basic care and comfort quiz

The nurse instructs a group of colleagues on actions to take to prevent back injuries when providing client care. Which statement by a colleague indicates that additional teaching is required? A. "A back belt prevents injuries." B. "It is safer to use an assistive device." C. "A lift team will help prevent back injuries." D. "An assistive device reduces the risk of client injury."

"A back belt prevents injuries."

An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion? A. "Actually it's not true that older people always stop having sexual activity when they get older." B. "It's true that they've probably stopped having sexual activity but it's important for them to have companionship." C. "That's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship." D. "Research has shown the nature of sexual activity changes with age but that it actually becomes more frequent."

"Actually it's not true that older people always stop having sexual activity when they get older."

A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness? A. "Have you spoken to the physician about using the Chinese herbs and acupuncture?" B. "What do you want to accomplish by using these methods rather than researched practices?" C. "Once you have recovered from this illness, you can go back to your traditional ways." D. "Let's discuss your desire to integrate these practices with the physician and advocate on your behalf."

"Let's discuss your desire to integrate these practices with the physician and advocate on your behalf."

A client has a prescription for an oil retention enema and a cleansing enema. The client asks the nurse to explain the purpose of the enemas. What is the most accurate response by the nurse? A. "It is common for people with constipation to need two different types of enemas to obtain results." B. "Oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement." C. "The cleansing enema is given first so that the oil retention enema is more effective." D. "Oil retention enemas lubricate the bowel lining and cleansing enemas soften the stool."

"Oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement."

A client asks to be discharged from the healthcare facility against medical advice (AMA). What should the nurse do first? A. Prevent the client from leaving. B. Notify the physician. C. Have the client sign an AMA form. D. Call a security guard to help detain the client.

notify the physician

The nurse is preparing to clean around a client's G-tube that was placed 1 week ago and change the gauze dressing. Based on the type of procedure, what type of precautions are needed? A. Sterile procedure, droplet precautions B. Clean procedure, universal precautions C. Clean procedure, contact precautions D. Sterile procedure, airborne precautions

Clean procedure, universal precautions

The nurse is educating a client who works with chemicals on immediate emergency care in the event of eye exposure. Which statement reflects correct teaching by the nurse? A. "You should not attempt to do anything at home - come directly to the emergency department." B. "You can flush your eyes briefly with sterile water to try to remove the chemical." C. "You should flush your eyes for about 15 minutes with tap water to remove the chemical." D. "You need to treat both eyes by flushing with water even if only one has been chemically exposed."

"You should flush your eyes for about 15 minutes with tap water to remove the chemical."

Which explanation would be most appropriate when teaching a child about general anesthesia induction? A. "You will be given an injection before you go to surgery to make you sleepy." B. "You will breathe in oxygen through a facial mask and receive intravenous medication to make you sleepy." C. "You will receive intravenous medication to make you sleepy." D. "You will breathe in medication through a facial mask to make you sleepy."

"You will breathe in medication through a facial mask to make you sleepy."

A nurse is caring for a male client of a different culture. Which nursing actions should the nurse include to provide culturally appropriate care to this client? Select all that apply. A. Asking the client's sibling to be involved in the plan of care. B. Allowing the daughter to bring food from home appropriate to the client's dietary plan. C. Inquiring about a dining ritual that is often used at home. D. Explaining to the client that good health is more important that cultural values. E. Including the religious leader when developing the plan of care per the client's wishes.

-Allowing the daughter to bring food from home appropriate to the client's dietary plan. -Inquiring about a dining ritual that is often used at home. -Including the religious leader when developing the plan of care per the client's wishes.

The nurse enters a client's hospital room and has difficulty identifying the hospitalized client among the six people in the room. The nurse is administering new medication. What are the nurse's best actions? Select all that apply A. Ask the client to identify his/her name and date of birth. B. Ask the client to show his/her hospital name band. C. Assume the client is sitting on the bed. D. Ask the visitors to step out of the room. E. Return to the room after the visitors leave.

-Ask the client to identify his/her name and date of birth. -Ask the client to show his/her hospital name band. -Ask the visitors to step out of the room.

The nurse has been assigned to a client who is hearing impaired and reads speech. Which care measure(s) should the nurse incorporate when communicating with the client? Select all that apply. A. Avoid being silhouetted against strong light. B. Do not block out the person's view of the speaker's mouth. C. Face the client when talking. D. Have bright light behind so the individual can see. E. Ensure the client is familiar with the subject material before discussing it. F. Talk to the client while doing other nursing procedures.

-Avoid being silhouetted against strong light. -Do not block out the person's view of the speaker's mouth. -Face the client when talking. -Ensure the client is familiar with the subject material before discussing.

A nurse is caring for a postsurgical client with two types of drains. Which task(s) can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A. Assess the drainage of an open drainage system, such as a Penrose drain. B. Document the drain site and surrounding tissue status. C. Stabilize an open drainage system, such as a Penrose drain. D. Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. E. Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain.

-Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. -Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain.

A client with mild dementia is experiencing back pain after a fall. Which nursing documentations are important? Select all that apply. A. The client is incontinent of urine. B. The client's bed alarm is set at low volume. C. The client is wearing nonskid socks while in bed. D. The incident report was sent to the nurse manager. E. The client reports lower back pain at a level of 5 on a 0-10 scale.

-The client is incontinent of urine. -The client is wearing nonskid socks while in bed. -The client reports lower back pain at a level of 5 on a 0-10 scale.

A nurse administers medications to the wrong client in a hospital. The client has an anaphylactic reaction to one of the medications and expires. What legal actions against the nurse can the family pursue? Select all that apply. A. There are no legal consequences with the common error. B. The family can open a legal claim for malpractice against the nurse. C. The family can open a legal claim for malpractice against the hospital. D. The family can seek a fair settlement outside the courtroom. E. The nurse can resign from the hospital and no further legal action will occur.

-The family can open a legal claim for malpractice against the nurse. -The family can open a legal claim for malpractice against the hospital. -The family can seek a fair settlement outside the courtroom.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply. A. The student nurse is responsible for the student nurse's actions. B. The student nurse is held to the same standard of care as a nurse. C. The student can practice as an employee during clinical experiences. D. The student nurse is not responsible for knowing the facility's policy and procedures. E. The nursing instructor can be liable if the assignment is above the student's

-The student nurse is responsible for the student nurse's actions. -The student nurse is held to the same standard of care as a nurse. -The nursing instructor can be liable if the assignment is above the student's competency.

A nurse is named as a defendant in a pediatric client case. What are guidelines for the nurse to follow prior to the trial? Select all that apply. A. Discuss the case with the involved physician. B. Limit contact with the assigned attorney. C. Add comments during the questioning to build the story. D. Use polite language while answering questions. E. Be prepared to answer questions about the case during the trial.

-Use polite language while answering questions. -Be prepared to answer questions about the case during the trial.

The nurse is taking care of a client with Clostridioides difficile. To prevent the spread of infection, the nurse should take which action(s)? Select all that apply. A. Wear a particulate respirator. B. Wear sterile gloves when providing care. C. Cleanse hands with alcohol-based hand sanitizer. D. Wash hands with soap and water. E. Wear a protective gown when in the client's room.

-Wash hands with soap and water. -Wear a protective gown when in the client's room.

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply. A. a client with bacterial meningitis B. an older adult client with influenza C. a client with a positive staphylococcus wound culture D. a client receiving antibiotics for a fever after surgery E. a client with a critically low white blood cell count

-a client with bacterial meningitis -an older adult client with influenza

The nurse on a medical-surgical unit has interventions to complete in the morning. Which tasks are most appropriate to delegate to an unlicensed assistive personnel (UAP)? Select all that apply. A. assisting a client with ambulation B. monitoring a client's pain level with activity C. evaluating a client's ability to perform self-care D. applying a hydrogel to a sacral pressure injury E. opening breakfast foods on the breakfast tray

-assisting a client with ambulation -opening breakfast foods on the breakfast tray

The nurse is evaluating a client who is at risk for skin breakdown. Which characteristics would the nurse observe to determine there is a Stage I pressure ulcer? Select all that apply. A. non-blanchable redness over a bony prominence B. intact skin C. blister D. eschar E. slough F. partial thickness loss of dermis

-non-blanchable redness over a bony prominence -intact skin

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply. A. respiratory distress B. redness C. pain around the infusion site warmth D. edema above the insertion site

-redness -pain around the infusion site -warmth -edema above the insertion site

The nurse is planning care for a client on complete bed rest. To prevent venous thrombosis, what should the nurse include in the plan of care? Select all that apply. A. turning every 2 hours B. passive and active range-of-motion exercises C. use of thromboembolic disease support (TED) hose D. maintaining the client in the supine position E. increasing fluid intake to 3,500 mL per day

-turning every 2 hours -passive and active range-of-motion exercises -use of thromboembolic disease support (TED) hose

A nurse is walking down the hospital corridor and sees a person collapsed outside the hospital dining room. In which order will the nurse respond? All options must be used. 1. Report findings to the rapid response team. 2. Call for emergency help. 3. Alert the family of the event. 4. Assess the client for breathing and pulse. 5. Begin emergency resuscitation as needed. 6. Complete an incident report.

2. Call for emergency help. 4. Assess the client for breathing and pulse. 5. Begin emergency resuscitation as needed. 1. Report findings to the rapid response team. 6. Complete an incident report. 3. Alert the family of the event.

A nurse is assessing the skin of a client that is receiving a warm compress applied to a wound. The nurse notes slight maceration and excessive redness of the surrounding skin. What should the nurse do, in order from first to last? All options must be used. 1. Assess client for other manifestations. 2. Report findings to healthcare provider. 3. Remove the compress. 4. Stop the heat application. 5. Apply new sterile dressing.

4.Stop the heat application. 3. Remove the compress. 5. Apply new sterile dressing. 1. Assess client for other manifestations. 2. Report findings to healthcare provider.

The nurse is assessing a client that is receiving the first dose of an antibiotic for a left leg staphylococcus aureus infection. Upon assessment, the nurse notes the client is experiencing dyspnea, cyanosis, and tachycardia. Place the steps that the nurse should perform in the correct order. All options must be used. 1. Document interventions and client's response. 2. Notify the rapid response team. 3. Implement interventions ordered. 4. Stop the antibiotic infusion. 5. Place the client in high Fowler's. 6. Monitor vital signs.

5. Place the client in high Fowler's. 4. Stop the antibiotic infusion. 2. Notify the rapid response team. 6. Monitor vital signs. 3. Implement interventions ordered. 1. Document interventions and client's response.

The client is to have pneumatic compression devices applied. The client is hesitant to have the device applied. What is the best response by the nurse? A. "This device will help push blood from the small vessels to the large vessels in your legs and prevent you from developing a blood clot." B. "Because you are in bed it is important for you to wear this device so you do not develop a blood clot." C. "The pressure from this device will provide comfort and prevent you from developing a blood clot." D. "Your healthcare provider feels it is important for you to wear this device to prevent you from developing a blood clot."

A. "This device will help push blood from the small vessels to the large vessels in your legs and prevent you from developing a blood clot."

The nurse is observing a spouse administer eye drops, as shown in the figure. What should the nurse instruct the spouse to do? A. Move the dropper to the inner canthus. B. Have the client raise their eyebrows. C. Administer the drops in the center of the lower lid. D. Have the client squeeze both eyes after administering the drops.

Administer the drops in the center of the lower lid.

Which statement is correct regarding the Omnibus Reconciliation Act of 1986? A. All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation. B. The medical examiner should be notified whenever donated organs or tissues may be available. C. The facility may not release the donor's name without the family's permission. D. Hospitals need not have designated requesters who approach families for organ and tissue donation.

All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation.

Which situation demonstrates correct principles of confidentiality? A. An emergency department nurse reports suspected child abuse. B. Two nurses alone in an elevator are discussing a client's status. C. A nurse talks about clients without disclosing their names on Facebook. D. During change-of-shift report, a nurse talks about a client's personal problems that the client disclosed to the nurse that day.

An emergency department nurse reports suspected child abuse.

Which circumstance likely requires the most documentation and communication by the nurse? A. An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. B. A client is being discharged home following a laparoscopic appendectomy 2 days earlier. C. A client is being transferred from one medical unit of the hospital to another to accommodate another client on isolation precautions. D. A client is returning to an assisted-living facility following a colonoscopy earlier that day

An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? A. Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. B. Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. C. Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. D. Ask the assistant manager to develop a plan for the review and revision of client-education materials.

Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members.

A client admitted to the hospital for chemotherapy states that using a peppermint-scented candle at home to helps control nausea. Which interventions would the nurse plan to promote comfort for this client? A. Telling the client she may use his scented candles B. Asking the client to try using peppermint oil in place of scented candles C. Asking the physician to increase the client's anti-nausea medication D. Asking the physician to order a sedative for the client to use during chemotherapy

Asking the client to try using peppermint oil in place of scented candles

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When teaching the client about the diet, the nurse should take which action first? A. Determine the client's knowledge level about cholesterol. B. Ask the client to name foods that are high in fat, cholesterol, and salt. C. Explain the importance of complying with the diet. D. Assess the client's and family's typical food preferences.

Assess the client's and family's typical food preferences.

A staff nurse would like to effect change to increase staffing levels on the nursing unit. What strategy should the nurse use to begin to create change on the unit? A. Assess the institutional resources available to increase staffing. B. Assess the current standards of practice related to staffing. C. Assess the impact of staffing on client-care quality. D. Assess the effect increased staffing will have on nursing recruitment.

Assess the impact of staffing on client-care quality.

A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first? A. Encourage the client to increase their oral fluid intake. B. Insert an intermittent urinary catheter. C. Use an ultrasound bladder scanner to determine urine volume in the bladder. D. Assist the client up to the toilet to attempt to void.

Assist the client up to the toilet to attempt to void.

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess on how to care for the wound at home. What information should the nurse give the spouse about cleaning the wound? A. Clean the incision and drainage sites simultaneously. B. Clean from the incision site to the drainage site. C. Clean from the drainage site to the incision site. D. Clean each site independently.

Clean each site independently.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention? A. All personnel should wear protective clothing, including a gown, gloves, and respiratory protection. B. Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. C. Clients should be instructed to wash thoroughly with soap and water. D. Access to the area should be restricted.

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day? A. Complete regular admission procedures. B. Schedule the client for screening tests. C. Prepare for long-term care needs. D. Provide detailed information on the procedure.

Complete regular admission procedures.

A nurse is caring for a morbidly obese client who has undergone surgery for weight loss. The client reports pain 8/10 despite morphine sulfate 1 mg/hour continuous infusion being administered via a patient-controlled analgesia (PCA) pump. Which action will best protect the nurse from issues of liability? A. Contact the health care provider with a request for a change in PCA B. Provide the client with nonpharmacologic means of pain control C. Add morphine sulfate 1 mg/8 min IV as a client-administered dose to the continuous infusion E. Explain to the client that pain is expected with weight loss surgery

Contact the health care provider with a request for a change in PCA

A client with a history of tuberculosis dies. What should the nurse do when caring for the body? A. Ask the mortician what needs to be done with the body. B. Perform routine postmortem care as identified by the facility. C. Contact the local health department to learn how to handle the body. D. Prepare to transport the body to an offsite facility for disease validation.

Contact the local health department to learn how to handle the body.

The nurse is caring for a client with a Jackson-Pratt drain. Which action by the nurse would be the most appropriate? A. Leave the drain open to the air to ensure maximum drainage. B. Ensure that the drainage receptacles are kept compressed to maintain suction. C. Attach the tube to straight drainage to monitor the output. D. Irrigate the drain with normal saline to ensure patency.

Ensure that the drainage receptacles are kept compressed to maintain suction.

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse? A. Explore other ways to control symptoms and address the family's concerns more effectively. B. Reinforce the meaning of supportive care to the family and restrict their visits so the client has more rest time. C. Provide support for the family and encourage the client to become more actively involved in the care. D. Determine where the client is regarding the stages of dying and discuss the findings with the family.

Explore other ways to control symptoms and address the family's concerns more effectively.

A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks if the nursing assistant has been validated on obtaining fingerstick glucose readings. The nursing assistant does not have the skill validated, but has observed it many times and reports confidence in the ability to perform the skill. What should the nurse do? A. Give the nursing assistant the glucose meter, and let the nursing assistant perform the fingerstick. B. Provide the nursing assistant with an article on the procedure. C. Go with the nursing assistant into the client's room, and validate the nursing assistant's ability to perform the procedure. D. Perform the fingerstick glucose testing instead of the nursing assistant.

Go with the nursing assistant into the client's room, and validate the nursing assistant's ability to perform the procedure.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? A. Splint the abdomen with a pillow and call the surgeon. B. Apply an abdominal binder. C. Reinforce the existing dressing with another dressing. D. Lift the dressing to assess the wound.

Lift the dressing to assess the wound.

The nurse prepares to administer medications via a gastrostomy tube (G-tube) and notes the measurement of the incremental marking is 0.5 cm difference from what is recorded on the medical record. What action should the nurse take? A. Do not aspirate or flush the tube and notify the healthcare provider immediately. B. Aspirate and note if tube feed is present as this verifies placement in stomach. C. Measure pH of aspirated contents and if less than 5.5, this verifies placement. D. Measure pH of aspirated contents and if more than 5.5, this verifies placement.

Measure pH of aspirated contents and if less than 5.5, this verifies placement.

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take? A. Refuse to float to the ICU. B. Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment. C. Report to the ICU and accept a total client assignment; ask the nurses for assistance when necessary. D. Report to the ICU, tell the ICU nurses the pediatric nurse has never worked in the ICU, and let the nurses decide what tasks the pediatric nurse can perform.

Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment.

The nurse walks into the room of a client who has a "do-not-resuscitate" prescription and finds the client without a pulse, respirations, or blood pressure. What should the nurse do first? A. Stay in the room, and call the nursing team for assistance. B. Push the emergency alarm to call a code. C. Page the client's health care provider (HCP). D. Pull the curtain and leave the room.

Stay in the room, and call the nursing team for assistance.

A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? A. Perform frequent mouth care. B. Use normal saline nose drops daily. C. Sneeze and cough with the mouth closed. D. Gargle every 4 hours with salt water.

Perform frequent mouth care.

The nurse is teaching a client how to prevent shoulder ankyloses following chest surgery. What should the nurse teach the client to do? A. Turn from side to side. B. Raise and lower the head. C. Raise the arm on the affected side over the head. D. Flex and extend the elbow on the affected side.

Raise the arm on the affected side over the head.

When the nurse is removing personal protective covering, what action should this nurse (see figure) take to avoid spreading nosocomial infections? A. Remove the face mask. B. Place the face mask over the mouth and nose before removing the hair covering. C. Wash hands before tying the strings on the mask. D. Tie the dangling strings of the mask around the neck.

Remove the face mask.

The nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 50 mg metoprolol extended release tablet to be given via the feeding tube once daily. How should the nurse give this medication? A. Crush the tablet, mix with a small amount of water, and infuse into the feeding tube, followed by a flush B. Add the tablet to the feeding tube whole, followed by a flush C. Request an alternate formulation D. Give the tablet by mouth instead

Request an alternate formulation

When a nurse observes a colleague preparing to irrigate the ear canal of a client with a suspected foreign body in the ear canal, which is the best nursing action? A. Request that the colleague does not irrigate. B. Notify the healthcare provider. C. Ensure that the irrigation solution is warm. D. Obtain a sterile specimen cup.

Request that the colleague does not irrigate

The nurse notices that a cart being used to transport a client has a nonfunctioning clasp on the safety belt. What should the nurse do next? A. Call the safety/security department to report the problem. B. Use a draw sheet to secure the client during transport. C. Contact the clinical engineering department to repair the clasp. D. Request that the transporter bring a different cart with a functional clasp.

Request that the transporter bring a different cart with a functional clasp.

The nurse is assessing a client who is receiving normal saline intravenously at 100 mL/hr through the right forearm. The nurse observes that the forearm is swollen, cold to the touch, and pale. What action would the nurse take? A. Turn the intravenous fluids off for 1 hour, and then reassess the right forearm. B. Decrease the normal saline rate to 30 mL/hr, and notify the health care provider. C. Gently flush the peripheral intravenous line. D. Restart the infusion at a different site.

Restart the infusion at a different site.

The nurse walks into a client's room to administer the 0900 medications and notices that the client is in an awkward position in bed. What should the nurse do first? A. Ask the client to state his or her name. B. Check the client's name band. C. Straighten the client's pillow behind the back. D. Give the client the medications.

Straighten the client's pillow behind the back.

A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which priority would be the most important? A. Explain the importance of a health professional evaluating gait and assessing for motor deficits. B. Discuss instability and effective use of ambulatory aids to stabilize the base of support. C. Teach about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness. D. Discuss decreasing activity and favoring the use of wheelchairs, rather than mobility aids, to reduce the incidence of falls.

Teach about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness.

Which action by the client indicates that the client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? A. The client breathes in through the nose and out through the mouth. B. The client breathes in through the mouth and out through the nose. C. The client uses diaphragmatic breathing in the lying, sitting, and standing positions. D. The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? A. The nurse dries from finger tips down toward elbows. B. The nurse dries from forearms up toward fingers. C. The nurse keeps hands lower than elbows while washing. D. The nurse uses at least 3 to 5 mL of liquid soap.

The nurse dries from forearms up toward fingers.

The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do? A. Obtain informed consent from the client. B. Explain the surgical procedure in detail. C. Verify that the client understands the informed consent form. D. Inform the client about the risks of the surgery to be performed.

Verify that the client understands the informed consent form.

The nurse unit manager is making rounds on a team of clients and notices a client with a color-coded armband that indicates the client is at risk for falling while walking down the hall unassisted. The client is at the end of the hallway and far from their room, but they are not tired. What should the nurse do first? A. Obtain a wheelchair, and take the client back to the room. B. Walk with the client back to the room, and assist the client to get in bed or a chair. C. Locate an unlicensed nursing personnel (UAP) to walk with the client back to the room. D. Instruct the client to walk only in the room at this time.

Walk with the client back to the room, and assist the client to get in bed or a chair.

The nurse has received a change-of-shift report. The nurse should assess which client first? A. a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 who has exhibited agitation, fearfulness, and sleeplessness over the last 36 hours B. a 36-year-old with chest tube due to spontaneous pneumothorax with current respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal cannula C. a 28-year-old who is 2 days post appendectomy with discharge prescriptions written and whose spouse is waiting to take the client home D. a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose hemoglobin is 13.8 g/dL (138 g/L)

a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 who has exhibited agitation, fearfulness, and sleeplessness over the last 36 hours

The nurse is concerned about poor nutritional status of several clients on the unit. The nurse recommends placement of a gastrostomy tube for feeding as most appropriate for which client? A. a young adult client with ulcerative colitis having bloody diarrhea B. an older adult client with terminal cancer prescribed comfort care only C. a client with dysphagia from a stroke 1 month ago and awaiting extended care D. a client with dysphagia from a stroke 48 hours ago awaiting rehabilitation

a client with dysphagia from a stroke 1 month ago and awaiting extended care

In a disaster situation in the emergency department, the nurse is assessing a client who is critically ill, with a high likelihood of mortality. Which triage level would be appropriate? A. a low priority B. treatment of care needed within 10 minutes C. no care necessary at this time D. critical emergent care

a low priority

The nurse is preparing the room for a client diagnosed with varicella. Identify which sign the nurse would place on the room door. A. Airborne B. Contact C. Droplet D. standard

airborne precaution

A nurse-manager must include which items as part of the personnel budget? A. anticipated overtime payments for staff B. computers for staff use C. office supplies for secretarial use D. videos for staff education

anticipated overtime payments for staff

A nurse is planning to implement nonpharmacological pain management strategies as part of a multimodal approach for managing the client's pain. For which strategy does the nurse seek a prescription from the health care provide A. massage B. application of an ice bag C. distraction D. deep breathing

application of an ice bag

A client informs the nurse that he is leaving the healthcare facility because he is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and few investigations are scheduled. Which is the most appropriate action by the nurse to prevent false imprisonment? A. restrain the client to prevent him from going B. call the physician and speed up the discharge process C. ask the client to sign release without medical approval D. tell the client that he will not be able to get access again

ask the client to sign release without medical approval

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort? A. assault B. battery C. negligence D. right to refuse care

assault

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should A. leave the client and get help. B. assess the client for pain. C. read the facility's policy on restraints. D. order soft restraints from the storeroom.

assess the client for pain.

Which option is an example of a primary preventive measure? A. participating in a cardiac rehabilitation program B. having an annual physical examination C. practicing monthly breast self-examination D. avoiding overexposure to the sun

avoiding overexposure to the sun

The nurse is teaching a client who has had a hemorrhoidectomy about postoperative care at home. The nurse should tell the client not to use sitz baths until at least 12 hours postoperatively to avoid causing which complication? A. bleeding B. rectal spasm C. urine retention D. constipation

bleeding

A primiparous woman has just given birth to a term infant. What topic should the nurse teach the client about first? A. sudden infant death syndrome (SIDS) B. breastfeeding C. newborn medications D. infant sleep-wake cycles

breastfeeding

The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client? A. postoperative hip arthroplasty B. varicella C. congestive heart failure D. pneumonia

congestive heart failure

The student nurse is admitting an elderly patient with congestive heart failure and sets up the room with standard precautions. Which is noted by the nursing instructor as the best action? A. wearing gloves for all client contact B. considering all body substances potentially infectious C. placing a body substance isolation sign on the client's door D. wearing a gown if the client is in respiratory isolation

considering all body substances potentially infectious

A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? A. a palpable radial pulse B. a palpable ulnar pulse C. cool, pale fingers D. pink nail beds

cool, pale fingers

The client has been prescribed vaginal cream for a yeast infection to be administered via a vaginal applicator. Which position would the nurse instruct the client to take for appropriate administration? A. supine position B. low Fowler's position C. Sims' position D. dorsal recumbent position

dorsal recumbent position

A client is admitted with peritonitis. Which is the priority of nursing care for this client? A. pain management B. fluid and electrolyte balance C. nutritional management D. psychosocial issues

fluid and electrolyte balance

The nurse is teaching the client with vitamin B12 deficiency about ways to increase the dietary intake of vitamin B12. Which foods would provide the best supply of vitamin B12? A. whole grains B. green, leafy vegetables C. meats and dairy products D. broccoli and brussels sprouts

meats and dairy products

Which nursing intervention is appropriate for a client with an arm 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 2 hours

monitoring circulatory status every 2 hours

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.

ground beef patties.

A scrub nurse in the operating room has which responsibility? A. positioning the client B. assisting with gowning and gloving C. handing surgical instruments to the surgeon D. applying surgical drapes

handing surgical instruments to the surgeon

A nurse is helping a client move up in the bed. Which action maintains good body mechanics? A. always keeping the bed in a low position B. having the client fold the arms across the chest C. raising the head of the bed D. having the client help as much as possible

having the client help as much as possible

A hospitalized client is experiencing "fight versus flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for which symptom? A. increased urinary output B. decreased arterial blood pressure C. increased blood glucose D. decreased mental acuity

increased blood glucose

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client? A. lactose enzyme deficiency B. tuberculosis C. sickle-cell anemia D. suicide

lactose enzyme deficiency

Which action most clearly demonstrates a nurse's commitment to social justice? A. lobbying for an expansion of Medicare eligibility and benefits B. ensuring that a hospital client's diet is culturally acceptable C. answering a client's questions about care clearly and accurately D. documenting nursing care in a timely, honest, and through manner

lobbying for an expansion of Medicare eligibility and benefits

The nursing instructor is working with a student in a preoperative unit. The student notices that the informed consent has not been signed. Which is the best action taken by the student nurse for obtaining informed consent? A. asking the primary nurse to get the informed consent B. notifying the physician involved with the procedure that the consent has not been signed C. asking the nurse working with the physician to get the informed consent D. notifying the social worker

notifying the physician involved with the procedure that the consent has not been signed

The nurse is scheduling postural drainage treatments for a client. What would be the most appropriate time of day to implement this? A. immediately upon awakening B. one hour before a meal C. before bedtime D. one hour after a meal

one hour before a meal

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? A. monitoring his temperature every 4 hours B. increasing fluid intake C. covering the client with a light blanket D. providing a low-calorie diet

providing a low-calorie diet

A client who suffered a stroke has a nursing diagnosis of ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal? A. repositioning the client every 2 hours B. restricting fluids to 1,000 ml/24 hours C. administering oxygen by nasal cannula as ordered D. keeping the head of the bed at a 30-degree angle

repositioning the client every 2 hours

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to A. immediately remind the night-shift nurses of the daily calibrations. B. arrange a meeting of the day-shift and night-shift nurses. C. review the capillary glucose monitoring calibration log book. D. counsel the night charge nurse about the discrepancy.

review the capillary glucose monitoring calibration log book.

A nurse is conducting a nutrition class for a group of teenagers. Which food choices would a nurse encourage this group as best to consume to increase their dietary fiber content? A. carrots with dressing B. sandwiches on whole grain bread C. peeled apples with peanut butter D. a serving of cashew nuts

sandwiches on whole grain bread

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? A. friction B. impaired circulation C. localized pressure D. shearing forces

shearing force

The nurse is recording information in the electronic health record for a client with dehydration who is at risk for skin breakdown. Which documentation demonstrates an area of insensible fluid loss for this client? A. temperature B. blood pressure C. urine output D. chest tube drainage

temperature

Professional regulations and laws that govern nursing practice are in place for which reason? A. to limit the number of nurses in practice B. to ensure that practicing nurses are of good moral standing C. to protect the safety of the public D. to ensure that enough new nurses are always available

to protect the safety of the public

The nurse is planning care for an older adult with an indwelling catheter who is at risk for septic shock. Which nursing action will be most important for this client? A. administering intravenous (IV) fluid replacement therapy as ordered B. obtaining vital signs every 4 hours for all clients C. monitoring red blood cell counts for elevation D. using aseptic technique when caring for the catheter

using aseptic technique when caring for the catheter

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is A. fluid intake and output. B. urine specific gravity. C. vital signs. D. weight.

weight.

The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? A. verbalizes the understanding that physical activity must be curtailed. B. will place an aspirin in the drainage pouch to help control odor. C. demonstrates how to catheterize the stoma. D. will empty the drainage pouch frequently throughout the day.

will empty the drainage pouch frequently throughout the day.

The mother of a client who has a radium implant asks why so many nurses are involved in their daughter's care. They state, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? Nurses: A. touch the client, which increases their radiation exposure. B. work with many clients and could carry infection to a client receiving radiation therapy if exposure is prolonged. C. work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. D. are at greater risk from the radiation because they are younger than the mother.

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.