Basic Care and Comfort - ML4

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse?

"I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication."

The nurse is preparing a client for a bladder irrigation. The client states, "I don't understand why I need this procedure." What is the nurse's best response?

"It helps to flush your catheter to decrease urine flow from being blocked."

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

"Limiting my salt intake to 2 grams per day will improve my blood pressure."

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.

1. Use of a tub/shower seat may be necessary if balance problems are present. 2. Water temperature should be monitored carefully due to decreased temperature sensation. 3. Use a long-handled shower brush or attachment to help with limited mobility.

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which client actions will the nurse document on the I&O record? Select all that apply

1. drinking milk 2. urination 3. vomiting 4. infusion of intravenous solution

A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.

42

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse?

Check the medical record for a provider's prescription for compression stockings.

The nurse listens to a client explain that she is receiving manipulations from a health care provider. The nurse documents in the client's chart that the client is using which therapy?

Chiropractic

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein

Which type of cast encloses the trunk and a lower extremity?

Hip spica

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?

Keeping the perineal area clean and dry

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

Music therapy may provide reality orientation, distraction, and sensory stimulation.

A client returned from surgery 8 hours ago and has not voided. Which action should the nurse take first?

Palpate over the synthesis pubis for fullness.

A client with paraplegia for the past 12 years is hospitalized with pneumonia. It would be best for the nurse to

Place the client's wheelchair next to the bed for independent transfer.

The family of a deceased client has yet to make funeral arrangements. What should the nurse expect to be done with the body?

Prepare it for storage in the facility's morgue refrigerator.

A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?

Provide an opportunity for the client to talk about concerns.

A client who was a victim of a motor vehicle accident dies in the emergency department. What should be done first to support the client's family at this time?

Provide the family with a private place to begin grieving.

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client?

Raise the hips using trapeze.

A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client?

Sleep Deprivation

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium daily.

A nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. What instructions would the nurse give to this client?

Take an afternoon nap.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleaners and moisture barriers.

A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client?

as often as needed

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for

diaphoresis, vomiting, and diarrhea.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough

A male client tells the nurse that he has been taking an herbal supplement to aid with insomnia. What herbal supplement is the client taking?

melatonin

A nurse in a nutrition clinic is to give 2 cups of organic prune juice to a client every night. The nurse is to document this on the nursing chart. What unit will the nurse use to document the amount of juice according to the metric system of measurement?

milliliter

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to

rest in an air-conditioned room.

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?

vitamin D