BASIC CARE AND COMFORT (82)

A nurse who is caring for a client discusses strategies to promote rest and sleep. Which of the following statements indicate a need for further teaching?

" I will walk briskly for 30minutes before bedtime."

A nurse provides teaching to a client on proper hearing aid use. Which of the following statements indicates a need for further instruction?

"I will clean the hearing aid with alcohol wipes." ** Alcohol use can break down the mechanism of the hearing aid.

A nurse is caring for a client who has total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. WHich of the following actions should the nurse takes?

Auscultate bowel sounds. ** assessment first.

A nurse is caring for a client on bedrest. which of the following is the priority action to include in the client's plan of care?

change client's position at least every 2 hrs.

A nurse is caring for a client who has acute pancreatitis. After the client's pain has been addressed, which of the following is the next intervention to include in the plan of care?

maintain NPO status. ** to rest the pancreas and reduce secretion of pancreatic enzyme.

A nurse is caring for a client following a left hip arthroplasty. Which of the following should the nurse implement to prevent dislocation?

maintain foam wedge between legs.

a nurse is caring for a client who has a halo traction device. which of the following actions should the nurse include when providing care?

monitor for elevated temperature.

A client who has a fracture of the right tibia has had a fiberglass cast applied. To teach the client how to observe and mange his casted extremity at home, the nurse should include which of the following instruction?

report any worsening or unrelieved pain.

A nurse is providing teaching to a client who has stomatitis. Which of the following statement by the client indicates a need for further teaching?

"I will season foods with dried spices before cooking." ** the client should avoid spices, acidic food, and salty foods b/c they can cause additional irritation to the oral mucosa.

A nurse is caring for a client who has thickened skin, hyperpigmentation, and parasthesia in the lower extremities. Which of the following actions should the nurse implement?

Apply elastic stockings. * This client is exhibiting s/s of venous insufficiency. Venous insufficiency occurs as a result of prolonged venous hypertension, which stretches the veins and damages the valves. t/x for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic stockings should be worn during the day and evening, and applied before getting out of bed. Elastic stocking reduce venous stasis and assist in venous return of blood to the heart.

a nurse is caring for a client who has been on strict bed rest for 1 week. which of the following finding indicates client readiness to ambulate?

performs active range of motion exercise to all extremities.

A nurse is caring for a client who has a new prescription for a low-sodium diet. the client's family has requested to bring in some of the client's favorite foods. which of the following food items should the nurse tell the family members to omit?

pickled vegetable. * Due to the pickling brine, pickled vegetable are high in sodium. The family should not bring this food item to the client.

A nurse is caring for an older adult client who has left-sided weakness. which of the following information regarding the use of a cane is appropriate?

place can on right side, and advance left foot forward.

A nurse is providing palliative care to a hospice client who is unconscious. Which of the following prescriptions should the nurse expect?( Select all that apply)

suction PRN. Perform mouth care every hour. Administer oxygen 2L/min per NC.

A nurse is providing palliative care to a client whose partner ask why music therapy has been recommended. which of the following responses would be appropriate for the nurse to make? (SATA)

Music therapy can help her verbally express emotion. Music therapy work as a distraction and can help alleviate her pain. Music therapy can help facilitate movement in some clients who have mobility limitations.

A nurse is providing teaching about ways to promote eating to a client with chronic obstructive pulmonary disease .Which of the following statements by the client indicates a need for further teaching?

"I will take my bronchodilators after meals." * Bronchodilator should be taken before meals, not after, in order to reduce SOB.

A nurse is caring for a client who is requesting prescription pain medication. Which of the following actions should the nurse perform first?

determine the location of the pain.

A nurse is implementing strick intake and output on a client. the client's output for the past 12hr includes the following: jackson-Pratt drain 35ml NG suction 120 ml Incontinence pads weighing 240g, 275g, 310g, and 270g. Incontinence pad dry weight 90g.

890 ml. ** 1g = 1ml.

A nurse is receiving report about assigned clients at the start of the shift. which of the following clients should the nurse plan to attend to first?

A client who experienced a cesarean birth 4 hr ago and report pain.

A nurse auscultates a client's bowel sounds. which of the following actions by the nurse would require intervention by a charge nurse?

Palpates the abdomen prior to performing auscultation.

A nurse is caring for a client who receives intermittent enteral feeding through an NG tube. Before administering a feeding, the nurse should measure the gastric residual to

identifying delayed gastric emptying.

a nurse is caring for a client who has a chronic illness and is admitted due to anorexia and malnutrition. which of the following finding should the nurse expect?

Decrease mental status.

A nurse provides enteral tube feeding teaching to a client. WHich of the following statements indicates a need for further teaching?

"the formula will be kept cold until each use". * Tube feeding formula should be administered at room temperature. If the formula is cold, it can cause gastric cramping, nausea, and vomiting.

Q nurse completes the I&O record for a client who consumed breakfast and lunch as follows: Intake: 4 oz clear soda, 1 pice of toast, 12 oz of water, 1 cup of fruit-flavor gelatin, 1/2 cup of chicken broth 300 ml of 0.9% sodium chloride IV. Output: 460 ml of urine. 90ml of drainage from the suction drainage system. What should the nurse document as the client's intake?

1140ml.

A nurse is caring for a client and is to maintain I&O. What is the client's intake during an 8hr period based on the following data? breakfast -- 4oz juice and 6 oz hot tea. Voided 450ml after breakfast. IV bolus of 150ml at 0900. 100ml of ice chips before lunch. Lunch -- 8oz of clear broth. Vomited 120ml and voided 600ml after lunch. Jackson Pratt drain emptied of 40ml bloody drainage at 1330ml.

790 ml

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the skin.

A client is reporting unrelieved episiotomy pain 8hr after delivery. Which of the following actions should the client's nurse take?

Apply an ice pack to the perineum. * During the first 24 hr, ice packs and cool water sitz baths should be used. This should reduce edema and reduce discomfort.

A nurse is providing postmortem care. Identify the sequence of steps the nurse should follow.

Certification of death declared by the provider. Organ/tissue donation status verified by the nurse. Medical equipment removed from the client. Body cleansed while adhering to body fluid precautions. Identification tag applied to the body.

A nurse is talking with a client who has a new dx of gastroesophageal disease (GERD).During D/c teaching the client asks the nurse which food he should avoid eating. Which of the following is an appropriate nursing response?

Chocolate. ** the client should avoid food that reduce pressure on the lower esophageal sphincter. These include: fatty n fried food, chocolate, caffeine, alcohol, and carbonated drinks.

A nurse is providing postmortem care to an adult client. Which of the following intervention should the nurse include? (SATA)

Determine whether an autopsy has been ordered. Cover body with a sheet and place head on pillow. Maintain cultural and religious rituals regarding death. Cleanse body, maintaining standards regarding body fluid.

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions performed by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter drainage bag.

A client has acute renal failure (ARF) and is receiving IV fluids to treat acute renal failure (ARF). which of the following findings should indicate to the nurse that a therapeutic affect is being achieved?

Glomerula filtration rate (GFR) 125ml/min. ** GFR: over 90ml/min. BUN: 10 -20mg/dl Urine specfific gravity: 1.005-1.030. serum creatinine: 0.5 - 1.1 ml/dl

A nurse is caring for client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon.

A nurse is teaching a client who has left hemiparesis how to properly use a cane. WHich of the following should the nurse include in the teaching?

Hold the cane on the right side to provide support for the weaker extremity. ** keep the can on the unaffected side of the body.

A nurse is reinforcing teaching about comfort measure for breast engorgement with a postpartum client who is breastfeeding. Which of the following statements by the client indicate a need for further teaching?

I should stimulate my nipples by squeezing softly." ** nipple stimulation should be avoided in breast engorgement. it cause milk production and may exacerbate the engorgement.

A nurse is caring for a post-op client. Which of the following comfort measure should the nurse recognize as appropriate to include in the care? (SATA)

Keep bed linens smooth. Monitor transcutaneous electrical nerve stimulation (TENS) therapy. (** this help to control pain) Give a back massage. Teach relaxation techniques such a guide imagery.

A nurse is caring for a child who has acute gastroenteritis but is able to retain oral fluids. The nurse should anticipate providing which of the following type of fluid?

Oral rehydration solution.

A nurse is caring for a client who is receiving heat application using an aquathermia pad. which of the following is an appropriate action when applying the pad?

Place a thin towel over the affected area before application. ** a thin towel or pillowcase is applied to the affected area before placing the pad.

A nurse is administering a cold application to a client. WHich of the following manifestations indicates the need to discontinue the application due to systemic response by the client?

Shivering. * shivering is a systemic response to cold in order to promote heat production.

A nurse is preparing to transfer a client who has limited mobility from the bed to a chair. THe client weighs 113.6 kg (250lbs). which of the following actions should the nurse take?

Use a mechanical lift, and transfer the client with the assistance of another nurse.

A nurse is caring for an infant who is receiving IV therapy. WHich assessment finding indicate fluid volume excess? SATA

heart rate of 190/min during sleep. Periorbital edema. crackle upon auscultation.

A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calories and protein intake? (SATA)

top fruit with yogurt. Add cream to soup. Use milk instead of water in recipes. Dip meat in eggs and bread crumbs before cooking.

a nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many ml on the client's intake and output record?

1170 ml. 1 cup = 8oz. 1oz = 30ml

A nurse is caring for a client whose right leg is placed in Buck's traction. Which of the following should the nurse implement to promote mobility?

Active range of motion to the left leg. * active ROM is the best way for a client to maintain joint function and mobility while on bed rest.

a client has a first-degree ankle sprain. which of the following interventions should the nurse reinforce immediately after the injury? (SATA)

Elevate ankle above the level of the heart. (promote venous return) Wrap ankle with an elasticized compression bandage. Apply intermittent cold compress to the ankle for the first 24-48 hours.

A nurse is caring for an older adult client who is at risk for skin breakdown. WHich of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Provide the client with a diet high in protein.

A nurse is assessing a 4 month old. Which of the following finding should be reported to the provider?

Unable to raise head when in prone position.

A charge nurse is making client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? (SATA)

Bathing a client who had an amputation 2 days ago. Assisting a client to ambulate using a gait belt. Feeding a client who had a stroke 3 months ago.

The nurse is caring for a client who has a newly inserted chest tube connected to suction and a water seal drainage system. Which of the following indicates the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber. ** fluctuation of fluid within the water seal chamber occurs with inspiration and expiration until the client's lungs have reexpanded or the system is occluded.

A nurse is implementing a bladder training program. Which of the following action by the assistive personnel (AP) who is assisting in the client's care indicates a need for further instruction?

Instructs the client to void whenever the urge occurs.

A nurse is caring for a client who is in Buck's traction. Which of the following nursing intervention is appropriate? (SATA)

Monitor peripheral pulses in the affected extremity. Examine the skin under the traction splint. Assess the temperature of the affected extremity.

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain a venous duplex ultrasould. ** this in a noninvasive dx test to detect distal DVT. Homan's sign is not useful and not advised.

a client is recovering from a cerebrovascular accident (CVA). which of the following information should the nurse include when teaching family members about repositioning? (SATA)

Remove pillows priors to repositioning. Elevate the bed to waist height. Stand with feet wide apart. Face the direction of movement when positioning the client.

A nurse is instructing the mother of a toddler who has iron-deficiency anemia to increase iron in the child's diet in addition to the prescribed iron supplement. Which of the following food should the nurse recommend?

Tuna fish. ** Good source of iron that are more readily absorbed than plant sources include: seafood, meat, and eggs.

A charge nurse observes a nurse administer intermittent tube feeding via an NG tube to a client. Which of the following actions should prompt the charge nurse to immediately intervene?

The nurse allow the client to sleep in supine position during feeding.

A nurse is listening to report on assigned clients at the beginning of the shift. which of the following information establishes a priority for the nurse?

a client had a catheter removed 7 hr ago and has not voided.

A client who has diverticulitis is being admitted to a nurse's unit. Which of the following menu selections should a nurse recommend for this client?

grilled chicken breast with white rice. ** diverticulitis diet: low fiber, low-residue diet.

A nurse provides teaching to a client who is being fitted for a prosthetic leg. Which of the following statements indicate to the nurse a need for further instruction?

"The prosthesis fitting will occur at the time the staples are removed." ** this is false statement. The staples are removed before the shrinking and shaping of the residual leg is complete. The prosthesis would not fit once this process is complete.

A client is caring for a group of clients. which of the following clients should the nurse know has an increased risk of aspiration while eating? (select all that apply)

A client who was admitted with a d/x of cerebrovascular accident. A client who is 4hr post-op following a leg amputation with general anesthesia. A client who is 8 hr following traumatic laryngeal nerve damage. A client who has a prior shift admission with a recent prolonged coughing episode.

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). which of the following strategies should the nurse implement to promote the infant's growth and development?

Allow infant to stand in the crib. * the infant should not be restricted from normal activities. The infant can be held and allowed to walk in a cast or orthotic device. Allowing the child to participate in normal developmental activities will promote growth and development.

A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following would be the best meal choice?

Beans. * an increase in protein is needed to aid in the promotion of tissue healing post-injury. vegan diets may be lower in protein. Nut and legumes will increase the amount of protein in the diet, which will aid in tissue repair.

A client who has undergone a right below-the-knee amputation due to trauma now has a prosthetic limb. When teaching the client about prosthetis and stump care, the nurse should include which of the following instructions?

Dry the prosthesis socket completely before applying it to the limb. ** the client should dry the prosthesis socket throughly with a clean cloth. Moisture between the socket and the stump can put the client at risk for fungal or bacterial infection and skin breakdown.

A nurse is planning care for a client following surgery who is having headaches due to receiving spinal anesthetic. Which of the following is included in the plan of care?

Encourage increased intake of fluids. ** increased oral fluid intake promote increases intracranial pressure which may relieve spinal headache.

A nurse is caring for a client who is postoperative following a cholecystectomy and is reporting pain. WHich of the following actions should the nurse take? (SATA)

Offer the client a back rub. identify the client's pain level. Change the client's position.

A nurse is planning teaching for the parents of a toddler who follow a vegetarian diet. The nurse should plan to include which of the following foods as the best source of dietary protein for the child?

Soy milk.

A nursing is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

The pacemaker spikes before each QRS complex. * The pacemaker stimulates the ventricle and the QRS complex appears, indicating that depolarization has occurred.

A nurse is reinforcing teaching about nutritional consideration with the parent of a toddler. which of the following statement by the parents indicates understanding of the teaching?

The quality of food I provide him is more important than the quantity.

A nurse is developing a plan of care to prevent skin break down for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (SATA)

Use pillow to keep heels off the bed surface. Minimize skin exposure to moisture.

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following are appropriate nursing action? (SATA)

Use sterile technique when preparing the irrigation solution. Ensure the drainage tubing is patent and without obstruction. Notify the surgeon if the urine is bright red in appearance or has large clot.

A nurse is preparing to remove an NG tube from a client. Which of the following should be the nurse's priority action?

Verify provider order to d/c the tube.

A nurse should reinforce teaching on how to use a three-point gait for which of the following clients requiring crutches?

a client who has a right femur fracture prescribed no weight bearing of affected leg.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, the nurse should:

check that the client lifts the walker and then places it down in front of her. ** the client should lift the walker and advance it about 6inches, then set it down. this allows her a wide base of support while she move forward.

a nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. the client is reporting anxiety, discomfort, and a feeling of bloating. which of the following is the nurse's priority action?

check to see if the suction equipment is working.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse includes on the client's lunch tray?

cranberry juice.

A nurse is caring for a 6-months-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?

increased crying episodes.

a nurse is caring for a toddler who is having difficulty sleeping during hospitalization. which of the following action should the nurse take to help promote sleep?

provide home bedtime rituals.

A nurse is caring for a client in a long-term care facility who is receiving enteral feeding via an NG tube. WHich of the following is an appropriate nursing action prior to administering the tube feeding?

test the pH of gastric aspirate.

A nurse is giving a client a cold compress for episiotomy pain. Which of the following would be the best measurement of pain relief?

asking the client to rate the pain.

A nurse is educating coworkers about how to minimize back pain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include?

avoid prolonged sitting. Sleeping in a side-lying position with flexed knees. Try shoe insoles.

A nurse is caring for a 5 year old client who is post-op following tonsillectomy. the surgeon initially prescribed a clear liquid diet. Which of the following items should the nurse include on the child's lunch tray? (SATA)

broth. grape juice. lemon gelatin.

A nurse is caring for a client who needs to increase his protein intake. the client suggests some food he think might help. Which of the following foods should the nurse recommend as the best source of protein of these suggestion?

chicken

A nurse provide a back massage as palliative care to an unconscious client who is grimacing and restless. which of the following indicates a therapeutic response? (SATA)

the shoulder droop. The facial muscle relax. The pulse is within normal range.