102 exam 2
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?
near the client's hip, with legs shoulder width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely.
The nurse is creating a professional development presentation about medication orders. Which teaching will the nurse include? Select all that apply
The health care providers must sign all orders. Be extra cautious with look-alike and sound-alike drugs.
The nurse is teaching a client with heart failure about taking digoxin safely. Which statement by the client indicates teaching was effective?
"I will call the health care provider if I develop dizziness, blurred vision, or nausea."
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?
"Put your arm in this sleeve." Explanation: When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed
Which statement made by the nurse would indicate that teaching regarding the absorption of topical medications in the older adult was effective?
Correct response: "Diminished subcutaneous fat will lead to the rapid absorption of topical medication." Explanation: Decreased subcutaneous fat is correct, as this could lead to more rapid absorption of topical medications. I
A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
Correct response: "To prevent your legs from rotating outward." Explanation: Trochanter rolls prevent the client's legs from rotating outward.
The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.
Correct response: -Lower the bed to the lowest position allowing the client's soles to contact the floor. -Provide the client with nonskid slippers to put on prior to standing up. -Provide step-by-step instructions to the client before the transfer begins. Explanation: Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse.
The nurse is preparing supplies for a tuberculosis screening. The nurse should choose which syringes and needles?
Correct response: 1 mL syringe; ½-inch (1.25-cm), 26-gauge needle Explanation: For a tuberculosis screening, the nurse should choose a 1 mL syringe with a ½-inch (1.25-cm), 26-gauge needle. An insulin syringe is used for insulin administration.
The charge nurse on the medical/surgical unit is reviewing physician orders for a client with a diagnosis of congestive heart failure. Which infusion orders would the nurse question?
Correct response: 1000 D5W to run in 30 minutes Explanation: Medications administered by intermittent infusion are supplied either in bags that contain 50 to 250 mL of IV fluid (0.9 normal saline or 5% dextrose in water) or in 20- to 60-mL syringes to be used with an infusion pump.
A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?
Correct response: Client is in supine position with arms in functional position and pillow support under the knees. Explanation: In the supine position, the client is lying on the back.
A nurse is administering medication to a client with a gastrointestinal tube. Which intervention is a recommended guideline for medication administration using this route?
Correct response: Crush medications to a fine powder and mix with 15 to 30 mL of water. Explanation: Medications should be crushed to a fine powder and mixed with 15 to 30 mL of water before delivery through the tube. Use liquid medications when possible, because they are readily absorbed and less likely to cause tube occlusions. Certain solid dosage medications can be crushed and combined with liquid.
The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?
Correct response: Equipment is positioned to the side, 50 degrees away. Explanation: Proper ergonomics promote comfort, performance, and health in the workplace. All findings support proper ergonomics, with the exception of equipment positioning. Equipment should be positioned 20 to 30 degrees away, in front, not off to the side, to avoid turning or twisting of the head, neck, and shoulders.
A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.
Correct response: Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys. Explanation: The benefits of exercise include increasing intestinal tone, increasing efficiency of the metabolic system, and increasing blood flow to the kidneys. Exercise decreases resting heart and blood pressure. Exercise increases appetite.
The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply.
Correct response: Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers Explanation: The standard range-of-motion exercises for the fingers of the left hand that will assist the client are extension, flexion, adduction, and abduction of the fingers. Hyperextension of the fingers is not appropriate and may cause injury to the client.
A nurse is administering a client's analgesic by the subcutaneous route. What should guide the nurse's action?
Correct response: Inject into the adipose tissue layer just below the epidermis and dermis. Explanation: Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis.
The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse?
Correct response: Insert a new IV medication lock and remove the old one.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?
Correct response: Raise the head of the bed to a sitting position. Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.
When the home care nurse visits a client, who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. Which action would the nurse take based on the assessment findings?
Correct response: Refer to the health care provider. Explanation: Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative. The nurse would refer the client to a health care provider for treatment of depression. Calling the health department or cleaning up the house will not help with the client's depression. Moving the client to an assisted living facility may not be necessary if the client receives treatment for the depression.
The nurse is preparing to administer a bolus of furosemide 0.8 mg to a client with congestive heart failure and kidney disease. Which right of drug administration would the nurse question and confirm in this client?
Correct response: Right drug Explanation: To ensure safe medication preparation and administration, the nurse should practice the rights of medication administration. Right client, right drug, right dose, and right route are rights of medication administration. In this client who has kidney disease, furosemide is contraindicated. Therefore, confirming the correct medication would be crucial.
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?
Correct response: The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight. Explanation: During any client-transferring task, if the lift is more than 35 lb (16 kg) of a client's weight, consider the client to be fully dependent and use assistive devices for the transfer. The nurse would encourage the client to help with the transfer if the client is able and can safely assist.
In an assessment for proper body alignment of a standing client, which finding is normal?
Correct response: The weight of the body is distributed on the soles and heels. Explanation: A client's body is in correct body alignment while standing when the weight of the body is distributed on the soles and heels. The chest is held upward and forward. The abdominal muscles are held upward and the buttocks downward. The line of gravity goes midline through the center of the knees and in front of the ankle joints.
A client has been receiving frequent injections. Which instruction(s) to reduce discomfort at the injection site will the nurse provide? Select all that apply.
Correct response: Use the smallest-gauge needle that is appropriate. Select a site that is free of irritation.
A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply.
Correct response: Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Face in the direction in which you are moving the load. Explanation: Standing with the feet apart and knees flexed will improve balance. Objects should be pushed, not pulled, if possible. Working close to the object and facing in the direction of movement improve strength
Which type of mobility aid would be most appropriate for a client who has poor balance?
Correct response: a cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance.
A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?
Correct response: a canister containing medication that is released when the container is compressed Explanation: A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed.
The registered nurse (RN) supervises the LPN/LVN administering a purified protein derivative (PPD) tuberculin skin test to a client. During which step should the RN establish the need to intervene? The LPN/LVN:
Correct response: inserts the tip of the needle at a 5-degree angle with the bevel partly under the skin. Explanation: The bevel of the needle needs to be just below the skin surface and not showing because the tuberculin would not be properly administered, and some would leak to the surface. This would result in an ineffective, flat intradermal wheal instead of one that is 8 to 10 mm in diameter. The RN needs to intervene to ensure that the injection is done properly. Otherwise, the injection would have to be repeated at least 2 in away from the original site.
The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse?
Correct response: leave the friction-reducing sheet in place once the client is transferred Explanation: Safe client handling and transfers involve the use of client assessment criteria, algorithms for client handling decisions, and proper use of client handling equipment. The client should be kept in good alignment and protected from injury while being moved. Once the client is transferred, the friction-reducing sheet should be left in place for the return transfer.
The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?
Correct response: lowering the height of the bed prior to moving the client Explanation: Lowering the height of the bed is an incorrect action that would require the nurse to intervene. The bed should be raised to the height of the caregiver's elbow, or to a comfortable working height before the client is positioned. All other options are appropriate positioning techniques.
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?
Correct response: predisposition to renal calculi Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume.
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
Correct response: supine Explanation: Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are inappropriate for placing an infant to sleep.
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?
Correct response: transfer belt Explanation: A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady.
The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?
Correct response: trapeze bar Explanation: Promoting client independence with movement and activity is an important intervention for clients who are bedbound, especially ones with musculoskeletal problems. Unlike log rolling, trochanter rolls, and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.
The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?
Correct response: trapeze bar Explanation: Promoting client independence with movement and activity is an important intervention for clients who are bedbound, especially ones with musculoskeletal problems. Unlike log rolling, trochanter rolls, and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?
Correct response: trochanter rolls Explanation: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward.
The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?
Correct response:"To preserve the client's functional ability to grasp and pick up objects." Explanation: Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?
Correct response:Shift their weight back and forth, from back leg to front leg. Explanation:The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.
A nurse is preparing a prescribed dosage of a steroid inhalant medication for a client with asthma. Which action should the nurse take after administering the medication?
Instruct the client to rinse the mouth following inhalation. Explanation: The inhalant method distributes medication to distal areas of the airways, but some clients find that the inhaled drugs leave an unpleasant aftertaste or can develop oral candidiasis. For this reason the client should rinse the mouth following inhalation. There is no need to hold the breath, exhale slowly or exhale deeply after inhalation.
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?
Submitting a written notice to all clients identifying the uses and disclosures of their health information Explanation: Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data.
The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?
When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. Explanation:The nurse teaching a group of UAPs about proper body mechanics recognizes the need for additional education when a class participant states that, when lifting and carrying a heavy box of supplies, the UAP will keep it at an arm's length from body. This motion will result in injury and the UAP should be instructed to keep items close to the body.
The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?
slight Trendelenburg Explanation: Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed. Placement into the other position choices does not accomplish the same purpose.
The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as:
spasticity. Explanation: Spasticity refers to stiff or awkward muscle movements. Hemiparesis refers to weakness on one side of the body. Ataxia refers to impaired muscle coordination. Disequilibrium would lead to balance problems.
A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?
to prevent blood clot formation Explanation: The intermittent infusion devices are irrigated or flushed with a small quantity of sterile saline to prevent blood clot formation, thus maintaining patency. Irrigating the device with a small quantity of sterile saline does not facilitate cannulation of the central vein. The intermittent infusion device itself maintains venous access without requiring the client to receive continuous infusion, thus allowing increased mobility for the client and minimizing danger of fluid overload.