutes 3 minutes 2 minutes

5 minutes each quadrant Bowel sound ass.

The licensed practical nurse removes a client's nasogastric (NG) tube according to the physician's order. The nurse should watch for which complication after removing an NG tube? a) Abdominal distention b) Flatulence # indicates that gas from the small intestine is passing through the colon. c) Constipation # isn't a complication associated d) Presence of bowel sounds # indicates that the GI tract is functioning.

Abdominal distention Explanation: After removing an NG tube, the nurse should assess the client for such complications as abdominal distention, nausea, and vomiting

After a surgical procedure, the health care provider orders a clear-liquid diet for a client. The nurse advises the unlicensed assistive personnel UAP to check the client's food tray for which of the following allowable items? SATA a) orange juice, farina, and coffee b) apple juice, chicken broth, and gelatin c) pineapple juice, a bran muffin, and milk d) orange juice, custard, and tea e) ginger ale, jello, and a fruitless popsicle

Apple juice, chicken broth, and gelatin ginger ale, jello, and a fruitless popsicle

The nurse is performing a dressing change as prescribed for a client with a red, granulating foot ulcer. Which action should the nurse perform when changing the dressing? a) Clean the wound with normal saline solution. b) Vigorously irrigate the ulcer with ½-strength betadine. c) Apply a dry gauze dressing. d) Pack the wound tightly with a wet-to-dry dressing.

Clean the wound with normal saline solution. Explanation: A red, granulating foot ulcer is healing well and should be cleaned with normal saline solution or a nontoxic wound cleanser. Minimal force should be used to prevent disrupting healthy granulation tissue. A dry gauze dressing would adhere to the wound and disrupt the granulation tissue when removed. When used in a healthy, healing wound, a wet-to-dry dressing can traumatize healing tissue during removal

The nurse is performing a dressing change as prescribed for a client with a red, granulating foot ulcer. Which action should the nurse perform when changing the dressing? a) Clean the wound with normal saline solution. b) Vigorously irrigate the ulcer with ½-strength betadine. c) Apply a dry gauze dressing. d) Pack the wound tightly with a wet-to-dry dressing

Clean the wound with normal saline solution. or nontoxic wound cleanser

The nurse finds the family member of a client in the nutrition room standing in a puddle of water holding the microwave door, shaking. What should the nurse do first? a) Pull client from the pool of water. b) Activate the emergency response team. c) Obtain vital signs. d) Unplug the microwave.

Electronic shock 1st Unplug the microwave # prevent further injury 2nd Pull client from the pool of water 3rd Activate the emergency response team. 4th Obtain vital signs.

A nurse is caring for a client with a history of falls. Which interventions take priority in this client's care? SATA a) Place the call light within the client's reach. b) Keep the bed in the lowest possible position. c) Implement neurological checks every 4 hours. d) Encourage the client change positions frequently while in bed. # avoid pressure ulcer e) Provide immediate response to the client's toileting needs. f) Assign security personnel to sit outside of the client's door.

Keep the bed in the lowest possible position. Place the call light within the client's reach. instructing the client not to get out of bed Provide immediate response to the client's toileting needs.

The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse plan to emphasize? Legumes # incomplete protein and cheese # protein & fat Whole-grain products # protein & carbohydrate Fruits and vegetable # carbohydrate Lean meats and low-fat milk

Lean meats and low-fat milk # protein

The nurse is gathering data from a client on the first day after a thoracotomy. The client has a temperature of 100°F (37.8°C); heart rate, 96 beats/minute; blood pressure, 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases, and reports incisional pain. Which nursing action has priority? a) Medicate the client for pain. b) Help the client get out of bed. c) Give ibuprofen as ordered to reduce the fever. d) Encourage the client to cough and deep breathe.

Medicate the client for pain. # the priority is to relieve the client's pain and make him/her comfortable. This would give the client energy and stamina to achieve the other objectives.

A client had gastric bypass surgery, is on nothing-by-mouth NPO status, and is in pain. The nurse gives morphine 4 mg as ordered. In 20 minutes, the client reports feeling nauseous. What would the nurse suspect as the most likely cause? a) The surgery is causing nausea. b) Being NPO, the increase in gastric secretions is precipitating this symptom. c) Morphine, which was given for pain, has a tendency to cause nausea. d) It is a reaction to blood still remaining in the mouth after extubation.

Morphine, which was given for pain, has a tendency to cause nausea

The nurse is caring for a client with stomatitis. To make eating less painful, which foods should the nurse suggest? a) Hot foods # irritating b) Soft, bland foods c) Liquid foods # not necessary& are less satisfying d) Dry foods # irritating

Soft, bland foods

A nurse is reinforcing discharge instructions to the parents of a child who had a tonsillectomy. Which instruction is the most important? a) The child should drink extra milk. # may encourage mucus b) The child shouldn't drink from straws. c) Orange juice should be given to provide pain control. # irratate d) The mouth should be rinsed with salt water to provide pain relief # # irratate

The child shouldn't drink from straws. Explanation: Straws and other sharp objects inserted into the mouth could disrupt the clot at the operative site

A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first? 1 a 57-year-old with a clavicle fracture 2 a 62-year-old with tachypnea 3 a 37-year-old with a scalp laceration 4 a 10-month-old infant who is crying uncontrollably # need comfort

a 62-year-old with tachypnea # The client with tachypnea requires immediate attention. Abnormally rapid breathing takes priority over a clavicle fracture or scalp laceration

A nurse is caring for a client with osteoarthritis. What collaborative treatment strategy should the nurse anticipate participating in for this client? a) administering narcotics for pain control b) assisting the client with maintaining bed rest for painful exacerbations c) administering nonsteroidal anti-inflammatory drugs for pain control d) assisting with vigorous physical therapy for the joints

administering nonsteroidal anti-inflammatory drugs for pain control Explanation: Nonsteroidal anti-inflammatory drugs (NSAIDs) are routinely prescribed clients with osteoarthritis because of their anti-inflammatory and analgesic effects. NSAIDs reduce inflammation that causes pain. Narcotics are not used for pain control in osteoarthritis. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

A nurse is reinforcing education for a client about using alcohol with certain drugs. Which medications should the nurse be most concerned about if the client reports combining them with alcohol? a) aspirin, antihistamines, and sedatives b) penicillin-class antibiotics and decongestants c) oral contraceptives and caffeine-based weight-reduction medications d) H2 receptor blockers and antacids

aspirin, antihistamines, and sedatives Explanation: Combining alcohol with antihistamines or sedatives potentiates the sedative effect. Taking aspirin with alcohol is dangerous because gastric irritation can cause GI bleeding

A client must undergo right thoracotomy for lung cancer. Which member of the health care team is responsible for obtaining informed consent from this client? a) Primary nurse # witness to the client's signature. b) Physician c) Nurse working with the physician # witness to the client's signature. d) Physician's assistant# need a physician must act as cosigner

b) Physician

A nurse has a four-client assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology? a) the client with diabetes mellitus (DM) b) the client with diabetes insipidus (DI) c) the client with diabetic ketoacidosis (DKA) d) the client with syndrome of inappropriate antidiuretic hormone SIADH secretion # RETAIN FLUID

b) the client with diabetes insipidus (DI) Explanation: Maintaining adequate fluid, replacing vasopressin, and correcting underlying intracranial problems E.G typically lesions, tumors, or trauma affecting the hypothalamus or pituitary gland- are the main objectives in treating diabetes insipidus.

A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus? sputum feces blood urine

feces Explanation: The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.

A nurse is caring for a client with lower back pain who is scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position? a) head of the bed elevated 45 degrees b) on the abdomen with the ankles elevated c) supine with legs elevated at the knees d) supine with the head lower than the trunk

head of the bed elevated 45 degrees Explanation: After a myelogram, positioning of the client depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed should be elevated to a 45-degree angle to slow the upward dispersion of the dye. The other positions are contraindicated when a water-soluble contrast dye is used.

During a multidisciplinary team conference, a nurse and dietitian discuss the care plan for a client recovering from burns that cover 15 percent of the client's body. Which diet is best for this client? a) high fiber b) low calorie c) high protein d) low sodium

high protein

The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse's best intervention? a) ask the client to be cooperative b) recognize the client behavior as part of the disease process c) have a witness present when delivering care d) include the client in the decision-making process

include the client in the decision-making process Explanation: Involving the client in the planning process individualizes care and promotes self-esteem and autonomy, which often prevents arguments and demanding behavior.

A nurse prepares to care for a client who has just transferred from the emergency department to the medical-surgical floor. Which is the most effective action that the nurse should take to prevent microbial transmission? a) wearing gloves during care b) using aseptic technique c) meticulous hand hygiene d) disinfecting all equipment

meticulous hand hygiene # more effective

A client who is a resident in a long-term care facility was found on the floor. The nurse completes an incident report and documents on the client's chart. Which of the following information should the nurse document on the client's chart? SATA a) an incident report has been filed b) client fell out of bed # not sure c) names of witnesses d) time health care provider was notified e) nursing interventions

names of witnesses time health care provider was notified nursing interventions Explanation: Filing an incident report is used by the agency for quality improvement purposes and should not be mentioned in the client's record.

The nurse is caring for a client after abdominal surgery. When reinforcing education for coughing and deep breathing, what should the nurse include? a) splint the incision and cough b) splint the incision, take a deep breath, and then cough c) lie prone, splint the incision, take a deep breath, and then cough d) lie supine, splint the incision, take a deep breath, and then cough

splint the incision, take a deep breath, and then cough Explanation: Splinting the incision with a pillow will protect the incision while the client coughs. Taking a deep breath will help open the alveoli, which promotes oxygen exchange and prevents atelectasis. Coughing and deep-breathing exercises are best accomplished in a sitting or semi-sitting position. Expectoration of secretions will be facilitated in a sitting position, as will splinting and taking deep breaths.

A client has an prescription for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, which action should the nurse take? 1. aspirate after the injection # NOT 2. use the Z-track method # I.M. injections 3. use a 45- to 90-degree angle 4. always use the same injection site # rotation

use a 45- to 90-degree angle # SC subcutaneous injection

The nurse is caring for a client 24 hours after abdominal surgery. The health care provider's order states, "Get client out of bed to chair twice daily." Which action should the nurse take when transferring the client to the chair? a) Stand with feet apart and pull the client up using the arms. b) Help the client sit up and dangle legs over the side of the bed. c) Stand behind the client holding the gait belt firmly. d) Place the chair facing away from the client's bed.

Help the client sit up and dangle legs over the side of the bed.

During a community clinical rotation, the nursing students interview an employer that established a physical exercise area in his workplace and encourages all employees to use it. The nursing instructor asks the student to indicate the level of health promotion exemplified by the exercise area. How would the student respond? a) "This is an example of primary prevention." b) "This is an example of secondary prevention." c) "This is an example of tertiary prevention." d) "This is an example of passive prevention."

"This is an example of primary prevention." Explanation: Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health from others' activities without doing anything themselves.

A client has a surgical wound with a drain. When cleaning around the drain, the nurse should wipe in which direction? a) Laterally, from the center to the opposite side # when cleaning a large horizontal wound b) From top to bottom # when cleaning a vertical incision. c) In a circle, from the center outward d) In a circle, beginning 6" away, from the center inward # cause contaminates

In a circle, from the center outward # When cleaning around the drain

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received appropriate skin care and has been turned every two hours. Which factor would the nurse assume is most likely responsible for the failure to heal? a) Inadequate vitamin D intake b) Inadequate protein intake c) Inadequate massaging of the affected area # NEVER due to pressure ulcer d) Low calcium level

Inadequate protein intake

The nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the counseling? a) "My son can't eat wheat, rye, oats, or barley." b) "My son needs a diet rich in gluten." c) "My son must avoid potatoes, rice, flour, and cornstarch." # a gluten-free diet d) "My son can safely eat frozen and packaged foods.

a) "My son can't eat wheat, rye, oats, or barley."

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, what rationale does the nurse provide for holding a cane on the uninvolved side? a) to distribute weight away from the involved side b) to maintain stride length c) to prevent edema d) to prevent leaning # Holding the cane close to the body

a) to distribute weight away from the involved side # holding a cane on the uninvolved sid

The licensed practical nurse (LPN) is caring for multiple clients that require various skills. Which client task should the LPN ask the registered nurse (RN) to complete? a) perform a first dressing change for a surgical client # responsibility of the surgeon b) administer intravenous push (IVP) medication c) administer subcutaneous injection d) administer eye drops

administer intravenous push (IVP) medication # scope of practice for an RN

A licensed practical nurse is caring for a client who underwent open reduction and internal fixation of a fractured left hip 1 day ago. Which intervention takes priority for this client during the first postoperative day? a) assessing and controlling pain b) assisting the client with full weight bearing and walking c) allowing the client to perform activities of daily living independently d) removing the client's surgical staples # by the surgeon

assessing and controlling pain

While preparing a client for a diagnostic study of the colon, the nurse teaches him how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? a) "I will administer the enema while sitting on the toilet." b) "I will administer the enema while lying on my left side with my right knee flexed." c) "I will administer the enema while lying on my right side with my left knee flexed." d) "I will administer the enema while lying on my back with both knees flexed."

b) "I will administer the enema while lying on my left side with my right knee flexed." Explanation: Lying on the left side allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum.

The student nurse describes how to position a client for a lumbar puncture to the primary care nurse. Which description indicates that the student nurse understands the correct positioning for the procedure? a) prone, with the head turned to the right b) supine, with the knees raised toward the chest c) lateral recumbent, with flexed knees d) lateral, with the right leg extended

lateral recumbent, with flexed knees

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator? a) pain level 3/10 one hour after administration of pain medication b) potassium 3.8 mEq/L (3.80mmol/L) before administration of intravenous fluid # Subjective c) blood pressure of 130/90 mmHg before a brisk walk # Subjective d) creatinine 3.5 mg/dL (309.40 µmol/L) while client is receiving dialysis # Subjective

pain level 3/10 one hour after administration of pain medication # objective data

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply? a) Dry sterile dressing # adhere to the wound and debride the tissue when removed b) Sterile petroleum gauze # supports healing but is expensive c) Moist sterile saline gauze d) Povidone-iodine-soaked gauze # is used as an antiseptic cleaning agent; however, it can irritate epithelial cells and is contraindicated for use on an open wound

Moist sterile saline gauze # Moist sterile saline gauze

A nurse in the emergency room receives multiple clients after a motor vehicle accident. Which client should the nurse see first? 1. a client who is confused and reporting abdominal pain 2. a client with a swollen ankle who is reporting pain 3. a client with a simple fracture of the tibia, which is immobilized 4. a client with multiple abrasions over the face and limbs

a client who is confused and reporting abdominal pain Explanation: A client with confusion can be indicative of poor perfusion to the brain and abdominal pain may indicate internal injury.

A nurse is caring for a client who underwent a retinal detachment repair using an air bubble. The nurse is informed by the health care provider to "Keep client in prone position." Which action should the nurse take? a) Call the health care provider to report that the prescription is in error and must be reviewed. b) Follow the prescription because this position will help keep the retinal repair intact. c) Instruct the client to maintain this position while awake but to sleep lying flat. d) Assume the dressing should be changed at bedtime and allow the client to lie flat.

b) Follow the prescription because this position will help keep the retinal repair intact.

When caring for a client with a 3-cm stage II pressure ulcer on the coccyx, which action can the nurse institute independently? a) cleaning the wound three times per day with a povidone-iodine wash # require a physician's order. b) gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary c) applying antibiotic cream to the area three times per day # require a physician's order. d) cleaning the wound with a wound cleanser and applying a hydrogel wound dressing # require a physician's order.

b) gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary

The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would: a) keep the area covered with the warm soaks continuously # injure the skin, so need a limited time b) remove the warm compress after 20 minutes for at least 15 minutes. c) alternate warm compresses with cold compresses. d) question the order because heat increases edema.

b) remove the warm compress after 20 minutes for at least 15 minutes.

A nurse changes the wet-to-dry dressing of a client who has an open abdominal incision. Which nursing intervention is appropriate? a) Irrigate the wound vigorously with sterile saline solution. # injury to the vascular bed and tissue b) Pack the wound tightly with wet-to-dry gauze sponges. # loose c) Label the dressing with the date, time, and nurse's initials. d) Use a plastic moisture resistant barrier to cover the dressing. # a dry gauze dressing

c) Label the dressing with the date, time, and nurse's initials.

The nurse cares for a client who is postoperative right modified mastectomy. The client has a pressure dressing on the surgical site. Which priority care intervention should the nurse provide for this client? a) promoting adequate intake of fluids # wound healing b) monitoring the client's right arm # wound care c) encouraging coughing and deep breathing d) inspecting the client's postoperative dressing # wound care

c) encouraging coughing and deep breathing

The nurse is caring for a client who suffered third-degree burns over 50% of the body. Which medication would the nurse anticipate using to prevent infection in this client? a) permethrin # a pediculicide used to treat lice infestation b) diazepam # antianxiety c) mafenide acetate d) morphine # analgesic

c) mafenide acetate topical antibiotic is prescribed to prevent infection in clients with second- and third-degree burns.

A client has a prescription for a low-fat diet. When reviewing the client's food diary, which food items would the nurse suggest that client eliminate from their diet? SATA a) steamed broccoli & fruit or vegetables # a low-fat diet b) broiled haddock # a low-fat diet c) cream cheese d) beef sausage e) Milk chocolate

cream cheese beef sausage Milk chocolate

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital and later tells the nurse, "I want to have everything possible done to help me get better." Which response by the nurse would be most appropriate? a) "It's too late to change your mind now." b) "We'll have to ask your health care provider if the DNR can be changed." c) "You should talk with your family before making this decision." d) "It isn't a problem to rescind your DNR order.

d) "It isn't a problem to rescind your DNR order

Which task can the licensed practical nurse LPN appropriately delegate to the nursing assistant? a) Obtaining vital signs on a client who has just returned from undergoing a colonoscopy b) Feeding a client for the first time after he has experienced a stroke c) Administering feedings through a nasogastric tube

d) Encouraging a client to drink fluids

What is an appropriate nursing intervention for a client with a soft wrist restraint? a) Applying the restraint loosely to prevent pressure on the skin b) Tying the restraint to the side rail c) Positioning the restrained arm in full extension d) Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm

d) Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take? a) Placing bilateral wrist restraints on the client b) Asking the physician to give the client a tranquilizer # very risky c) Delaying I.V. fluid administration until the client's confusion ceases d) Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

d) Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

A nurse prepares to perform postural drainage on a client. How should the nurse determine the best position to facilitate clearing the lungs? a) inspection of chest expansion b) percussion of the chest wall c) palpation for tactile fremitus d) auscultation of lung sounds

d) auscultation of lung sounds Explanation: The nurse should auscultate the client's lung sounds before doing postural drainage to determine the areas that need draining. Inspection, percussion, and palpation are all evaluation parameters that give good information about the respiratory system, but they are not necessary to determine lung areas requiring postural drainage.

A health care provider prescribes a biophysical profile for a pregnant client. When preparing the room for this test, which equipment would the nurse most likely gather? a) sphygmomanometer and thermometer b) ultrasound machine and fetal monitor c) ultrasound machine and sphygmomanometer d) fetal monitor and electronic blood pressure measuring device

ultrasound machine and fetal monitor Explanation: During a biophysical profile, the amount and quality of fetal movement and the amount of amniotic fluid are measured via ultrasonography; this evaluation is followed by a nonstress test, which requires a fetal monitor.