Basic Physical Care

The nurse is working on an ethics committee that is reviewing client-nurse interactions. Which nursing action indicates negligence? A nurse crushed medication ordered for oral administration and gave it through the PEG tube. A nurse failed to complete a fall risk assessment on a client until right before discharge. A nurse administered a generic drug instead of a brand-name drug per the pharmacist's orders. A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue injury.

A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue injury.

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first? Put a heavy blanket over the lamp. Call for help. Remove the client from the room. Use the fire extinguisher.

Remove the client from the room.

The nurse is caring for the following clients in the emergency department. Which client, scheduled for surgery, is a candidate for informed consent? 25-year-old client with Down syndrome 30-year-old client who is an involuntary admission 50-year-old client who is scheduled for elective surgery 40-year-old client with a concussion to the brain

50-year-old client who is scheduled for elective surgery

A nurse is assisting with the plan of care for a client who experienced a stroke in the right hemisphere of the brain. What intervention is appropriate for this client's care? Support the right arm with a sling or pillow to prevent subluxation. Provide close supervision due to the client's impulsiveness and poor judgment. Anticipate the client will exhibit some degree of expressive or receptive aphasia. When transferring the client into a wheelchair, place the wheelchair on the client's left side.

Provide close supervision due to the client's impulsiveness and poor judgment.

A nurse and unlicensed assistive personnel (UAP) are caring for six clients on a unit. Which action for promoting a safe environment can be delegated to the UAP? decision for safety measures placing alarm devices assessing a client's behavior administering chemical restraints

placing alarm devices

A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse? Stand at the head of the bed and slide the client toward the pillow. Ask for assistance from the lift team. Raise the head of the bed before repositioning. Roll the client side to side.

Ask for assistance from the lift team.

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? Chicken cutlet, spinach, and soda Spaghetti with cream sauce, broccoli, and tea Baked beans, hamburger, and milk Bouillon, spinach, and soda

Baked beans, hamburger, and milk

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take? Starting cardiopulmonary resuscitation Stopping the feeding and removing the NG tube Making the client comfortable Clearing the client's airway

Clearing the client's airway

A client is scheduled for a bronchoscopy. Pre-procedure, the nurse should instruct the client to avoid which activity? Eating Coughing Walking Talking

Eating

Which task can the licensed practical nurse (LPN) appropriately delegate to the nursing assistant? Encouraging a client to drink fluids Feeding a client for the first time after he has experienced a stroke Administering feedings through a nasogastric tube Obtaining vital signs on a client who has just returned from undergoing a colonoscopy

Encouraging a client to drink fluids

A nurse changes the wet-to-dry dressing of a client who has an open abdominal incision. Which nursing intervention is appropriate? Label the dressing with the date, time, and nurse's initials. Pack the wound tightly with wet-to-dry gauze sponges. Use a plastic moisture resistant barrier to cover the dressing. Irrigate the wound vigorously with sterile saline solution.

Label the dressing with the date, time, and nurse's initials.

A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse? Recommend the client remain in bed until strength returns. Apply a back belt before beginning the transfer. Break the transfer down into smaller steps. Obtain an assistive device to help with the transfer.

Obtain an assistive device to help with the transfer.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? Assess cognitive status. Assist the client to the bathroom. Offer the client sips of clear liquids. Remove restraints and assess skin and circulation.

Remove restraints and assess skin and circulation.

A client arrives in the clinic and informs the nurse they were bitten by a tick about a week ago on the back and are concerned about having contracted Lyme disease. When gathering data from this client, what early client clinical manifestations of Lyme disease should the nurse document? Select all that apply. The client reports severe neck stiffness. Swollen lymph nodes are present in the axillae. The client reports fatigue for the last 2 days. The client reports diarrhea for 1 day. There is a "Bull's eye" rash on the back.

There is a "Bull's eye" rash on the back. Swollen lymph nodes are present in the axillae. The client reports fatigue for the last 2 days.

A nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, where in the eye should the nurse instill the eyedrops? on the pupil on the sclera into the conjunctival sac into the vitreous humor

into the conjunctival sac

A nurse prepares to put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that does not have removable arms. Which method should the nurse select as the best way to return this client to bed? use a transfer belt to lift and transfer the client to the bed obtain assistance to use a mechanical lift to move the client use a plastic slider underneath the client to return the client to bed lift the client with assistance from other staff members

obtain assistance to use a mechanical lift to move the client

A nurse is caring for clients in a subacute unit. Which client care takes priority? changing a colostomy bag that is full suctioning a tracheostomy client with oxygen saturation of 90% changing a dressing on a wound with serosanguinous drainage administering pain medication to a client with a pain level of 7 out of 10

suctioning a tracheostomy client with oxygen saturation of 90%

A client has an prescription for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, which action should the nurse take? use a 45- to 90-degree angle always use the same injection site use the Z-track method aspirate after the injection

use a 45- to 90-degree angle

A client has been diagnosed with sleep apnea and the nurse is reinforcing education regarding the use of the continuous positive airway pressure (CPAP) device for home use. What statement made by the client indicates to the nurse that further reinforcement of the information should be done? "If I start to have stomach bloating and discomfort, I should discontinue use and call the healthcare provider." "I only have to use the CPAP if I am at home, but I don't have to use it when I am traveling away from home." "I will use the mask that has been designated for my use with the machine." "I need to be sure to clean the mask and tubing daily in order to prevent respiratory infections."

"I only have to use the CPAP if I am at home, but I don't have to use it when I am traveling away from home."

A client who's scheduled for surgery asks the nurse to keep $50 for him until he returns from surgery. How should the nurse respond? "I'll notify your physician about the money." "I'll notify the business office to make arrangements for your money to be placed in the hospital safe." "I'll put your money in an envelope and keep it in my locker until you return from surgery." "You can place your the money in your bedside drawer; it will be safe there."

"I'll notify the business office to make arrangements for your money to be placed in the hospital safe."

A child is brought to the emergency department with life-threatening bleeding that needs immediate intervention. The child's parents cannot be reached to give consent. The nurse continues to assist with the child's care based on which understanding about consent? Consent must be obtained from a neighbor or close friend of the family. Consent may be given by the family health care provider. Consent is not needed in a life-threatening situation. The consent must be in the form of a signed document; therefore, parents or guardians must be contacted.

Consent is not needed in a life-threatening situation.

The nurse is preparing to insert a nasogastric tube. What position would best facilitate insertion? supine prone Fowler's side-lying

Fowler's

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take? Asking the physician to give the client a tranquilizer Delaying I.V. fluid administration until the client's confusion ceases Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client Placing bilateral wrist restraints on the client

Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

Which example may illustrate a breach of confidentiality and security of client information? The nurse provides information to a professional caregiver involved in the care of the client. The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse informs a colleague that the colleague should not be discussing client information in the hospital cafeteria. The nurse accesses client information on the computer at the nurse's station then logs off before answering a client's call bell.

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

A nurse is preparing to change a client's sterile surgical dressing. Which is the first step the nurse will perform? Remove the old dressing with clean gloves Open sterile packages, and moisten the dressings with sterile saline solution Apply sterile gloves Wash her hands

Wash her hands

The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply. a 16-year-old who is obtaining an elective breast reduction for back pain relief a 72-year-old widow with dementia who needs a mastectomy for cancer removal a 7-year-old who needs an open reduction internal fixation (ORIF) of the right arm a married 17-year-old who requires a cholecystectomy for relief of nausea and pain a 62-year-old with macular degeneration who is ordered a routine colonoscopy

a 62-year-old with macular degeneration who is ordered a routine colonoscopy a married 17-year-old who requires a cholecystectomy for relief of nausea and pain

A client admitted with dehydration has urinary incontinence and excoriation in the perineal area. Which action would be a priority? maintaining a fluid intake of 1 L/day offering the urinal every 3 hours applying moist, warm compresses to the client's perineal area keeping the perineal area clean and dry

keeping the perineal area clean and dry

The nurse is caring for a client admitted with a fever, prolonged vomiting, and diarrhea for the last 2 days. The health care provider has diagnosed food poisoning. When assisting with the plan of care, what interventions does the nurse anticipate providing? encouraging fluids by mouth administering cleansing enemas to eliminate bacteria from colon administering IV antibiotics maintaining hydration with intravenous (IV) fluids

maintaining hydration with intravenous (IV) fluids

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator? creatinine 3.5 mg/dL (309.40 µmol/L) while client is receiving dialysis blood pressure of 130/90 mmHg before a brisk walk potassium 3.8 mEq/L (3.80mmol/L) before administration of intravenous fluid pain level 3/10 one hour after administration of pain medication

pain level 3/10 one hour after administration of pain medication

A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should: palpate the bladder above the symphysis pubis. feel that the bladder is smooth. palpate the bladder at the umbilicus. be unable to palpate the bladder.

palpate the bladder above the symphysis pubis.

The nurse observes a client, who has left-sided paralysis from a stroke, dress independently. Which action by the client indicates proper technique for dressing the upper-extremities? requests help because this activity is impossible to do independently places the affected arm in the shirt before the unaffected arm puts the shirt over the head before pulling it onto the affected arm buttons the shirt first before placing it on over the head

places the affected arm in the shirt before the unaffected arm

A nurse is caring for a client who had a transurethral resection of the prostate 1 day prior and is on continuous bladder irrigation. The nurse suspects the catheter is blocked. Which nursing intervention is appropriate? use sterile technique to irrigate the catheter gently slow the irrigation rate to prevent bladder distention prepare to reinsert a new three-way urinary catheter tell the client to try to urinate around the catheter

use sterile technique to irrigate the catheter gently

While preparing a client for a diagnostic study of the colon, the nurse teaches him how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? "I will administer the enema while sitting on the toilet." "I will administer the enema while lying on my right side with my left knee flexed." "I will administer the enema while lying on my left side with my right knee flexed." "I will administer the enema while lying on my back with both knees flexed."

"I will administer the enema while lying on my left side with my right knee flexed."

The nurse is caring for a client with a fever of 103°F (39°C) due to a respiratory infection. The client states, "I am freezing and I have a terrible headache!" What is the appropriate nursing action? Apply extra blankets to warm the client. Assist the client into a cool bath. No intervention should be provided since the fever will kill the bacteria. Administer acetaminophen as prescribed.

Administer acetaminophen as prescribed.

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action? considering a 1-inch edge around the sterile field as contaminated holding sterile objects above the level of the waist opening the outermost flap of a sterile package away from the body pouring solution directly onto a sterile field barrier

pouring solution directly onto a sterile field barrier

New evacuation procedures are being developed for the unit by a task committee at the long-term care facility, but have not been approved. A bomb threat has occurred in the facility. Which action is appropriate by the nurse? Ask staff members to quickly meet among themselves and decide what procedures to follow. Determine that the procedures currently in place must be followed. Tell staff members to use whatever procedures they feel are best. Tell staff members to assemble in the staff lounge to quickly offer their opinions about what to do.

Determine that the procedures currently in place must be followed.

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation? Cover by assessing the first nurse's patients hourly. Ask the nurse on the day shift to report the situation to the nurse manager. Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Nothing; the first nurse's patients did not call for assistance.

Discuss the situation with the first nurse, including the safety implications of sleeping on the job.

A registered nurse (RN) and licensed practical nurse (LPN) are reviewing the charts of their assigned clients. The LPN asks which clients the RN would identify as clients that may qualify for hospice care? Select all that apply. a client with late-stage acquired immunodeficiency syndrome (AIDS) a client who had coronary artery bypass surgery 2 weeks previously a client with cirrhosis/liver failure and encephalopathy a client who's undergoing treatment for heroin addiction a client with left-sided paralysis resulting from a stroke

a client with late-stage acquired immunodeficiency syndrome (AIDS) a client with cirrhosis/liver failure and encephalopathy

A nurse is reinforcing education for a client about using alcohol with certain drugs. Which medications should the nurse be most concerned about if the client reports combining them with alcohol? aspirin, antihistamines, and sedatives H2 receptor blockers and antacids penicillin-class antibiotics and decongestants oral contraceptives and caffeine-based weight-reduction medications

aspirin, antihistamines, and sedatives