Basic Care and Comfort

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders don't need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Most elderly actually sleep more than younger adults.

3. Correct: Caffeine and some medications may interfere with sleep.

A client consumes a lacto-ovo-vegetarian diet. During hospitalization, dietary intake has decreased 40%. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

1. Correct: The client can eat milk and dairy products along with grain products on this diet.

Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? Select all that apply: 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Administer acetacylic acid 325 mg every 4 hours in order to thin the blood.

2. & 3. Correct: Apply local massage gently to affected areas to help reduce muscle tension. This helps to decrease swelling, thus decreasing pain.

The nurse is teaching relaxation therapy to a client. A client asks, "How is relaxation therapy going to help reduce my stress?" What would be the nurse's best response? 1. This therapy works on some people, so it is worth a try don't you think? 2. Relaxation therapy reduces stress by releasing small doses of epinephrine into the body. 3. Stress can be eliminated from your life when you use this therapy. 4. Relaxation therapy can counteract the physiological and behavioral manifestations of stress.

4. Correct: This is a true statement.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply: 1. Substitute 2% milk for whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Use vegetable oil instead of solid shortening. 4. Incorporate plant sources of protein instead of a serving of meat. 5. Fry foods in olive oil.

1., 2. & 4. Correct: Two percent milk can reduce the amount of fat consumed daily, not only in milk that the client drinks, but also in foods that contain milk as an ingredient. Air-popped corn contains no fat unless butter is added after popping. The client still is able to have a crunchy snack without the fat. Plant proteins such as kidney, black, or lima beans are good sources of protein without the fat from a meat source.

The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? Select all that apply: 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises

1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent DVT.

After a retropubic prostatectomy for treatment of benign prostatic hyperplasia, a client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. On the initial assessment of the urine in the indwelling urinary catheter bag, the nurse observes the drainage is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage from the indwelling urinary catheter. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Correct: An expected urine color would be dark red. The nurse would need to increase the irrigation rate until the urine becomes light pink. There is nothing here to indicate that the client is hemorrhaging.

The nurse is providing care to a 5 year-old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by asking the client to sing with the nurse. 3. Suggest that the client try to relax. 4. Encourage the client to control the pain.

2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, watch TV with the client, or look at pictures.

Immediately following a below-the-knee amputation, the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. In a position of comfort 4. In a dependent position

2. Correct: Immediately after surgery, the foot of the bed should be elevated to reduce swelling.

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener. 2. Increase intake of fruit in the diet. 3. Monitor elimination habits for the next week. 4. Rest after each meal.

2. Correct: Increased fiber intake may help to establish regular elimination habits.

The nurse has previously identified sleep deprivation as a problem with an adult client. Which outcome indicates that the nursing interventions have been effective? 1. Client reports that she is sleeping 5 hours per night. 2. Client reports feeling rested upon awakening. 3. Client reports drinking 6-8 cups of coffee to stay awake. 4. Client reports being able to sleep if uninterrupted.

2. Correct: When a client is sleep-deprived, he is most likely to report feeling tired upon awakening. Reports of feeling rested upon awakening indicates that nursing intervention has been effective.

A hospice nurse is visiting for the first time a client reporting a lot of pain. In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client? 1. Physical therapist 2. Nutritionist 3. Massage therapist 4. Occupational therapist

3. Correct: The massage therapist provides alternative therapies that complement the medical pain control therapies being provided by the primary healthcare provider and the nurse.

The nurse is assessing a client's pain management. Which outcome indicates that pain management has been inadequate or ineffective? 1. Completes physical therapy with slight discomfort. 2. Performing activities of daily living with little discomfort. 3. Tolerates pain as long as possible before requesting treatment. 4. Reports feeling like a new person.

3. Correct: This comment indicates that the client has not received adequate pain management or that he has not been taught to request treatment before the pain becomes severe.

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

3. Correct: We want to position for comfort with the knees flexed and on the side for airway.

The hospice nurse has been assigned a new client who is being cared for at home by family members.Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time? 1. Providing temporary relief of care giving duties to allow the family to rest. 2. Providing education regarding the symptoms the client will likely experience. 3. Coordinating a visiting schedule for the family that is approved by everyone. 4. Communicating news of the client's impending death to the family while they are together.

4. Correct: Communicating news of the client's impending death to the family while they are together. The nurse's most important role in the care of the family is compassionate communication. The family needs to be informed about the situation so that they are prepared for the client's death and can provide support to one another.

The nurse is assessing a client for crutches. How does the nurse choose the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and then adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel. Then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 3-finger widths below the axilla to 6 inches lateral to the client's heel.

4. Correct: Measuring the client from 3 finger widths below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches.

The nurse is preparing to collect a capillary blood specimen for measuring blood sugar. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level when making the stick. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick.

2. Correct: Warming the finger will increase circulation to the site, thereby increasing blood flow.

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity

4. Correct: Specific gravity is an indicator of hydration status. In a dehydrated client, specific gravity is increased, indicating highly concentrated urine.

The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate electrolyte intake through foods and/or dietary supplements. Since the client is taking a loop diuretic, which foods should the nurse suggest to the client? 1. Cereals and breads 2. Avocados and milk 3. Table salt and spinach 4. Blueberries and summer squash

2. Correct: Avocados, milk, fruit juices, bananas and cantaloupe are good sources of potassium. Loop diuretics deplete the electrolyte potassium.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy should the nurse tell the class uses substances found in nature? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically based therapies.

4. Correct: Biologically based therapies use substances found in nature such as herbs, foods, and vitamins.

The nurse is teaching a newly diagnosed diabetic about proper foot care? Which are correct? Select all that apply: 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Check water temp

3., 4. & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold which could cause injury.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins.

The nurse is caring for a male of Arab descent admitted to the outpatient clinic for a colonoscopy. The client refuses to allow the female nurse to administer the enema, saying, "My wife will give me the enema." What should the nurse do? 1. Inform the client that allowing the wife to give the enema is not policy. 2. Teach the wife how to give the enema. 3. Notify the primary healthcare provider. 4. Assign a male unlicensed assistive personnel (UAP) to administer the enema.

4. Correct: In many Arab groups, it is not appropriate for a man to be alone with a woman other than his wife and vice versa. The clinical implication of this culture gender belief is that, for many clients from Arab cultures, nurses cannot provide direct physical care for clients of the opposite gender. A male UAP can give an enema.

The nurse instructs a client taking isoniazid regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with Blue Cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon 4. Pear salad

4. Correct: Pears are acceptable fruit.

The nurse instructs a client taking isoniazid regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon 4. Pear salad

4. Correct: Pears are acceptable fruit.

Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Thin skin on upper extremities. 2. Skin dryness on back, chest, and legs. 3. Redness of face and upper chest. 4. Small abrasion on great toe of right foot.

4. Correct: Skin breakdown on the foot is priority. Healing is likely to be impaired and the abrasion can be an entry point for microorganisms. There maybe other risk factors observed in the assessment; however, this finding should receive priority.

The nurse is bathing a confused client in the acute care unit. The nurse talks quietly with the client and explains each procedure. In the middle of the bath, the client becomes very agitated, kicking and calling for help. What should the nurse do? 1. Complete the bath as quickly as possible. 2. Reassure the client that everything is okay. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, then dress and reassure the client.

4. Correct: The nurse should not continue bathing if the client is becoming so distressed. Perhaps the bath can be completed at a later time

A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. *Have the client stand by the side of the bed for a few seconds. *Apply a gait belt to the client's waist. *Ambulate in the room. *Assess the client's orientation. *Assist the client to sit on the side of the bed for 1-2 minutes.

*Assess the client's orientation. *Assist the client to sit on the side of the bed for 1-2 minutes. *Apply a gait belt to the client's waist. *Have the client stand by the side of the bed for a few seconds. *Ambulate in the room.

The nurse plans to teach a client how to manage the use of a behind the ear hearing aid. What teaching strategies should the nurse include? Select all that apply: 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.

1. & 4. Correct: The residual from the hair spray causes the hearing aid to become oily and greasy. The client should routinely inspect the hearing aid for damage, especially where damage is more likely: ear mold, earphone, dials, cord, and connection plugs.

The nurse is assessing the clients listed below. Which client would benefit most from a quad cane? 1. A recent stroke victim with partial left leg paralysis. 2. A client with recent right total knee replacement. 3. A client with an unsteady gait requiring two people to assist with walking. 4. A recent stroke victim with complete right hemiplegia.

1. Correct: A recent stroke victim with partial left leg paralysis would benefit most from a quad cane. The quad cane provides the best support when there is partial leg paralysis.

The nurse is planning care for four clients. Which client would benefit most from an integrative medicine healthcare strategy? 1. A client with chronic fatigue syndrome who has had no relief of fatigue. 2. A client with diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. A client with cholecystitis who wants surgery to treat the symptoms definitively. 4. A client with a history of a cough for 4 days with green sputum production, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies.

The nurse instructs a client about deep breathing and coughing to be done after returning from surgery. Which statement by the client indicates that teaching has been effective? 1. "I will take deep breaths and cough hourly." 2. "Deep breathing and coughing is a form of relaxation." 3. "If I take deep breaths when I feel nauseous, I will not vomit." 4. "In order to be effective, I will stand up to cough and deep breathe."

1. Correct: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis.

The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take? 1. Inform the primary healthcare provider of the observations made regarding quad cane use. 2. Inform client that there are only a few assistive devices available to help with ambulation. 3. Instruct the client on proper quad cane use. 4. Do not notify the primary healthcare provider of the observations due to client confidentiality.

1. Correct: Inform the primary healthcare provider of the observations made regarding the quad cane. This client would most likely benefit from a walker.

The nurse is caring for a client of Puerto Rican descent. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted upon assessment? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

1. Correct: Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain.

What should the nurse teach the mother about appropriate sleep in teenagers? 1. Require 9 hours of sleep at night. 2. Tend to wake early in the morning. 3. Typically do not need a lot of sleep. 4. Do not usually suffer any ill effects from lack of sleep.

1. Correct: Teens need approximately 9 to 10 hours of sleep per night

The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? 1. Promotes return of venous blood to the heart and assists in preventing the blood from clotting in the legs. 2. Since the operating room is very cold, the stockings assist in maintaining a healthy core body temperature during surgery. 3. Promotes joint mobility and strengthens the leg muscles. 4. Promotes the return of arterial blood to the heart and prevents blood from clotting in the legs.

1. Correct: The anti-embolic stockings promote return of venous blood to the heart and assist in preventing the blood from clotting in the legs.

The parents of a 5 year old child have recently had a new baby and want to discuss their 5 year old's recent bedwetting. The parents report that the child had been dry all night for about 8 months, and now has started wetting the bed again. What should the nurse tell the parents is the most likely reason for this change? 1. There is a new baby in the house. 2. The child may have poor urination habits. 3. There may be a problem with the urinary system. 4. The child has been participating in sports.

1. Correct: The child may be feeling stressed by the addition of the new baby and less attention from the parents.

A client is complaining of pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? 1. Distraction 2. Biofeedback 3. Progressive relaxation 4. Cutaneous stimulation

1. Correct: The nurse uses distraction in the form of music while the oral analgesic takes effect.

What is the best method for the nurse to verifying correct nasogastric (NG) tube placement after insertion? 1. X-ray 2. Gastric aspiration and pH testing 3. Auscultation 4. Visualization of the tube markings

1. Correct: X-ray verification of tube placement is the most reliable method for verifying correct placement of the nasogastric tube in the stomach.

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication.

1. Correct: Yes, this is the best goal for pain and is age appropriate.

The nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complementary and/or alternative therapies? 1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki 5. Music

1., 2, 3, 4., & 5. Correct: All are considered complementary and/or alternative therapies.

The client reports having trouble sleeping at night. "My mind is constantly working and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? Select all that apply: 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercising for 45 minutes each evening before dinner.

1., 2. & 3. Correct: Working on job-related tasks before bedtime may increase anxiety and contribute to difficulty sleeping. Suspenseful night-time drama TV shows may be too stimulating prior to going to bed. Caffeine following dinner may interfere with sleep.

The nurse is providing foot care to the client who has diabetes. During foot care, the nurse teaches the client proper care of the feet. What should the nurse include in the teaching? Select all that apply: 1. Inspect the feet daily for abrasions or pressure areas. 2. Check water temperature with the hands before getting into tub. 3. Do not use heating pads on the feet or lower legs. 4. Thoroughly dry the feet, especially between the toes. 5. Cut toenails rather than file them. 6. Cut nails in a rounded fashion.

1., 2., 3. & 4. Correct: The feet should be inspected daily. Small tears or abrasions can occur without the client awareness due to decreased sensation in the feet. The client may be burned by getting into water that is too hot due to decreased sensation in the feet. There is less chance of decreased sensation in the hands. Heating pads may burn the client's feet. It is better to apply blankets for warmth. Drying the feet and between the toes will prevent skin breakdown.

What should the nurse suggest to promote sleep and rest in the preschool child? 1. Allow the child to choose own bedtime based on degree of fatigue. 2. Develop a consistent routine before going to bed. 3. Encourage the child to play until becoming sleepy. 4. Have the child go to bed with the parents.

2. Correct: A consistent routine helps to prepare the child for sleep. Reading or telling stories before bedtime may help the child to relax and fall asleep more easily.

The nurse is instructing a client in the use of a cane. Which is the best description of correct cane technique? 1. Place the cane on weaker side of body to support weaker leg. Using the cane for support, step forward with good leg, and then move weaker leg and cane forward to the good leg. 2. Place the cane on stronger side of body. Place cane forward 6 to 10 inches while client stands with body weight divided between two legs. Weaker leg is advanced to cane, with body weight divided between good leg and the cane. 3. Place cane on weaker side of body. Cane is placed forward 6 to 10 inches while client stands with body weight divided between two legs. Weaker leg is advanced to cane, with the body weight divided between good leg and cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with good leg and then move weaker leg and cane forward to good leg.

2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client stands with the body weight divided between the two legs. The weaker leg is then advanced to the cane, with the body weight divided between the good leg and the cane. Finally the stronger leg is advanced past the cane and the weaker leg, with the body weight divided between the cane and the weaker leg.

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

2. Correct: The client may be lonely and miss the interaction with others. Eating with others may help to improve appetite and intake of food.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hand 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the groin prior to bathing 4. Elevating the casted leg on two pillows

2. Correct: The new cast should not be covered so that heat from the cast can evaporate.

The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Confusion and disorientation. 2. Scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.

2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client.

A home health nurse is caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the best action of the nurse? 1. Leave and return once the curandero has left. 2. Discuss the plan of care with the client, family, and curandero. 3. Ask the curandero to leave so that the client can be assessed. 4. Explain to the family that the curandero is not a reliable healthcare option.

2. Correct: This is the best course of action for the nurse. The health and healing of a client comes from many components, including spirituality, religion, folk remedies, alternative therapies, and modern medicine. Unless something is harmful to the client, it is best to incorporate all components into the care of the person.

The nurse is caring for a client with Clostridium Difficile. Which interventions should be included in the plan of care for an adult client with diarrhea? Select all that apply: 1. Consume four glasses of water per day. 2. Encourage client to eat bananas or clear soups. 3. Encourage client to consume foods containing insoluble fiber. 4. Increase soluble fiber foods in the diet such as potatoes or rice. 5. Advise client to seek medical care if the condition persists.

2., 4. & 5. Correct: These foods contain potassium and sodium which are lost during diarrhea. Soluble fiber is suggested for clients with diarrhea; however, insoluble fiber is not. If diarrhea persists for more than 48 hours, the client should seek medical care.

The home care nurse, working with an infant in the home, is concerned about the infant developing diaper rash from wearing cloth diapers. Which strategies should the nurse teach to the parents to prevent skin irritation? Select all that apply: 1. Change diapers every four hours. 2. Wash diapers with antibacterial soap. 3. Rinse diapers twice when washing. 4. Apply a protective ointment to diaper area with each diaper change. 5. Check infant at least hourly for wet or soiled diapers.

2., 3., 4. & 5. Correct: Antibacterial soap will remove skin bacteria as well as urine from the diaper. Antibacterial soaps are irritating to the skin and may cause dryness; therefore, adequate rinsing is important. A protective ointment is even more important to use with cloth diapers, as they do not have the same wicking properties of the disposable diapers. Frequent check of the diaper for wetness and soiling will limit the contact time for urine or feces to be in contact with the skin.

The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better, but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? Select all that apply: 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Provide heat therapy. 5. Using distraction techniques.

2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to the mom's comment? Select all apply: 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2., 3., 4. & 5. Correct: Preschoolers typically require 11 - 13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical. The nurse should determine if the child has difficulty falling asleep. If so, perhaps more restful nighttime rituals should be implemented.

A client reports difficulty sleeping since starting a new job. The nurse's assessment identifies that the client is also working after hours from home. Which teachings are appropriate to promote sleep in this client? Select all that apply: 1. Vary bed times to determine time best to promote sleep. 2. Only use the bedroom for sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

2., 3., 4. & 5. Correct: The client should associate bed with sleep, not work. Eating late in the evening may interfere with sleep, especially if a heavy meal. Caffeine late in the evening may increase alertness and interfere with sleep. Many people respond positively to white noise. Music on the other hand may make it more difficult to sleep.

The nurse is planning discharge teaching regarding safety for a client with thrombocytopenia. Which points should the nurse include? Select all that apply: 1. Floss between teeth twice a day. 2. Eat soft foods. 3. Take bisacodyl every day to prevent straining 4. Wear shoes with firm soles while ambulating. 5. If bumped, apply ice to site for 20 minutes.

2., 4. & 5. Correct: Hard food can cause bleeding as it passes through the esophagus, and can cause gums to bleed. Firm soles on shoes can prevent puncture wounds while ambulating. Ice will prevent hematoma formation and stop bleeding.

The nurse is assigned four clients to care for on an inpatient medical floor. When planning care, the nurse recognizes which client to be at the greatest risk for ineffective oral hygiene? 1. Client who has just had knee surgery after a skiing accident. 2. Right-handed client who has had a stroke causing mild weakness on the left side of the body. 3. Client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. Independent, elderly client having elective surgery.

3. Correct: A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the normal bacterial flora of the mouth.

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning 2. Tell the client that the primary healthcare provider will not prescribe anything stronger than acetaminophen. 3. Rate the client's pain using the pain scale used by the ED 4. Administer ibuprofen and send the client to the waiting room

3. Correct: Just because a client is a frequent visitor to the emergency department reporting migraines does not mean that the client is addicted to narcotics or that the client is not really experiencing the pain.

The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? 1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed.

3. Correct: Placing a turn sheet under the client before moving will prevent shearing forces which may lead to an abrasion or skin tear.

The nurse is caring for a preoperative client who received lorazepam 5 minutes ago and is now requesting to void. What is the appropriate nursing action? 1. Ask the unlicensed assistive personnel to assist the client to the bathroom. 2. Insert a indwelling urinary catheter since the client is going to surgery. 3. Place the client on a bedpan. 4. Allow the client to go to the bathroom.

3. Correct: Placing the client on a bedpan is the safest and least invasive choice.

The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation? 1. 1000 2. 300 3. 500 4. 800

3. Correct: The client needs an extra 500 kcal/day above the usual allowance because the average woman will secrete between 425-700 kcals per day in her breast milk. By increasing the daily caloric intake by 500 kcal the client will offset these losses.

The nurse is caring for a client who is unresponsive during a postictal state. Which position is correct for this client? 1. Prone 2. Supine 3. Side lying 4. Semi-fowlers

3. Correct: The client should be placed on the side, in the recovery position, to prevent aspiration. Think safety.

The nurse has been caring for a client in the home who is experiencing new onset of constipation. Which goal is most appropriate for a client reporting constipation? 1. Client will have one bowel movement each day. 2. Client will no longer experience constipation. 3. Client will return to his normal bowel elimination habits. 4. Client will have more frequent bowel movements.

3. Correct: The client's normal pattern of elimination is important. A thorough assessment would reveal this information.

The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary? 1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion." 4. "When I have inhaled in as much as possible, I will hold my breath for a few seconds before exhaling."

3. Correct: The proper method is to inhale slowly and deeply through the nose, allowing the abdomen to expand. The chest should be moving only slightly.

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy? Which position would be best for this client? 1. Fowlers 2. Modified sims 3. Side lying 4. Supine

3. Correct: We want to position for comfort with the knees flexed and on the side for airway.

The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. How should the nurse document this handwriting change? 1. Fetor 2. Ataxia 3. Apraxia 4. Asterixis

4. Correct: Yes, the liver flap, abnormal muscle tremor, is usually found in clients with diseases of the liver.