Exam 1 Review Questions P3

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Owen is a 15-year-old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. A support team was called and 4-point restraints were applied in this emergent situation. How soon does a licensed provider need to assess the client and place the restraint order? 15 minutes 4 hours 1 hour 30 minutes

1 hour Restraints can be placed emergently without the order of a licensed provider. However, a face-to-face assessment of the client must be made within 1 hour of restraint placement.

A nurse is selecting a product to provide a complete bed bath to a client who is on bed rest. Which product would be best to use in this manner? Bathing wipes Bar soap Body foam Bathing cloths

Body foam Body foam can be used as a body wash, no-rinse shampoo, and perineal cleanser. Bathing wipes and cloths would not be used on the hair. Bar soap is not normally used in clinical settings.

A nurse is reading a journal article about evidence-based practice. The nurse understands that this practice is an outcome of which type of research? Translational Quantitative Qualitative Experimental

Translational Although quantitative, qualitative, and experimental are types of research, evidence-based practice is an outcome of translational research, the bridge between theory and practice.

The nurse is caring for a bedbound client who reports not being able to rest comfortably on their back. In which position will the nurse place the client to improve sleep? supine lateral prone Sims

lateral Because many people routinely fall asleep in the side-lying position or lateral position, this is a comfortable alternative to the supine position for the client on bed rest. Supine is on the back, prone is lying face down, and Sims is halfway between lateral and prone positioning. Sims position places the body out of alignment, which can be more uncomfortable for the client. Sims is the position utilized for the administration of enemas. Prone positioning is lying face down and may not be a comfortable alternative due to the torsion pressure applied to the neck when lying prone.

1 hour Restraints can be placed emergently without the order of a licensed provider. However, a face-to-face assessment of the client must be made within 1 hour of restraint placement.

The nurse is caring for four clients. For which client is a sitz bath most appropriate? 42-year old recovering from a C-section delivery 51-year old with hemorrhoids 60-year old who is 1-day postop from a knee replacement 73-year old with pneumonia who can get up to bedside commode

51-year old with hemorrhoids A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. Therefore, the client with hemorrhoids would benefit from this type of cleansing treatment. The other clients do not get as much benefit from this type of bath.

A nurse who is infected with human immunodeficiency virus (HIV) accidentally gets a cut while debriding a wound, exposing the client to possible HIV infection. Failure of the nurse to report this incident violates which ethical principles? Select all that apply. Justice Autonomy Nonmaleficence Veracity Fidelity

Nonmaleficence Veracity Fidelity Nonmaleficence means "doing no harm" or avoiding an action that deliberately harms a person. By not reporting this incident, the nurse is deliberately harming the client. Veracity means the duty to be honest and avoid deceiving or misleading a client. Fidelity means being faithful to work-related commitments and obligations, such as reporting the incident. Justice and autonomy do not apply in this scenario.

The nurse is preparing to reposition a client on bedrest to the left side. Which action should the nurse prioritize? Seek assistance from another health care worker. Ensure a friction-reducing pad is in place. Raise the siderails before moving the client. Stand opposite the client's center

Seek assistance from another health care worker. The nurse should seek assistance from another health care worker before repositioning the client to ensure safety. The other options would be addressed when both health care workers are ready to reposition the client.

A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? She has hot water to bathe in. She has good mobility around her home. She has motivation to participate in self-care. She has family and friends who help her with self-care.

She has motivation to participate in self-care. An internal resource is one that comes from within the client. An external resource is one her environment and community offer her.

The nurse observes slight bruising on the client's left thigh during a bed bath and palpates a lump on the anterior surface of the thigh. Which will the nurse document on the electronic health record (EHR)? "During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh." "Bed bath completed." "Client has bruising on left thigh from previous fall." "During bed bath, nurse palpated 5-cm lump on client's left thigh."

"During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh." Bathing promotes assessment of the client's physical condition by noting injured areas, such as bruises, rashes, or any other unusual signs. Documentation should be complete and factual. Documentation that includes objective findings, such as slight bruising noted to the left thigh and 5 cm hard lump noted on palpation on anterior aspect of the left thigh, is complete and factual. Documenting just that the bed bath is completed and only documenting either the bruising or the lump is incomplete documentation.

A nurse is caring for an older adult client who has expressed concern regarding their decreased level of mobility, particularly walking around the house. Which question by the nurse is most appropriate to gain more information related to the client's safety at home? "Have you fallen down at all in the last few months?" "Do you have anyone that can help you at home?" "Do you use a cane or a walker at home?" "Do you have any throw rugs in the home?"

"Have you fallen down at all in the last few months?" Asking about any previous falls is a significant predictor of future falls and risk of fracture and should be the priority assessment for safety. Having someone to help at home would be appropriate for someone expressing difficulty with activities of daily living, but it does not address the client's current safety risk. Asking about assistive devices and throw rugs is appropriate but is not the priority over previous falls.

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use a washcloth to clean the auricles and cerumen when needed." "I use cotton-tipped applicators daily to remove cerumen." "I never use bobby pins or other sharp objects when cleaning cerumen." "I clean my ear mold on my hearing aid daily before use."

"I use cotton-tipped applicators daily to remove cerumen." Healthy ears require little to no care. Cerumen (ear wax) can accumulate, causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal. Clients should be educated to not use cotton-tipped applicators because it may push cerumen further back into the ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries.

The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful? "I will start a walking program, walking as fast as I can." "Ideally, I should exercise for an hour 2 times a week." "I will do the same kind of activity or exercise every day." "I will invite a friend to exercise with me."

"I will invite a friend to exercise with me." Exercising with a friend will add the support of a buddy. Joining a spa, health club, or exercise group is also recommended to provide support to exercise. Exercise sessions should be introduced gradually to prevent overexertion and injury to muscles. Clients should be encouraged to exercise for 30 to 45 minutes 3 or 4 times per week. Alternating types of exercise will help prevent boredom.

The nurse is teaching a client who has experienced multiple dental caries in the past year. Which client statement indicates that the teaching has been effective? Select all that apply. "I will brush once a day." "I will rinse with water when I cannot brush." "I will drink clear soda instead of brown soda." "I will increase my intake of calcium." "I will not chew ice cubes or crushed ice."

"I will rinse with water when I cannot brush." "I will increase my intake of calcium." "I will not chew ice cubes or crushed ice." The client should brush teeth twice daily, rinse with water when brushing cannot be accomplished, avoid soda of any kind, increase calcium intake, and refrain from chewing ice.

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? "Put on your shirt." "Don't put on your shoes yet." "Put your arm in this sleeve." "Put your pants on and zip the zipper."

"Put your arm in this sleeve." When communicating with a client with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. "Put your arm in this sleeve" gives one step in the process of getting dressed. "Put on your shirt" involves many steps and should be broken down into the steps of putting on a shirt. "Put your pants on and zip the zipper" should be broken down into steps and given in clear, short sentences. Furthermore, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the "Don't"; the client may put the shoes on if the nurse states "Don't put on your shoes yet."

A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply. "Stand centered between the back legs of the walker." "Keep your arms relaxed at the side of the walker." "Line up the top of the walker with the crease on the inside of your wrist." "Your elbows should be nearly straight when you grasp the walker." "Move the walker forward 12 to 18 in (30 to 45 cm) with each step and set it down."

"Stand centered between the back legs of the walker." "Keep your arms relaxed at the side of the walker." "Line up the top of the walker with the crease on the inside of your wrist." Regardless of the type of walker used, the client stands between the back legs of the walker with arms relaxed at the side, the top of the walker should line up with the crease on the inside of the client's wrist. When the client's hands are placed on the grips, elbows should be flexed about 30 degrees. Have the client move the walker forward 6 to 8 in (15 to 20 cm) and set it down, making sure all four feet of the walker stay on the floor. Then, tell the client to step forward with either foot into the walker, supporting himself or herself on his or her arms. Follow through with the other leg.

A nurse is conducting an in-service on the early history of the education of nurses in the 19th century. Which statement made by the nurse demonstrates how far nursing has come as a profession from the 19th century? "Education was founded on theoretical knowledge behind interventions." "The focus was on students providing direct care to clients without pay." "The focus was on promoting nursing as a profession." "It occurred in the university setting."

"The focus was on students providing direct care to clients without pay." In the early history of nursing education, training was based on an apprenticeship model. It was often hard to distinguish nursing service from nursing education. An example of this was students providing direct client care without pay. The setting for the training was in hospital-owned schools, not the university setting. Education was based on sound clinical medical evidence and the use of Florence Nightingale's influence. Early nursing education did not promote nursing as a profession

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary? "The hand rolls help keep my thumb positioned away from my hand." "The hand rolls help me develop strength in my grip." "I can use a rolled-up washcloth if I don't have a hand roll." "I need to remove the hand roll often to exercise my hand muscles."

"The hand rolls help me develop strength in my grip." Hand rolls prevent contractures (permanently shortened muscles that resist stretching) of the fingers. They keep the thumb positioned slightly away from the hand and at a moderate angle to the fingers. The fingers are kept in a slightly neutral position rather than a tight fist. A rolled-up washcloth or a ball can be used as an alternative to commercial hand rolls. Hand rolls are removed regularly to facilitate movement and exercise. Hand rolls are not used to strengthen the grip

A lawyer is describing the litigation process to a nurse named in a malpractice lawsuit. Which statements by the lawyer accurately describe this process? Select all that apply. "The defendant is the person who is initiating the lawsuit." "The process of bringing and trying this lawsuit is called litigation." "As the defendant, you will be presumed guilty until proven innocent." "We will start litigation in the first-level court known as the appellate court." "The opinions of appellate judges are published and become common law." "Common law is based on the principle of stare decisis."

"The opinions of appellate judges are published and become common law." "Common law is based on the principle of stare decisis." "The process of bringing and trying this lawsuit is called litigation." The process of bringing and trying a lawsuit is called litigation. The opinions of appellate judges are published and become common law. Common law is based on the principle of stare decisis, or "let the decision stand." After a decision has been made in a court of law, the principle in that decision becomes the rule to follow in other similar cases (precedent). The other options listed are not true about the litigation process.

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis, what question should be asked first? "Has this, or something very similar, ever happened on the unit before?" "Why did the second nurse administer this drug to the client?" "What could the two nurses have done to ensure this did not happen?" "What were the possible adverse outcomes that could have resulted from this error?"

"What could the two nurses have done to ensure this did not happen?" Asking multiple levels of questions is essential to the process of root cause analysis and can be helpful in revealing underlying causes. Understanding how the behavior of the two nurses involved in aspects of care that contributed to the error is critical in this scenario. This opens avenues for future corrective actions to reduce the chance of repeating such an error. Each of the other listed questions addresses a valid aspect of the event, but none address the underlying causes, which is the focus of root cause analysis.

Which statement(s) by a nurse to a charge nurse indicates that the nurse requires further training? Select all that apply. "When I sign the consent form as a witness, I am saying that the person knows all the risks and benefits of the procedure." "I must make sure I give the client all necessary information about the procedure before I have the client sign the consent form." "When a client is having surgery, it is my responsibility to get the consent." "My signature as a witness indicates the consent is signed and I saw the client sign it." "In the event of an emergency that threatens a client's life or health, consent is not needed."

"When I sign the consent form as a witness, I am saying that the person knows all the risks and benefits of the procedure." "I must make sure I give the client all necessary information about the procedure before I have the client sign the consent form." "When a client is having surgery, it is my responsibility to get the consent." The person performing the procedure is responsible for providing all information about the procedure and obtaining informed consent. If the client has questions about the consent, the nurse may answer them. The nurse's signature indicates that the consent was signed and the nurse witnessed the client's signature. If there is an immediate threat to life or health, consent is not needed.

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? 224 mmHg 132 mmHg 112 mmHg 40 mmHg

40 mmHg The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40.

The nurse is assisting with morning care for a group of clients. For which clients is a safety razor contraindicated? Select all that apply . 68-year-old taking anticoagulants for deep venous thrombosis 45-year-old with liver disease and impaired clotting 45-year-old with pneumonia who prefers to shave twice daily 26-year-old who is suicidal and requests to shave 30-year-old with inflammation of facial skin

68-year-old taking anticoagulants for deep venous thrombosis 45-year-old with liver disease and impaired clotting 26-year-old who is suicidal and requests to shave 30-year-old with inflammation of facial skin Use of a safety razor is contraindicated for clients who receive anticoagulants, have liver disease with impaired clotting, have rashes or skin inflammation on the face, and those who are suicidal. A client with pneumonia has no factors for using a safety razor.

When performing fall risk assessments, which client does the nurse determine is most at risk for falls? A 50-year-old male being cared for in an unfamiliar health care environment A 60-year-old male with weakness in his left side and slowed reaction time A 70-year-old female with postural hypotension who wears eyeglasses An 80-year-old female with a history of falling last year

A 70-year-old female with postural hypotension who wears eyeglasses Risk factors for falls include age older than 65 years, documented history of falls; impaired vision or sense of balance; altered gait or posture; a medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics; postural hypotension; slowed reaction time; confusion or disorientation; impaired mobility; weakness and physical frailty; and/or an unfamiliar environment. The 70-year-old client with postural hypotension who wears eyeglasses, but has no history of falls, has three of these risk factors. The other clients listed each have only two risk factors.

The nurse is caring for several clients on a telemetry unit. Which client(s) requires the nurse to assess the pulse rate need for 1 full minute? Select all that apply. A client with a pulse rate of 38 beats/min. A client with a temperature of 97.7°F (36.5°C). A client diagnosed with arrhythmia. A client recovering from anesthesia. A client with a pulse rate of 130 beats/min.

A client with a pulse rate of 38 beats/min. (bradycardia) A client diagnosed with arrhythmia. A client with a pulse rate of 130 beats/min (tachycardia) The nurse assesses clients with irregular or abnormally slow or fast pulse rates for 1 full minute. The time interval used to assess the pulse depends on the client's condition and the agency's norms. Clients with regular rhythms and normal rates may be assessed for a shorter time. Intervals of 15 seconds may be used for clients with regular rhythms when the pulse is reassessed frequently, as during recovery from anesthesia. Clients with normal temperatures should not require the pulse rate to be assessed for 1 full minute. Tachycardia is associated with high body temperature. The nurse may assess the pulse rate for 1 full minute if there is an unexpected change in other vital signs.

Which clients are most at risk for falling due to altered mobility? Select all that apply. A client with a spinal cord injury A middle-aged woman who had surgery 2 weeks ago and wears high heels All older adults An older adult client with an unsteady gait A client who requires crutches in unfamiliar health care settings

A client with a spinal cord injury An older adult client with an unsteady gait A client who requires crutches in unfamiliar health care settings Limitations in mobility are unsafe and can cause client injury. The nurse should be aware that clients with spinal cord injuries, older adults with unsteady gaits, and clients who require assistive walking devices such as crutches, especially in unfamiliar health care settings, may be at risk for falling. Not all older adults are at risk for falls. Most females who wear heels are not most at risk for falls, even if they had surgery 2 weeks ago.

The facility is conducting an educational seminar for newly employed nurses. The program addresses the reporting of sentinel events. Which occurrences qualify for this criteria? Select all that apply. A client reports plans to file a complaint concerning the amount of time it took for a nurse to respond to a call light. A client's baby is misidentified and receives breast milk from another mother. A client experiences a reaction to a unit of blood, resulting in itching and hives. A client faints during ambulation with the nurse, resulting in a concussion. The nurse administers a lethal dosage of medication in error.

A client's baby is misidentified and receives breast milk from another mother. A client faints during ambulation with the nurse, resulting in a concussion. The nurse administers a lethal dosage of medication in error. A sentinel event is one in which a client experiences death or serious injury.

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. Fires are responsible for most hospital incidents. Between 15% and 25% of falls result in fractures or soft tissue injury. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk for falls. A history of falls puts the person at risk for falls in the future. Some people are more careless with behaviors, which makes them more prone to injury. Diuretics increase the risk for falls because the client may stand quicker or get up during the night to urinate. Analgesics may cause the client to have an unsteady gait due to drowsiness. Falls are responsible for most hospital incidents, not fires. Approximately 33% of falls result in fracture or soft tissue injury. Responsible and prudent behavior of the nurse will decrease the risk of client injury.

A nurse is discussing care of her four clients with an unlicensed assistive personnel (UAP). The UAP is planning morning care and hygiene for the clients. Which client should the nurse instruct the UAP to offer hygiene measures to first? A comatose 65-year-old man whose vital signs are: T: 98.7, P;60, R:9, B/P: 86/46. A pleasantly confused 86-year-old female requiring partial care being discharged today. A 20-year-old man who is able to independently perform self-care and is recently medicated for pain. A client with body odor refusing to bathe.

A pleasantly confused 86-year-old female requiring partial care being discharged today. There are several factors that affect one's ability to perform self-care. These are factors that nurses must take into consideration when planning and delegating care of clients. Clients should have stable vital signs, be pain free, and have a desire to perform self-care. It is also important to prioritize client needs throughout the day. A client being discharged requiring partial care would be the priority client.

A new mother inquires about the use of a car seat for her infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant? A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. A rear-facing safety seat should be used for infants and toddlers younger than 2 years old and weighing less than 20 lb (9 kg). A rear-facing safety seat should be used for infants younger than 1 year old or up to the maximum weight for the seat. A rear-facing safety seat should be used for infants younger than 1 year old and weighing more than 20 lb (9 kg).

A rear-facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should remain in a rear-facing safety seat.

Which is an example of the sociocultural dimension influencing a person's health-illness status? A family lives in a city environment where the air pollution levels are high. A father who is a practicing Jehovah's Witness refuses a blood transfusion for his son. An adolescent who was in an automobile accident worries that his scars will cause him to lose friends. A single mother of two applies for food stamps in order to feed her family.

A single mother of two applies for food stamps in order to feed her family. The sociocultural dimension refers to health practices and beliefs that are strongly influenced by a person's economic level, lifestyle, family, and culture. In general, low-income groups are less likely to seek medical care to prevent illness, and high-income groups are more prone to stress-related habits and illness. The family living in a city environment with high air pollution is an example of the environmental dimension. The father who refuses a blood transfusion for his son is an example of the spiritual dimension. The adolescent who worries that his scars will cost him friends is an example of the emotional dimension.

A client arrives at the emergency department after an industrial explosion involving an unknown chemical contaminant. What is the nurse's priority action? Assess client's respiratory depth and effort Activate external disaster protocol Identify chemical agent before treating Flush skin while rinsing with sterile saline

Activate external disaster protocol Before performing assessments or interventions, it is essential that the nurse inform others about the incident in order to mobilize assistance. In most cases, this involves the activation of an emergency protocol.

During a routine wellness exam, a parent of a 14-year-old adolescent is concerned with how many showers the adolescent takes every day. Which response by the nurse is appropriate? Adolescents begin to care more about their appearance so they may bathe more. It is nothing to worry about. Your adolescent will grow out of it. Have you asked your adolescent why they are showering more frequently? When did you notice your adolescent started to shower more?

Adolescents begin to care more about their appearance so they may bathe more. As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. Answering a family member's question with a question as well as telling the parent not to worry are nontherapeutic and inappropriate responses.

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse? Ask the client to read and discuss a passage from a pamphlet. Ask the client "what if" questions to determine level of thought organization. Ask the client to review his medical health history to assess for the level of organization of his thought processes. Discuss with the client's family any concerns about his mental stability.

Ask the client "what if" questions to determine level of thought organization. When reviewing mental health and level of decision-making ability, the best method is to ask the client "what if" type of questions. Assessing the client's reading ability and understanding of passages read will not provide the needed information. Asking the client to discuss his medical history will provide some information but will not provide information on his ability to reason and make clear decisions. Questioning the family provides only a secondary source of information and will not be as effective.

Which methods can be used to remove a client's soft contact lenses? Select all that apply. Ask the client to remove them, if able. Use the pads of the index finger and thumb to gently pinch and remove the lens. Use a commercially available tool with a small suction cup. Apply gentle pressure to the lower eyelid until the lens pops out. Use two cotton-tipped applicators to gently grasp the lens.

Ask the client to remove them, if able. Use the pads of the index finger and thumb to gently pinch and remove the lens. When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should have the client remove the lenses, if able. To remove a client's soft contact lenses, the nurse should do the following: using the pads of the thumb and index finger, grasp the lens with a gentle pinching motion and remove. A tool with a small suction cup is appropriate for the removal of hard lenses but not for soft lenses. Applying pressure to the lower eyelid is used to remove hard lenses, not soft ones. A small pair of rubber grippers (not two cotton-tipped applicators) is used to remove soft lenses that are difficult to remove.

The nurse takes a client's vital signs and notes a blood pressure of 88/56 mm Hg with a pulse rate of 60 beats/min. Which action should the nurse take first? Assess the client for dizziness. Retake the client's blood pressure. Place the client in a supine position. Notify the health care provider

Assess the client for dizziness. The nurse should first assess the condition of the client and determine if physical signs of hypotension are present. After assessing the client's condition, the nurse should retake the blood pressure for accuracy. The client should remain in bed and not get up since dizziness and further drop in blood pressure could occur. Placing the client in the supine position (or flat on their back) will not assist with improving the blood pressure. Placing the client in the Trendelenburg (flat on the back with the feet higher than the head by 15-30 degrees) is appropriate. The nurse can check the chart to determine the client's normal range of blood pressure and notify the health care provider if there are symptoms associated with the hypotension.

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What action(s) by the nurse demonstrate to the client the appropriate way to apply the stockings? Select all that apply. Estimate the size of the client's legs, and obtain the stockings. Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. Massage the client's legs before applying. Apply the stockings in the evening.

Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying The nurse needs to measure the client's legs to determine the proper size of stocking. Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be ordered to ensure correct fitting on each leg. The size should not be estimated. The nurse will apply the stockings in the morning before the client is out of bed and while the client is supine. If the client is sitting or has been up and about, the nurse will have the client lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. The nurse will not massage the client's legs before applying the stockings. If a clot is present, massaging the leg may break it away from the vessel wall and it can circulate in the bloodstream.

The nurse is caring for a client who cannot swallow or expectorate. What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. Provide frequent mouth care. Apply mineral oil to the lips. Arrange for suctioning to remove mucus. Change the client's position every 2 hours. Assist the client to a lateral position.

Assist the client to a lateral position. Arrange for suctioning to remove mucus. Provide frequent mouth care When caring for a client who cannot swallow or expectorate, the nurse should provide frequent mouth care, arrange for suctioning to remove mucus, and assist the client to a lateral position to keep the mouth and throat free of accumulating secretions. Mineral oil is applied to the client to overcome dryness of the lips caused by oxygen therapy. The client's position should be changed every 2 hours to promote comfort and circulation for the skin primarily.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply. Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat. Consider the use of an electronic personal alarm.

Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat. Nurses should teach older clients ways to prevent falls at home. They include the following: Clean up clutter. Repair or remove tripping hazards. Install grab bars and handrails. Avoid wearing loose clothing. Lighting should be bright. Wear shoes and make them nonslip. Live on one level. The use of an electronic personal alarm is not a product that would prevent falls.

An older adult client recently suffered a stroke. The client is bedbound from the resultant paralysis of the right arm and right leg. Which intervention by the nurse is the best strategy to maintain skin integrity? Perform active and passive range-of-motion (ROM) four times daily. Provide a diet high in carbohydrates. Scoot the client up in bed with assistance. Avoid hot water during bathing.

Avoid hot water during bathing. The skin is the body's first line of defense against infection. As such, skin strategies, such as avoiding hot water during bathing will help maintain skin integrity. Performing active and passive ROM four times daily will help to prevent contractures and maintain muscle tone but it does not directly prevent skin breakdown. Providing a well-balanced diet containing protein, not carbohydrates, helps to maintain epidermal cells. Scooting the client up in bed creates a shearing force that may cause development of a pressure injury.

The nurse is caring for an older adult client. Which situational assessment findings establish the need for interventions? Select all that apply. Bedside table with client's personal items is at the foot of the bed. Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. Bed is in low position and brakes are in place. Call light is at top of bed under the pillow. Trash bag on side rail for used tissues.

Bedside table with client's personal items is at the foot of the bed. Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. Call light is at top of bed under the pillow. The nurse performs the situational assessment by observing the client, family, and environment to identify and solve any potential problems before they can lead to safety concerns. The nurse should assess the need to place the bedside table by the client to provide items at close reach and decrease risks for falls. The nurse should establish that the oxygen tubing needs to be connected to the flow meter. The nurse determines that the bed is in its safest position. The trash bag secured on the side rail provides a convenient location for used tissues, decreasing clutter. The nurse determines that the call light needs to be secured and within reach for the client to use it.

Which guideline should the nurse follow when removing contact lenses from a client's eyes? Before removing hard lenses, use gentle pressure to center the lens on the cornea. Once removed, place both lenses in a cup and label the cup with the name of the client. If an eye injury is present, remove lenses immediately to avoid causing additional injury. If the contact lenses cannot be easily removed, they will have to be removed by the health care provider under sterile conditions.

Before removing hard lenses, use gentle pressure to center the lens on the cornea. Gentle pressure should be used to center hard or gas-permeable lenses on the cornea. Once removed, lenses should be placed in the appropriate container, identifying the right and left lenses. If an eye injury is present, the lenses should not be removed because of the danger of causing an additional injury. If the lenses cannot be removed easily, they should be removed with the appropriate tool designated for the type of lenses in place.

The nurse is teaching the caregiver of a school-age child (5-9 years old) about safety. Which teaching will the nurse include? Supervise your child on the changing table. Place all household cleaners out of reach. Buy protective sporting equipment. Peer pressure causes children of this age to take risks.

Buy protective sporting equipment. School-age children are physically active, which makes them prone to play-related injuries. Therefore, the nurse teaches the caregiver about buying protective sporting equipment. Telling the caregiver to supervise the child on the changing table is appropriate for infants, not school-age children. Placing household cleaners out of reach is appropriate for toddlers. Teaching about peer pressure risks is appropriate for adolescents.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take? Step in front of the client so that the other client will be protected. Call for assistance to remove the client from the area. Forcefully remove the client and place in four-point restraints. Inject the client while being restrained with antipsychotic medication.

Call for assistance to remove the client from the area. The nurse should attempt to redirect the client away from the other client with assistance prior to attempting to use force. Stepping in front of the client who is violent may result in the nurse or other personnel becoming injured. Restraints should be a last measure to keep the client under control and avoid injury to the client or others. Injecting a client without their consent is a form of chemical restraint.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. 1. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options. 1.Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. 2.Wrap the cuff around the limb smoothly and snugly, and fasten it. 3.Place a small amount of conducting gel over the artery. 4.Place the Doppler tip in the gel and move it around until hearing the pulse. 5.Inflate the cuff while continuing to use the Doppler device on the artery. 6.Note the point on the gauge where the pulse disappears.

Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. Wrap the cuff around the limb smoothly and snugly, and fasten it. Place a small amount of conducting gel over the artery. Place the Doppler tip in the gel and move it around until hearing the pulse. Inflate the cuff while continuing to use the Doppler device on the artery. Note the point on the gauge where the pulse disappears.

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States? Centers for Disease Control and Prevention American Medical Association American Nurses Association World Health Organization

Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) and the National Safety Council determined that unintentional injuries were the fifth-leading cause of all deaths in the United States in 2009. The American Medical Association and American Nurses Association do not monitor such data. The World Health Organization focuses on global issues and events.

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply Check agency policy for the application of restraints and secure a physician's order. Choose the most restrictive type of device that allows the least amount of mobility. Pad bony prominences. For a restraint applied to an extremity, ensure that the restraint is tight enough that a finger cannot be inserted between the restraint and the client's wrist or ankle. Fasten the restraint to the side rail. Remove the restraint at least every 2 hours or according to agency policy and client need.

Check agency policy for the application of restraints and secure a physician's order. Pad bony prominences. Remove the restraint at least every 2 hours or according to agency policy and client need. A restraint can be applied if there is a justifiable reason, such as a client threatening the safety of another client, but a physician's order must be obtained as soon as possible. Bony prominences should be padded to protect skin integrity. The restraint should be removed so the extremity can be moved through range-of-motion and to ensure that circulation is not impaired. The least restrictive type of restraint should be chosen. A finger should be able to fit between the restraint and the body part to ensure the restraint is not too tight. The restraint should be fastened to non-moving parts of the bed. Fastening a restraint to a side rail may cause the restraint to tighten or injure the body part when the rail is lowered or raised.

A client who was receiving care on a psychiatric unit died by suicide at a time when nurses are known to have been handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event? Inform local health care institutions about the event to promote safety. Change the institution's policies regarding supervision of clients. Appropriately discipline the nurses who were participating in the shift change. Report the event to the Joint Commission.

Hospitals are required to report serious safety and sentinel events to regulatory agencies such as the Joint Commission and to state health agencies. There is no formal responsibility to inform other local institutions. There is no obvious need for discipline, though education may be needed. Policies and procedures would be reviewed, but may not need to be changed.

The nurse is transferring a client who has dementia from the bed to a wheelchair. Which instructions will the nurse use? Select all that apply. Scoot over here to the side of the bed while I raise up your head. I am going to put your shoes on you. Don't get up until you have sat there a few minutes. Stand up by the bed. Sit down in the wheelchair.

I am going to put your shoes on you. Stand up by the bed. Sit down in the wheelchair. The nurse should use direct, one-action statements. The client may be confused by the direction to "scoot" and by the two actions in the statement. Instructions should be stated in the positive, rather than started with the negative "don't."

The nurse is creating a plan of care for a client. Which actions by the nurse demonstrate the components of the nursing process? Select all that apply. Applies rationales for the actions of the nurse. Plans medical care of the client Identifies the needs of the client Evaluates the effectiveness of the plan of care Plans interventions to meet the client's health care needs

Identifies the needs of the client Evaluates the effectiveness of the plan of care Plans interventions to meet the client's health care needs Nurses implement their roles through the nursing process by identifying the needs of the client, planning the care of the client to meet those needs, and evaluating the effectiveness of the interventions. Although the rationales should be readily known when creating the plan of care, it is important for the nurse to explain and include the client in the plan of care. This is not part of the nursing process. Medical needs are not a part of the nursing process.

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis? Imbalanced Nutrition: Less than Body Requirements Risk for Infection Impaired Skin Integrity Confusion

Imbalanced Nutrition: Less than Body Requirements When a client is receiving radiation, she develops stomatitis, an inflammation of the oral mucosa. The inflammation is painful and makes eating difficult. The priority diagnosis is the potential for impaired nutrition. There is no indication that confusion is a problem. Stomatitis is a form of impaired skin integrity, but nutrition is a priority. Infection is a less likely consequence.

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients? In most age groups, motor vehicle accidents are major causes of death. Suicide is the leading cause of death in adults and adolescents. Occupational safety practices can eliminate all workplace hazards. Environmental lead exposure is a primary cause of death in adult clients.

In most age groups, motor vehicle accidents are major causes of death. Motor vehicles continue to be the major cause of deaths related to unintentional injuries for all age groups up to 80 years. Suicide is not the leading cause of death in adolescents and adults. Safety practices can reduce, but not completely eliminate, workplace risks. Lead exposure is significant but is not a primary cause of death.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply. Apply physical restraints at regular periods throughout the day. Have facility security personnel assist when the client is agitated. Check that all exit doorways have a STOP sign posted. Encourage the client to walk outdoors when weather permits. Place a bell over the client's room and other facility doors.

Check that all exit doorways have a STOP sign posted. Place a bell over the client's room and other facility doors For older adult clients with cognitive impairment, such as when clients are diagnosed with dementia or Alzheimer disease, the tendency to wander can pose a serious risk to the client's safety. In the nurse's plan of care for this client, it is necessary to ensure the client's environment is assessed for and adapted to prevent the client from exiting the care facility unaccompanied. The nurse will place STOP signs on all exit doors to communicate to the client that the client should not open exit doors. The nurse can ensure there is a bell over the client's room door so there is an audible signal to care providers when the client is out of the room. Physical restraint is an intervention that is used sparingly with clients with cognitive impairment because it is invasive and traumatizing. The application of physical restraint is reserved for situations in which the client is placing one's own safety in danger. An intervention such as this would not be used periodically throughout the day. The nurse will implement nonviolent crisis intervention such as therapeutic communication, redirection and occasionally chemical restraints if the client is sufficiently agitated to place oneself or others at risk. Security personnel can be perceived as threatening by the client, and their presence could lead to further agitation and long-term harm to the client. The presence of security is required only on a case-by-case basis. The client should only take a walk outdoors if accompanied by a care provider or family member.

A nurse is caring for an older adult client who has osteoporosis. Upon further examination the client reports smoking one pack of cigarettes per day, social alcohol consumption, a low-fat low-carb diet, and walks for exercise at least once a week. What primary intervention would the nurse recommend to help the client prevent further bone loss? Add moderate weight-lifting exercises at least 3 times per week. Increase regular weight-bearing exercises such as brisk walking, dancing, and yoga to at least 3 times per week. Increase dietary intake to include foods with beneficial fats such as avocados, chia seeds, and dark chocolate.

Increase regular weight-bearing exercises such as brisk walking, dancing, and yoga to at least 3 times per week. Osteoporosis is a condition where bone destruction exceeds bone formation and in which the resultant thin, porous bones fracture easily. Bone loss can be decreased by smoking cessation, no or limited alcohol and caffeine consumption, and a diet rich in calcium and vitamin D. However, adding regular weight-bearing exercises and increasing the frequency would be the primary intervention as this has proven to prevent further bone density loss. A diet high beneficial fats would not affect bone density directly and weight-lift

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply. Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. Children over 30 lb (13.5 kg) only need a lap and shoulder belt. Infants should remain in the infant seat until the age of 2 years. A child may sit in the front seat when 8 years old

Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. Infants should remain in the infant seat up to the maximum weight limit or until their length exceeds the length of the seat. Children from 20 to 40 lb (9 to 18 kg) should remain in a forward-facing car seat. Due to the force of a deployed airbag, sitting in the front seat is not recommended until the child is 13 years old.

nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply. Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. Children over 30 lb (13.5 kg) only need a lap and shoulder belt. Infants should remain in the infant seat until the age of 2 years. A child may sit in the front seat when 8 years old

A client undergoing chemotherapy who has had a stroke will need a hospital bed at home. Which essential information does the nurse teach the family to maintain a safe client care environment? Select all that apply. Check that the bed wheels are locked. Keep the bed at the highest position. Keep the foot of the bed elevated at 30 degrees. Keep bed side rails up when your family member is in the bed. Keep the head of the bed always at 45 degrees angle

Check that the bed wheels are locked. Keep bed side rails up when your family member is in the bed To promote bed safety, the caregivers need to assure that the wheels or casters are locked to prevent the bed from moving when the client gets into or out of the bed. The side rails can be kept up if the client desires, especially if the side rails will assist with helping the client get into and out of bed or move and change position while in bed. The caregivers do need to ensure the proper protection is provided to prevent potential accidents with the side rails. The caregivers do not need to keep the bed in the highest position; they can raise the bed to a height that permits the caregivers to perform their tasks without back strain and than return the height to the lowest position to enable the client to get in and out of bed easily and safely. Elevating the foot of the bed is only done when the legs need to be placed above the level of the heart to reduce swelling or provide comfort. The caregiver does not have to always keep the foot of the bed elevated.

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? Select all that apply. Caries may exist in the teeth, resulting from the failure to remove plaque. Gingivitis may be present involving the alveolar tissues. Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. Stomatitis may be noted as an inflammation of the tongue. Cheilosis may present as reddened fissures at the angles of the mouth. Oral malignancies may be present in the form of a dry oral mucosa.

Cheilosis may present as reddened fissures at the angles of the mouth. Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. Caries may exist in the teeth, resulting from the failure to remove plaque. A buildup of plaque generally leads to tartar on the teeth, which is a common cause of dental caries. Cheilosis is an ulceration and dry scaling of the lips with fissures at the angles of the mouth; it is most often caused by vitamin B complex deficiencies (especially riboflavin). Gingivitis is an inflammation of the gingiva, the tissue that surrounds the teeth. Stomatitis, an inflammation of the oral mucosa, has numerous causes, such as bacteria, virus, mechanical trauma, irritants, nutritional deficiencies, and systemic infection.

Which intervention(s) does the nurse use in perineal care for a postoperative uncircumcised client? Select all that apply. Clean the penile shaft from the tip downward toward the scrotum Retract foreskin and wash the glans penis Clean the genitals after the buttocks, with client in a side-lying position Cleans the tip of the penis from the urethral meatus outward in a circular motion Place the client in the supine position to perform perineal care

Clean the penile shaft from the tip downward toward the scrotum Retract foreskin and wash the glans penis Cleans the tip of the penis from the urethral meatus outward in a circular motion Proper perineal care for the uncircumcised male client includes starts with placing the client in a side-lying position and then cleaning the penile shaft from the tip downward toward the scrotum, retracting foreskin and washing the glans penis, and cleaning the tip of the penis from the urethral meatus outward in a circular motion. Cleaning the client's genitals after the buttocks, with client in a supine position both risks contamination of the client's skins with fecal matter and makes it difficult to clean the anal area with the client laying on the area to be cleaned.

During morning care, client who is postoperative day 1 blinks excessively and has dried secretions in the corners of the eyes. Which step(s) does the nurse include in eye care for the client? Select all that apply. Cleans from the inside of the eye toward the outside Cleans the eyes with a washcloth or cotton ball soaked with saline or sterile water If infection is not suspected, cleans each eye with a different part of the washcloth Cleans each eye with a different wash cloth soaked in boric acid

Cleans from the inside of the eye toward the outside Cleans the eyes with a washcloth or cotton ball soaked with saline or sterile water If infection is not suspected, cleans each eye with a different part of the washcloth The nurse wears gloves and cleans from the inside of the eye toward the outside to prevent contamination and introduction of bacteria into the eye. The eyes are cleaned with a washcloth or cotton ball soaked with saline or sterile water, and if infection is not suspected, a different part of the washcloth is used for each eye. A separate cloth would be needed only if infection is present. The eyes are not cleaned with different wash cloth for each eye. Although boric acid was once popular for cleaning the eyes, it is no longer recommended.

Which intervention(s) does the nurse initiate to assist a client in preventing corns on the feet? Select all that apply. Client will wear clean, dry socks. Client will inspect feet daily. Client will wear shoes that have extra padding. Client will wear shoes that are not tight around the toes. Client will wear shoes that are straight and thin.

Client will wear clean, dry socks. Client will inspect feet daily. Client will wear shoes that have extra padding. Client will wear shoes that are not tight around the toes. The strategies that the nurse initiates to prevent corns on a client's feet include having the client wear clean, dry socks because the continued application of moisture to the skin has an eroding effect and once the skin has lost its natural toughness, corns and bunions will form. The nurse also instructs the client not to wear shoes indoors but to rather go with bare feet when at home which is the natural, healthiest way to treat the feet unless the client has an orthopedic foot condition. The nurse will tell the client not to wear shoes that are tight around the toes because, if the toes rub against the inside of the shoe all day, they are likely to develop a painful corn. The nurse tells the client to look for shoes that have extra padding because this padding creates a buffer into which the foot will settle and maintain its normal position as it would if one had on no shoes. Shoes that are straight and thin may lead to corns and bunions because shoes need to have the shape of a foot to prevent undue pressure on the sides of the toes.

A nurse attends to the hygiene needs of a client with a traumatic head injury as a result of a motor vehicle accident. What action would the nurse take when providing rehabilitative care for this client? Staying with the client longer and engaging the client in conversation to improve the nurse-client relationship Teaching the client self-care skills about bathing and oral care Assisting the client to a chair in front of a mirror, providing the client with a hairbrush and comb, and encouraging the client to do one's hair care Communicating the needs of the client to the interdisciplinary team and coordinating the evaluation and care of the client with team members

Communicating the needs of the client to the interdisciplinary team and coordinating the evaluation and care of the client with team members Clients with self-care deficits will often need to learn new skills or relearn old ones. Successful rehabilitation involves a team of health care members working together, and it is often the nurse that coordinates rehabilitation. Placing the client in front of the mirror to perform hair care is good to do if the client has the desire and the ability to do it. Teaching and engaging the client in conversation can help to improve care, but for the best long-term results, a multidisciplinary team of professionals coordinated by the nurse is the best way the nurse can provide improved care.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Request a sedative from health care provider Conceal IV tubing with gauze wrap Ask visiting family member to stay Assure bed alarms are activated

Conceal IV tubing with gauze wrap Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.

A nurse is asked to wash the hair of a client who has a spinal cord injury. Which guideline should the nurse follow when performing this procedure? Use extra padding on the shampoo board before placing it under the client's head. Only use dry shampoo on a client with a spinal cord injury. Place a protective pad under the head of the client and divide the hair into four sections to be washed individually. Create a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container. TAKE ANOTHER QUIZ

Create a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container. A makeshift protection area can be created to wash the client's hair without using the board. Place a protective pad underneath the client's head and shoulders. Roll a towel into the bottom of the protective pad and direct the roll into one area so that water will drain into the container.

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority? Decreasing the incidence of hospital-acquired pneumonia Promoting the client's sense of well-being Preventing dental caries Preventing deterioration of the oral cavity

Decreasing the incidence of hospital-acquired pneumonia Diligent oral care inhibits the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, hospital-acquired non-ventilator pneumonia and ventilator associated pneumonia. While the other choices are expected outcomes of oral care, preventing respiratory complications is the priority.

Which client goal related to infection control is a priority? Demonstrate adequate knowledge on infection control. Demonstrate use of good health practices. Participate in treatment regimens to prevent infection. Minimize infection exposure.

Demonstrate adequate knowledge on infection control. Examples of client goals related to infection include the client or caregiver demonstrating adequate knowledge to recognize and report signs of infection. Knowledge and information drive all other goals.

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention? Determine cause Evaluate pulse rate quality Evaluate blood pressure Assess for history of heart disease

Determine cause Following the assessment of the pulse of 125 beats/min, the nurse would first determine the cause for the high rate. This will lead to determining an appropriate intervention. Anxiety, medications, caffeine, and other stimulants and disorders can cause tachycardia. The nurse will also need to check the quality of the pulse to determine regularity, but this would be included in assessing for causes and interventions. The nurse also will check the client's blood pressure, temperature, and pain level because an increase in any of these can be correlated with increased pulse, but again not what should be done first. While assessing a history of heart disease is important, this is not a first step alone and should be included in a full interview upon client intake and triage.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care? Always proceed from the most contaminated area to the least contaminated area. Do not retract the foreskin in an uncircumcised male. Dry the cleaned areas and apply an emollient as indicated. Powder the area to prevent the growth of bacteria.

Dry the cleaned areas and apply an emollient as indicated. When providing perineal care it is important to completely dry the skin and apply emollient in order to prevent skin breakdown. Perineal care should be given by proceeding from the least contaminated area to the most contaminated area; this prevents cross-contamination. Infection and skin breakdown may occur if the foreskin is not retracted when cleansing the penis of a male. It is also imperative to replace the foreskin when finished cleansing the penis, thus preventing constriction of the penis. Powdering the perineal area is not recommended because the powder becomes a medium for bacterial growth.

The nurse is caring for an infant after cleft lip repair surgery. The primary care provider ordered bilateral infant elbow immobilizers. Which considerations should the nurse make when applying the elbow restraints? Select all that apply. Ensure that the elbow restraint is just below the axilla and right above the wrist. Apply the elbow restraints before placing the long sleeve shirt over the infant. Assess skin color, temperature, and presence of breakdown at baseline and every 2 hours. Check the capillary refill at baseline and every 2 hours. Apply elbow restraint so one finger can fit under the restraint.

Ensure that the elbow restraint is just below the axilla and right above the wrist. Assess skin color, temperature, and presence of breakdown at baseline and every 2 hours. Check the capillary refill at baseline and every 2 hours. The nurse should make sure that the elbow restraint is below the axilla and above the wrist. The clothing should be placed on the infant before applying the elbow restraints, which will help pad and protect the skin below. The nurse should assess at baseline—and every 2 hours thereafter— the client's skin color, temperature, and check for the presence of skin breakdown. The nurse also assesses circulation by assessing capillary refill in the hand. The elbow restraints must be applied so two fingers, not one, can fit under the restraint to prevent from making them too tight.

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize? Establish the nurse's role during a disaster Provide simple explanations to maximize client safety Identify the resources available for the nursing unit Notify the organization's leader that a disaster has been called

Establish the nurse's role during a disaster During a disaster nurses will have multiple roles. In addition to their clinical knowledge, they may be responsible for triage, counseling and various other duties. Fear, panic, anger, and exaggerated concerns are expected. Disaster preparedness is imperative, as well as knowledge of resources. Communication with leadership should be established and sources for reliable information monitored. However, none of the necessary actions can be performed if the nurse lacks clarity on his or her role.

The nurse is discussing hygiene with a client. The client states that not understanding the importance of daily bathing or the use of antiperspirants. What information should be provided by the nurse? Select all that apply. Perspiration may result in viral growth if not managed frequently. Excessive perspiration will result in potentially offensive odor. Bacteria can flourish in the presence of excessive perspiration. There is no medical rationale to avoid excessive perspiration. Perspiration promotes skin breakdown.

Excessive perspiration will result in potentially offensive odor. Bacteria can flourish in the presence of excessive perspiration. Perspiration promotes skin breakdown. Keeping skin intact and healthy is important in preventing infection. Perspiration interacts with bacteria on the skin to cause body odor, which can be offensive and may decrease client comfort, promote bacterial growth, and increase the likelihood of skin breakdown. Regular bathing removes excess oil, perspiration, and bacteria from the surface of the skin.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. Exercise increases resting heart rate and blood pressure. Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys. Exercise decreases appetite. Exercise decreases rate of carbon dioxide excretion.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys. The benefits of exercise include increasing intestinal tone, increasing efficiency of the metabolic system, and increasing blood flow to the kidneys. Exercise decreases resting heart and blood pressure. Exercise increases appetite. Exercise increases the rate of carbon dioxide excretion.

The nurse is performing bilateral comparison of pulse sites for strength and quality instead of counting the beats per minute. Which pulse locations will the nurse palpate to gather this assessment data? Select all that apply. Femoral Dorsalis pedis Apical Popliteal Posterior tibial

Femoral Dorsalis pedis Popliteal Posterior tibial Palpate pulses bilaterally (except for carotids) to compare quality. Equality of pulsation provides information about local blood flow. For example, partial occlusion of a right femoral artery would result in weaker femoral, popliteal, pedal, and posterior tibial pulses on the right compared to the left. Bilateral pulse comparison is used to monitor for complications after procedures that are invasive to the arteries, such as arteriography. After an arteriogram, during which a large artery is punctured and injected with radiographic dye, the normal clotting to seal the artery may cause total arterial occlusion. Weakened or absent pulses distal to the puncture site would signal an occlusion. Apical pulse is used to count heart rate and not for palpation of the strength of the

A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety? filling out an incident report accurately after a client went missing from the unit appreciating the relationship between continuing education and client safety understanding the functions of a new automated intravenous pump that has been introduced to the unit valuing the contributions of clients and their families who suggest possible improvements in care

Filling out an incident report correctly is an example of a skill that aligns with the QSEN competency of safety. According to the ANA, there are six focus-area competencies in QSEN: 1) client-centered care, 2) evidence-based practice, 3) teamwork and collaboration, 4) safety, 5) quality improvement, and 6) informatics. "Valuing" and "appreciating" are indications of a nurse's attitude, not skills. "Understanding" is an indication of knowledge.

A nurse is making an unoccupied bed for a hospitalized client. Which actions are appropriate steps for the nurse to perform? Select all that apply. First, adjust the bed to the high position and lower the side rails. Fold reusable linens on the bed in fourths and hang them over a clean chair. Snugly roll the soiled linens into the bottom sheet and place on the floor next to the bed. Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. Tuck the bottom sheets securely under the head of the mattress to form a corner, according to agency policy. Place the pillow at the head of the bed with the closed end facing toward the window.

First, adjust the bed to the high position and lower the side rails. Fold reusable linens on the bed in fourths and hang them over a clean chair. Place the bottom sheet with its center fold in the center of the bed and place the drawsheet with its center fold in the center of the bed. Tuck the bottom sheets securely under the head of the mattress to form a corner, according to agency policy. Adjusting the bed to the high position and lowering the side rails supports good body mechanics for the nurse while making the bed. Folding reusable linens and hanging them over a clean chair saves laundering and keeps the linen from becoming wrinkled. Placing the bottom sheet and drawsheet with the center fold in the center of the bed reduces strain on the nurses arms and prevents the spread of microorganisms. Tucking the bottom linen securely under the head of the mattress and forming a corner will keep the linen from wrinkling. Linen should never be placed on the floor; it should be placed into a linen hamper or bag. For a neat appearance, the closed end of the pillow should face the door.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. For increased cardiac workload, instruct the client to lie in the prone position. For ineffective breathing patterns, encourage shallow breathing and coughing. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For impaired physical mobility, perform ROM exercises every 2 hours. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours.

For orthostatic hypotension, have the client sleep sitting up or in an elevated position. For constipation, increase fluid intake and roughage. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours. The nurse would implement the following nursing interventions when caring for clients with alterations in mobility: Have the client sleep sitting up or in an elevated position for orthostatic hypotension; have the client increase fluid intake and roughage (if not contraindicated) to address constipation concerns; reposition the client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues. The client would decrease the cardiac workload if lying in the prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns. Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility.

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply. Instruct the UAP to leave the linens on the floor for now and suggest a meeting to discuss the actions being performed Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back Assist the UAP to pick up the linens and place them in the linen basket Avoid confronting the UAP until there is a more appropriate time

Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back The UAP is at risk for back injury or straining due to lifting the linens using the back muscles and the shift in gravity beyond the base of support. The UAP should move close to and work as closely as possible to an object that is to be lifted or moved to avoid injury. The linens should not be placed on the floor for any length of time due to the increase risk for transmission of microorganisms from the hospital room to other areas of the hospital. It is important to educate all health care personnel when a potential risk to safety or possible harm is occurring. This will help minimize possible injury. Avoiding the conversation with the UAP until there is a more appropriate time is not an appropriate action.

An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action? Place the client in a prone position to apply the restraint. Remove the client's upper body clothing and reapply it over the restraint. Insert a fist between the restraint and the client to ensure that her breathing is not constricted. Assess the client at least every 2 hours or according to facility policy, as required.

Insert a fist between the restraint and the client to ensure that her breathing is not constricted. The client should be in a sitting position. Apply the restraint over the clothing and insert a fist between the restraint and the client to ensure that breathing is not constricted. Assessments should be made every hour to ensure respirations are not obstructed.

The nurse places the client on a hypothermia blanket to manage the client's temperature. Which action does the nurse take? Document the client's vital signs once every hour. Turn the client every 2 hours and as needed. Insert a rectal thermometer probe and secure it in place. Ensure all body surface areas are in contact with the cooled surface.

Insert a rectal thermometer probe and secure it in place. Unless contraindicated, the client undergoing hypothermia therapy must have a rectal thermometer probe inserted to accurately assess core body temperature. The client's vital signs are taken once every 15 minutes, looking for overall hemodynamic stability and a return to an acceptable temperature. Sensitive surfaces such as the head and genitalia should not come into contact with the cooled surface. The client should be turned every 30 minutes to 1 hour because the hypothermia device increases the risk of integumentary damage.

A nurse assists a client to clean his dentures. Which action should the nurse perform? Apply force with a 4 × 4 gauze to grasp upper denture plate to remove it. Pull the bottom denture straight up to remove it from the client's mouth. Place both dentures in a clean sink to clean them thoroughly. Insert the upper denture in the client's mouth and press firmly, then insert the lower denture.

Insert the upper denture in the client's mouth and press firmly, then insert the lower denture. After cleaning, insert upper denture in mouth and press firmly, then insert lower denture. Gentle pressure should be used to remove the upper plate, and a rocking motion should be used to remove the lower plate. Dentures should be placed immediately in a denture cup upon removal.

A client is hospitalized with uncontrolled diabetes. Which action(s) does the nurse take to promote circulation and prevent circulatory complications? Select all that apply. Inspect the client's feet daily. Clean the feet daily with warm water and a mild soap. Cut the toenails straight across and file the edges with an emery board. Soak the feet every day in very warm water and a mild soap. Apply lotion to the tops and bottoms of the feet and between the toes.

Inspect the client's feet daily. Clean the feet daily with warm water and a mild soap. Cut the toenails straight across and file the edges with an emery board. (would recommend to be very careful) Clients with diabetes have decreased sensation in the feet, placing them at great risk for injury from burns or foreign objects so the nurse should inspect the feet daily, clean the feet daily with warm water and a mild soap, and cut the toenails straight across filing edges with an emery board. The feet should not be soaked every day in very warm water and a mild soap because soaking will dry skin, which may lead to cracking. Lotion can be applied to the tops and bottoms of the feet but should not be applied between the toes, because moisture between the toes from lotions can cause infection or fungus.

The home health nurse is performing fall risk assessments for several new older adult clients. Which factor should the nurse prioritize in developing a care plan to address a high risk for falling? Select all that apply. Long-term use of benzodiazepines Poor lighting in the home Scatter rugs throughout the home Documented history of previous falls History of asthma History of occasional dysrhythmias

Long-term use of benzodiazepines Poor lighting in the home Scatter rugs throughout the home Documented history of previous falls Major causes of falls in the home include slippery surfaces, poor lighting, clutter, and improperly fitting clothing or slippers. Additionally, polypharmacy has long been listed as a risk factor, but research has indicated that adverse effects related to the use of antiepileptics and benzodiazepines are more predictive of falling. A history of a previous fall has consistently been identified as a predictor of another fall. A history of asthma or dysrhythmias is not recognized as a potential risk factor for falls.

Which actions by the nurse demonstrate the ethical principle of fidelity? Select all that apply. Maintaining current nursing registration and meeting continuing education requirements Performing an intervention for a client at the time that was promised Taking scheduled breaks on time Calling in sick due to a lack of sleep Taking an extra client assignment so that the client will be cared for

Maintaining current nursing registration and meeting continuing education requirements Performing an intervention for a client at the time that was promised Taking an extra client assignment so that the client will be cared for Fidelity is being faithful to the promise a nurse made to the public to be competent and to be willing to use competence to benefit the clients entrusted to the nurse's care. Following through on promises, maintaining professional standards, and taking on extra workload to preserve clients' interests are examples of fidelity. They demonstrate the promise to be competent and faithful to clients. Taking breaks on time is beneficial, but is not a direct example of fidelity. Calling in sick due to a lack of sleep is not an acceptable practice in most cases.

The surgical nurse is preparing a client for surgery on the left leg. Which nursing action(s) are appropriate? Select all that apply. Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedural verification protocol. Call for a "time-out" immediately before surgery begins. Provide education about the procedure to the client.

Mark the appropriate lower extremity as the one intended for surgery. Have the client mark the body part intended for surgery. Go through a preprocedural verification protocol. Call for a "time-out" immediately before surgery begins. To prevent wrong site, wrong procedure, and wrong person surgery, the nurse will mark the left leg as the one intended for surgery, have the client mark the body part intended for surgery, conduct a preprocedural verification protocol, and perform a "time-out" immediately before surgery to double-check all the surgical information regarding the client and required documents. It is not within the nurse's scope of practice to explain the surgical procedure to the client. The client will have been provided with a detailed education about the procedure in the preoperative assessment. The client will not have been able to provide informed consent to the procedure without a detailed description provided by the surgeon.

The nurse is caring for a client on a mechanical ventilator who has developed periodontitis. Which intervention(s) would the nurse include in the nursing care plan? Select all that apply. Monitor for bleeding gums and other signs of infection Administer local antimicrobial agents as prescribed Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth Lightly brush all surfaces of the teeth, gums, and tongue with a soft-bristled nylon or foam brush Rinse the oral mucosa with hydrogen peroxide to remove exudate

Monitor for bleeding gums and other signs of infection Administer local antimicrobial agents as prescribed Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth Lightly brush all surfaces of the teeth, gums, and tongue with a soft-bristled nylon or foam brush Periodontitis is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone and symptoms include bleeding gums; swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the teeth and gums; yellow exudate (pus) that appears when pressure is placed on gums. Therefore, it is imperative for the nurse to monitor for signs of infection as well as perform oral care including keeping the oral mucosa moist. Antimicrobial agents can be administered as prescribed and foam sticks can be used to moisten the mucosa and remove debris. A soft nylon brush should be used to prevent bleeding gums and pain. Hydrogen peroxide should not be used as a rinse, especially in clients that are mechanically ventilated.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? Most people who die in house fires die of smoke inhalation rather than burns. Most fatal home fires occur while people are cooking. About 10% of home fire deaths occur in a home without a smoke detector. Most home fires are caused by children playing with matches.

Most people who die in house fires die of smoke inhalation rather than burns. Most people who die in house fires die of smoke inhalation rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping.

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply. No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation Walks 20 feet Able to lift head from pillow

No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation The nurse should document the size, shape, color, and symmetry of joints: note any masses, deformities, or muscle atrophy. Range of motion of each joint. Any limitation in the normal range of motion or any unusual increase in the mobility of a joint (instability); range of motion varies among people and decreases with aging. Muscle strength when performing range-of-motion exercises against resistance. Any swelling, heat, tenderness, pain, nodules, or crepitation (palpable or audible crunching or grating sensation produced by motion of the joint). Comparison of findings in one joint with those of the opposite joint.

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that he is wearing contact lenses. What is the priority action by the nurse? Notify the emergency department health care provider that the client is wearing contact lenses. Remove the contact lenses and place in a storage case marked L and R. Irrigate the eyes with 0.9% normal saline to aid in removal of the contact lenses. Ask the client to remove the contact lens from the unaffected eye and place in a storage case marked L or R.

Notify the emergency department health care provider that the client is wearing contact If client who is wearing contact lenses receives an injury to the eye, the priority is to notify the health care provider about the presence of the contact lens to minimize injury. Removing the lens places the client at risk for further injury and should not be performed by the nurse. Asking the client to remove the lens from the unaffected eye may not cause further injury, but it is not the priority.

The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action? Apply the waist restraint over the gown and abdominal dressing. Notify the primary care provider and obtain an order for a client sitter. Apply bilateral wrist restraints and secure to the bed frame with a quick-release knot. Call the out-of-state family and ask if they can take turns watching the client.

Notify the primary care provider and obtain an order for a client sitter. The nurse's best next action is to call the primary care provider for a client sitter, an alternative way to provide around-the-clock safety. Alternatives to restraints should be explored first. The client has a postoperative abdominal incision, which is a contraindication for the application of a waist restraint because it would increase intra-abdominal pressure and place strain on the wound. The primary care provider did not order wrist restraints, so the nurse would have to get an order for them, if they were needed. Wrist restraints are applied when a client may try to pull out an intravenous line and harm self from such action. It is not used to help keep the client in bed. The family is out of state and may not be able to come and watch the client around the clock or arrive in a timely manner to be able to help.

A nurse is attempting to gain insight into a client's cultural beliefs and attitudes. Which methods would the nurse likely use? Select all that apply. Open-ended interviewing Ethnographic interviewing Key informants Short-term observation Use of the client's language

Open-ended interviewing Ethnographic interviewing Key informants Use of the client's language Methods to gain the client's perspective include open-ended interviewing (a variant of which is the ethnographic interview); the use of key informants; observation over time (not short-term); and use of the client's language.

A client has been diagnosed with peripheral vascular disease of the lower extremities. What will the nurse assess to accurately chart the circulation status in the client's legs? Select all that apply. Pitting edema Pedal pulses Skin temperature of feet Capillary refill time Breath sounds

Pitting edema Pedal pulses Skin temperature of feet Capillary refill time In order to describe the circulation in the legs of the client with peripheral vascular disease the nurse assesses pedal pulse, pitting edema, skin temperature of legs and feet, and capillary refill time; all of which indicate blood flow and peripheral tissue perfusion. While assessment of breath sounds provides data about oxygenation, it will not be documented as part of the assessment of circulation of the lower extremities as this relates to the client's underlying condition of peripheral vascular disease.

The nurse is providing care for an older adult client with a hip fracture utilizing a walker. Which action by the nurse would be the priority? Assess the mobility of the client Monitor neurological status Place a falls risk bracelet on client Provide 1:1 companionship at bedside

Place a falls risk bracelet on client Nurses are responsible for identifying clients who are at risk for falls and applying intervention to decrease risk and ensure safety. Placing a falls prevention risk bracelet on the client informs all staff and visitors to use care with this client to prevent another fall. Assessing multifunctional status is an important intervention for healing. This client's risk for falls is related to musculoskeletal factors, not neurologic factors. Additionally, 1:1 companionship is not a priority

A nurse makes an occupied bed that is stained with fecal matter. What should the nurse do with the dirty linens? Roll the linens into a ball and place them in a biohazard bag. Place the linens on the floor on top of a protective pad and roll them in the pad before placing in the linen hamper. Place a protective pad over and under the soiled linens to protect the clean linens. Place them in a garbage bag and mark "disinfect" on the outside of the bag.

Place a protective pad over and under the soiled linens to protect the clean linens. If linens are soiled with fecal matter, the nurse should obtain an extra towel or protective pad and place it under and over the soiled linens so that new linens will not be in contact with soiled linens. Linens are not placed in biohazard bags and destroyed, nor are they placed in garbage bags.

A client with a stroke has left-sided paralysis. Which action(s) does the nurse take to ensure proper positioning and support for this client? Select all that apply. Place a small pillow under client's waist Straighten the left elbow and support it on a pillow Place the left leg far enough in front of the body to prevent the client rolling onto the back Bend the left knee and support the left leg on a pillow Bend the left arm at a 90-degree angle and place it flat on the bed

Place a small pillow under client's waist Straighten the left elbow and support it on a pillow Place the left leg far enough in front of the body to prevent the client rolling onto the back Bend the left knee and support the left leg on a pillow The nurse should place a small pillow under the client's waist to maintain the line of the spine. The nurse should ensure that the left (affected) arm is forward, keeping the elbow straight and supported on a pillow. The nurse should bring the left (affected) leg far enough in front of the body to prevent the client rolling onto the back, with the left knee bent and leg supported on a pillow. The nurse should not bend the left arm at a 90-degree angle nor place it flat on the bed; the nurse should position it with the elbow straight and supported on a pillow.

The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply. Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe Place a pillow behind the neck for support

Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe Appropriate information for the nurse to provide the UAP includes placing the client in an upright position in the bed or chair, providing verbal cues regarding location of food on plate, cutting food into small pieces, and ensuring that the temperature of the food is safe. It is not appropriate to place a pillow behind the neck as this could cause difficulty swallowing. The bed should be at least a 45-degree, preferably at a 90-degree, angle to prevent aspiration while eating.

Which strategy(ies) does the nurse use to maintain proper body mechanics and prevent self-injury? Select all that apply. Place feet shoulder width apart when lifting an object Plant feet firmly on the floor when supporting the client during dangling Bend at the waist when lifting an object Lock elbows when grasping onto objects Hold objects an arm's length away when lifting and carrying them

Place feet shoulder width apart when lifting an object Plant feet firmly on the floor when supporting the client during dangling When lifting an object, the nurse will place the feet shoulder width apart with feet planted firmly to provide a stable base of support. When supporting the client during dangling, the nurse will tighten the gluteal and abdominal muscles to avoid back strain or injury. When lifting an object, the nurse will bend at the knees instead of the waist because the thigh muscles are larger in mass than either the buttocks or back muscles. The nurse will get close to the object to be lifted to prevent excess stress on arm and back muscles. The nurse does not hold heavy object away from the body nor lock the elbows during lifting and carrying objects. These actions put extra stress on the muscles of the back and this strain could lead to injury.

A nurse is caring for a 66-year-old man admitted to their unit status post left hip replacement. He has been out of surgery for 3 days. On the nurse's initial assessment, the client has a heart rate of 96 bpm and a respiratory rate of 32. He is diaphoretic. On a scale from 0 to 10, the client describes his pain as a 7 and points to the left side of his chest. What is the most likely cause of the client's distress? Pneumonia Myocardial infarction Referred postoperative pain Urinary tract infection

Pneumonia The client is exhibiting signs of an infection: tachycardia, tachypnea, and diaphoresis, which likely indicates fever. Pneumonia is most common 2 to 5 days postoperative. Mr. Porter is particularly at risk because, following a hip replacement, he is unable to ambulate. This can lead to pooling of respiratory secretions, which attracts microorganisms.

A nurse is reviewing The International Council of Nurses (ICN) Code of Ethics for Nurses. Based on this code, the nurse would identify which responsibilities as being fundamental? Select all that apply. Promoting health Preventing illness Restoring health Alleviating suffering Providing holistic care

Promoting health Preventing illness Restoring health Alleviating suffering According to the ICN Code of Ethics, nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. Providing holistic care is not a fundamental responsibility of nurses, according to the ICN Code of Ethics.

The registered nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply. Assess the client's need to continue the waist restraint. Chart the skin findings during the 2-hour check. Provide a bedpan and pericare. Determine if the waist restraint is too tight. Obtain, record, and report vital signs.

Provide a bedpan and pericare. Obtain, record, and report vital signs. The registered nurse (RN) cannot delegate the nursing process, so the RN should assess the client's continued need for the waist restraint and perform the ongoing assessment, including the condition of the client's skin, circulation, and if the restraint is too tight. The nurse may safely delegate to UAP the following tasks: providing a bedpan; providing pericare; and obtaining, recording, and reporting vital signs to the RN.

A client has been diagnosed with a debilitating neuromuscular disease that has left the client tired, confused, and in pain. Which action(s) will the nurse choose to advocate for this client in planning future care? Select all that apply. Provide education about treatments. Offer opinions on care options. Facilitate involvement of people essential to the decision. Reiterate the importance of the client making all decisions. Explain laboratory and radiology findings.

Provide education about treatments. Facilitate involvement of people essential to the decision. Explain laboratory and radiology findings. Advocacy includes ensuring the client is educated about treatments, that findings are explained, and that others important to the process are involved in decision-making. The nurse should not offer opinions on care options but should offer information about the options. The client does not have to make all decisions regarding care, but the client's general wishes should be considered in all decision-making.

A nurse is preparing to perform oral care for a client who has full dentures. Which action(s) should the nurse take? Select all that apply. Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Rinse the dentures with water or normal saline if the client is dehydrated. After cleaning, insert the lower denture followed by the upper denture. Use a sterile 4 × 4 in (10 × 10 cm) gauze to remove debris from the gums and mucous membranes. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.

Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Rinse the dentures with water or normal saline if the client is dehydrated. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. Putting paper towels or a washcloth in the sink protects against breakage. The nurse should provide privacy to the client during removal of the dentures, which many people are embarrassed by. A toothbrush and paste are appropriate to clean dentures. Although the nurse can rinse the dentures with normal saline, plain water is fine. Upper dentures should be placed before lower dentures. A toothbrush and paste, not sterile gauze, should be used to clean gums and mucous membranes.

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply. Put on gloves before removing soiled linens. Place a bath blanket over the client. Help the client turn toward the opposite side of the bed and fan-fold soiled linens as close to the client as possible. Grasp the mattress and shift it down to the foot of the bed. Place soiled linen on the floor. Secure clean top linens under the head of the mattress.

Put on gloves before removing soiled linens. Place a bath blanket over the client. Help the client turn toward the opposite side of the bed and fan-fold soiled linens as close to the client as possible. Gloves prevent the spread of microorganisms. The blanket provides warmth and privacy. Having the client roll to the opposite side of the bed makes it easier to remove the soiled linens. The nurse should shift the mattress up to the head of the bed to allow the client more foot room, not shift it down to the foot of the bed. The nurse should not place the soiled linens on the floor or furniture or hold it against the uniform. The floor is heavily contaminated; soiled linen will further contaminate furniture and the nurse's uniform. The nurse should secure the clean top linens under the foot, not head, of the mattress.

A client has a nursing diagnosis of Self-Care Deficit: Bathing. What would an appropriate "related/to (r/t)" statement include? R/t the inability to recognize the need to urinate or defecate R/t right-sided weakness R/t the inability to perform bathing independently R/t impaired mobility

R/t right-sided weakness Self-care deficit: Bathing is related to lack of motor skills, coordination, mental status, and endurance when performing bathing activities. Right-sided weakness is an appropriate statement about why this problem exists. A person's inability to perform bathing independently is more of a sign or symptom in the "as evidenced by (AEB)" statement of a nursing diagnosis. Related to impaired mobility is a nursing diagnosis and cannot be used as a "related/to" statement.

Which action is acceptable for the nurse to perform when assessing blood pressure? During the initial nursing assessment of a client, take the blood pressure on both arms and use the arm with the lower reading for subsequent pressures. Use electronic monitoring devices on clients with irregular heartbeats, tremors, or the inability to hold the arm still. Raise the client's arm over the head for 30 seconds to help relieve congestion of blood in the limb and make the sounds louder and more distinct. In newborns, take the blood pressure in one arm and one leg and document the difference to check for heart defects.

Raise the client's arm over the head for 30 seconds to help relieve congestion of blood in the limb and make the sounds louder and more distinct. Raising the client's arm over the client's head helps relieve congestion of blood in the limb and increase pressure differences to make the sounds louder and more distinct. On initial assessments, use the arm with the higher reading for subsequent pressures. Electronic monitoring devices are contraindicated for clients with heart problems or tremors. Blood pressure should be taken on all four extremities for newborns.

The nurse is preparing the client to use the hypothermia blanket. How does the nurse measure the client's temperature while the blanket is in use? Oral temperature every 2 hours Rectal probe continuously Rectal temperature every 2 hours Tympanic temperature every hour

Rectal probe continuously During the client's use of the hypothermia blanket, the temperature is monitored by the use of a rectal probe, so that the temperature can be measured continuously. The probe is attached to the control panel for the blanket so that the blanket temperature is maintained at a safe level. If a client is comatose or anesthetized, an esophageal probe is used to monitor the temperature. The temperature needs to be monitored continuously, not hourly or bihourly. The other placements also would not measure core temperature.

The older adult client is confused and wanders at night at home. The caregiver is seeking assistance with this problem. The caregiver states, "I am so worried about my family member. What can I do and still get some rest at night?" What instruction(s) would the nurse provide to the caregiver? Select all that apply. Reduce stimulation, noise, and light a few hours prior to bedtime. Provide low lights in the rooms in which the client may wander. Encourage the client to toilet prior to bedtime. Have the client exercise in the evening to ensure the client is tired at hours of sleep. Place locks on any doors to the outside that the client would be able to open.

Reduce stimulation, noise, and light a few hours prior to bedtime. Provide low lights in the rooms in which the client may wander. Encourage the client to toilet prior to bedtime. Place locks on any doors to the outside that the client would be able to open. The nurse would tell the caregiver to reduce stimulation, noise, and light in the hours prior to sleep to encourage relaxation and to set an appropriate bedtime routine. For safety reasons, the caregiver should provide sufficient lighting for the client at night in case the client wanders. Another appropriate bedtime routine is toileting prior to bedtime. For safety reasons, the caregiver can place locks on doors so the client is unable to get through and wander outside. Having the client exercise at night is stimulating and would make it more difficult for the client to fall asleep at night.

The nurse is caring for a client that is agitated and combative. What action can the nurse take other than the use of physical restraints? Select all that apply. Reduce stimulation, noise, and light. Place all four side rails up. Provide a safe environment. Distract and redirect in a commanding voice. Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the designated area.

Reduce stimulation, noise, and light. Provide a safe environment Use simple, clear explanations and directions. Use a large plant or piece of furniture as a barrier to limit wandering from the designated area. Reducing environmental stimuli, using simple directions, using furniture as safety barriers, and concealing necessary health care devices are appropriate alternatives to restraints. Teaching restraint application to significant others and using a commanding voice are not appropriate measures. Provide a safe environment for the client.

An older adult client has developed diabetic neuropathy. What would be the most important education intervention for the client and family? Obtain a carbon monoxide detector in the home. Reduce the temperature on the water heater. Keep the environment warmer in winter. Increase the amount of ventilation in the house.

Reduce the temperature on the water heater. The principles of a safe environment for older adults follow the same general guidelines as those for all ages: comfortable temperature range, adequate clothing, bath water of the right temperature (the setting on the hot water heater may need to be reduced), adequate ventilation, and lighting that allows for safe navigation throughout the house at all times of day. Clients with neuropathy will definitely need the hot water heater temperature reduced.

The nurse manager notices that a nurse is wearing artificial fingernails. What is the appropriate nurse manager action? Select all that apply. Remind the nurse that artificial fingernails can spread fungal infections. Refer the nurse to the agency policy on artificial fingernails. Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene. Demand that the nurse remove the artificial fingernails immediately. Ask the nurse to use only fingernail polish instead of artificial fingernails.

Remind the nurse that artificial fingernails can spread fungal infections. Refer the nurse to the agency policy on artificial fingernails. Provide the nurse with evidence that demonstrates outcomes of appropriate hand hygiene. Fungal nail infections can result from application of artificial fingernails if unsanitary application utensils are used. The nurse manager will educate the nurse on outcomes associated with use of artificial nails, refer the nurse to the agency policy on wearing artificial nails, and provide the nurse with literature that demonstrates outcomes of appropriate hand hygiene. Demanding that the nurse remove the artificial fingernails immediately does not educate the nurse and can contribute to a hostile working relationship. The agency policy may prohibit nurses from wearing any fingernail treatment, so polish should not be recommended.

Which nursing action is appropriate when providing foot care for a client? Soak the feet in a solution of mild soap and tepid water. Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. For diabetic clients, trim the nails with nail clippers. Cut off any corns or calluses.

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms. Rinsing and drying the feet thoroughly, and providing moisturizer to the tops and bottom of the feet helps prevent excessive dryness and cracking of the skin. Soaking the feet can cause maceration of the tissues, which can lead to skin breakdown. The toenails of diabetic clients should be filed (not trimmed) in order to prevent injury to the feet, which can lead to infection or poor wound healing. The nurse should never cut off corns or calluses; this should only be performed by a podiatrist.

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next? File the safety event report in the appropriate file and document in the nurse's notes the date and time that it was filed. Make a copy of the safety event report for the client. Place the safety event report in the client's medical record for future reference. Submit the safety report to the appropriate department within the facility so that it can be reviewed.

Submit the safety report to the appropriate department within the facility so that it can be reviewed. When an adverse event occurs, a safety event report should be filed and submitted according to facility policy. Safety event reports should not become a part of the client's medical record, nor should they be mentioned in documentation or copied and given to the client.

The nurse is educating parents of toddlers on how to prevent injuries and promote safety for their children. What are age-appropriate safety interventions for this age group? Select all that apply. Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Instruct the child to wear proper safety equipment when riding bicycles or scooters. Do not leave the child alone in the bathtub or near water. Provide drug, alcohol, and sexuality education. Practice emergency evacuation measures with the child.

Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Do not leave the child alone in the bathtub or near water. Measures to prevent injuries and promote safety of toddlers include having the poison control center phone number in readily accessible location; using an appropriate car seat for the toddler; supervising the child closely to prevent injury; childproofing the house to ensure that poisonous products, drugs, and small objects are out of toddler's reach; never leaving the child alone and unsupervised outside; and keeping all hot items on the stove out of the child's reach. Proper safety equipment for bicycles and scooters, and practicing emergency evacuation measures, are appropriate education measures for the preschooler. Providing drug, alcohol, and sexuality information is appropriate for the school-age child.

A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply. Keep elbows close to sides. Crutches should be at least 3 inches from the feet. Support body weight with hands and arms. Place pressure on the axillae when walking. When descending stairs, move crutches and the unaffected leg first, followed by the affected leg. When climbing stairs, advance the unaffected leg past the crutches, place weight on the unaffected leg, and then advance the affected leg followed by the crutches.

Support body weight with hands and arms. Keep elbows close to sides When climbing stairs, advance the unaffected leg past the crutches, place weight on the unaffected leg, and then advance the affected leg followed by the crutches. The client should keep the elbows close to sides. The crutches should not be any closer than 12 inches from the feet to help prevent the client from falling. The client should support body weight with hands and arms and should not put pressure on the axillae when walking. Pressure on the axillae can cause damage to nerves and circulation. When climbing stairs, the client should advance the unaffected leg past the crutches, then place weight on the unaffected leg. Then the client should advance the affected leg and the crutches to the step. When descending stairs, the client should move crutches and the affected leg first, followed by the unaffected leg.

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? Tell the client he can remove them for 20 or 30 minutes during this shift. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. Permit the client to remove the stockings indefinitely and speak to the physician about the necessity of having the client wear them.

Tell the client he can remove them for 20 or 30 minutes during this shift. Antiembolism stockings should be removed once every shift for 20 to 30 minutes to allow for assessment of circulatory status and the condition of the skin on the lower extremity and for skin care. The nurse should not disregard the health care provider's prescription and allow the client to remove the stockings indefinitely, as this could endanger the client's health.

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature? Temporal artery Oral Tympanic Axillary

Temporal artery The best way to evaluate the client's temperature is the temporal artery since the area is unobstructed. The oral route is not feasible because the client is mouth breathing because of the rhinorrhea (drainage from the nose). The oral route is not accurate when the client is wearing an oxygen mask, too. The tympanic route should not be used because of the basilar skull fracture and the client has otorrhea, or drainage from the ears. The client has a full body cast so it will be difficult to close the arm close to the body, making the axillary route inaccurate.

At a well-child visit, the nurse is observing siblings at play. Which observed behaviors would be of concern to the nurse and would require additional assessment? Select all that apply. The 5-year-old is jumping off a step pretending to fly. The 3-year-old sits by as the 5-year-old stacks a tower of blocks. The 3-year-old does not join the 5-year-old in the jumping game. The 3-year-old runs circles while the 18-month-old chases. The 18-month-old does not follow the others up a set of three stairs.

The 3-year-old sits by as the 5-year-old stacks a tower of blocks. The 3-year-old does not join the 5-year-old in the jumping game A 3-year-old should be able to build a tower with blocks and should be able to jump. The 18-month-old should be able to run, but climbing steps is not an expected behavior.

The nurse is supervising the unlicensed assistive personnel (UAP) who is performing denture care for a client in a long-term care facility. The nurse stops the UAP from performing any further denture care when which action(s) is observed? Select all that apply. The UAP dons clean gloves to remove dentures with dry gauze. The UAP uses a regular toothbrush and natural brushing motions. The UAP uses warmed sterile water to cleanse the denture set. The UAP stores the denture set in a covered container. The UAP holds dentures firmly in hands while carrying them to the sink to prevent breakage.

The UAP uses warmed sterile water to cleanse the denture set. For clients who cannot remove their own dentures, the UAP puts on gloves and uses a dry gauze square or clean face cloth to grasp and free the denture from the mouth. The UAP cleans dentures and removable bridges with a toothbrush, denture cleanser or toothpaste, and cold or tepid water and uses the same technique one would use to brush natural teeth. If the UAP removes a client's bridge or dentures during the night, he or she stores them in a covered cup to prevent contamination. The UAP takes care to hold dentures over a plastic basin or towel so that they will not break if dropped.

The nurse has assessed a pulse deficit when taking the pulse of a client. What does this assessment indicate for the client? Select all that apply. the total volume of blood during ventricular contraction the difference between apical and peripheral pulse rate the pulse pressure created when there is friction between the blood and the vessel walls The apical pulse is higher than the radial pulse. The health care provider should be notified of any increase in pulse deficit.

The apical pulse is higher than the radial pulse. The health care provider should be notified of any increase in pulse deficit. the difference between apical and peripheral pulse rate When some of the ventricular contractions do not perfuse, a difference exists between the apical and peripheral pulses—a pulse deficit. When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. Stroke volume, or the amount of blood, may vary from beat to beat during cardiac contraction, resulting in a pulse wave so weak that it cannot be perceived by palpation at a peripheral site. It is important to recognize this situation because it provides information about the heart's ability to perfuse the body adequately. Document and report to the provider any new finding of a pulse deficit so that evaluation and follow-up can occur.

The nurse uses the QSEN competency of Informatics when planning care for clients. What is an example of the use of this skill? The nurse works collaboratively with a dietitian to devise a client meal plan. The nurse orients a visually impaired client to the hospital room. The nurse checks with the client for priorities when planning client care. The nurse researches new technological advances in the treatment of cancer.

The nurse researches new technological advances in the treatment of cancer. The QSEN definition specifies the integration of best current evidence with clinical expertise, along with client and family preferences and values, for delivery of optimal health care. QSEN informatics expands the definition of QSEN competencies by calling for the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making. Working with the dietitian demonstrates the QSEN teamwork and collaboration competency. Orienting a visually impaired client to his room demonstrates the QSEN safety competency. QSEN competency of client-centered care is illustrated by the nurse working with the client to prioritize care.

A client's surgical wound dehisced when a nurse removed the staples before a health care provider prescription was given. Following root cause analysis, which organizational response is appropriate? Select all that apply. The nurse's actions will be deemed intentionally reckless. The nurse will be found to have committed a human error. Systems around the documentation of prescriptions will be reviewed. The nurse will be disciplined by an impartial review board. The nurse will be sued by the hospital for malpractice.

The nurse will be found to have committed a human error. Systems around the documentation of prescriptions will be reviewed. The nurse's action will likely be categorized as a human error. There is no evidence of malice (intentional recklessness) or failing to appreciate the gravity of an action (at risk behavior). As such, legal or disciplinary actions are an unlikely response. As with any error, systemic factors must be examined. There is no suggestion in this scenario that there was any confusion with the applicable provider prescription for care.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? The blood pressure is elevated. A baseline pulse rate is needed. The carotid pulse is bounding. The radial pulse is difficult to obtain.

The radial pulse is difficult to obtain. Auscultation of the apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. While this is an excellent method to determine baseline pulse, it is not the reason for using the apical pulse method. Elevated blood pressure and bounding carotid pulse are not reasons to obtain an apical pulse.

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply. Toothbrush Toothpaste Emesis basin Towel Disposable gloves Lip lubricant

Toothbrush Toothpaste Emesis basin Towel Disposable gloves Necessary supplies for tooth brushing include toothpaste, toothbrush, emesis basin, towel, and disposable gloves. The nurse would also include other PPE as needed, a glass of water, and mouth rinse. Lip lubricant is optional but should be offered to the client.

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? Powered stand-assist Transfer chair Repositioning lift Gait belt

Transfer chair Chairs that can convert into stretchers are available. These are useful with clients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the client. Powered stand-assist and repositioning devices require the client to have weight-bearing capacity in one leg. Gait belts are used to assist clients to ambulate safely.

The nurse provides care for a female client having difficulty urinating after a vaginal hysterectomy. Which strategy(ies) does the nurse use to assist the client with urinary elimination? Select all that apply. Turn on the water in the bathroom Pour warm water over the perineum Place client in sitting position Provide a sitz bath Encourage client to drink large quantities of water

Turn on the water in the bathroom Pour warm water over the perineum Place client in sitting position Provide a sitz bath Strategies that the nurse uses to most effectively assist the female client with urinary elimination after a vaginal hysterectomy include turning water on in the bathroom and pouring warm water over the perineum to stimulate the release of urine. Also, placing the client in the sitting position and providing a sitz bath will relieve some of the pain associated with urination after hysterectomy. Drinking large quantities of liquid can stretch out the bladder and cause additional urinary problems, so it is important for the client to stay hydrated, but not to overconsume.

A pediatric nurse is discussing injury prevention with a group of new parents. What are the leading causes of mortality and morbidity in children? Select all that apply. Unintentional gunshot wounds Drowning Accidental poisoning Suffocation Complications of medical care

Unintentional gunshot wounds Drowning Accidental poisoning Suffocation Unintentional gunshot wounds, drowning, poisoning, and suffocation are a leading cause of mortality and morbidity in children. Complications of medical care are a more significant cause of death among older demographics.

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply. Use a chair alarm when the client is out of the bed. Keep all bed rails up at night. Use a bed alarm to signal when the client gets up Hold diuretic medications. Keep the client's slippers at the bedside for easy reach.

Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up Interventions for decreasing fall rates and decreasing the severity of injury if a fall occurs have become a focus to ensure safe client care. By identifying clients at greatest risk, the nurse can increase and individualize surveillance and preventive interventions. Some fall prevention strategies for all clients include orientating the client to the environment and keeping a call light and personal belongings within reach. If the assessment determines that the client is at high risk for falling, the nurse should individualize the plan based on the specific risk factors. One thing to consider is using a bed or chair alarm for confused clients.

Which are recommended guidelines for daily care of a client who has an indwelling urinary catheter? Select all that apply. Perform care of the indwelling urinary catheter before perineal care. Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. Put on sterile gloves before cleaning the catheter. Clean 6 to 8 in of the catheter, moving from the meatus downward. Slightly pull on the catheter during the cleaning motion to dislodge crusts. Inspect the meatus for drainage and note the characteristics of the urine.

Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. Clean 6 to 8 in of the catheter, moving from the meatus downward. Inspect the meatus for drainage and note the characteristics of the urine. If the client has an indwelling catheter and the facility recommends daily care for the catheter, this is usually done after perineal care. Facility policy may recommend use of an antiseptic cleaning agent or plain soap and water on a clean washcloth. Put on clean gloves before cleaning the catheter. Clean 6 to 8 in of the catheter, moving from the meatus downward. Be careful not to pull or tug on the catheter during the cleaning motion. Also inspect the meatus for drainage and note the characteristics of the urine.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible. Twist or bend electric cords to make sure the cords are not dragging on the floor. Clean all equipment with soap and water after use.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible. Nurses work with mechanical and electrical equipment on a daily basis. Proper care to avoid injury and damage to these items includes using them only for the specific purpose, using three-pronged plugs, and having working knowledge of the correct procedures for safety. Bending cords can cause internal wire damage. Many types of sensitive technical equipment can be damaged if cleaned with soap and water.

A female client with a Foley catheter requires perineal care. Which intervention(s) does the nurse use to prevent a health care-acquired infection? Select all that apply. Use front-to-back cleaning technique. Turn folded washcloth over to new area each time a section of perineal area is cleaned. Spread labia majora and wipe down the center, working from inner to outer areas. If the catheter is soiled, clean with soap and water using proximal-to-distal technique. With each draining of the collection bag, also cleanse perineal areas with premoistened, rinse-free, disposable washcloths.

Use front-to-back cleaning technique. Turn folded washcloth over to new area each time a section of perineal area is cleaned. Spread labia majora and wipe down the center, working from inner to outer areas. If the catheter is soiled, clean with soap and water using proximal-to-distal technique. With each draining of the collection bag, also cleanse perineal areas with premoistened, rinse-free, disposable washcloths. The dark, warm, moist perineal and vaginal areas increase the likelihood of bacterial growth. When cleaning the perineal area of a female with an indwelling Foley catheter, the nurse always uses the front-to-back cleaning technique, turning the folded washcloth over to a new area each time a section of perineal area is cleaned. The nurse spreads the labia majora and wipes down the center, working from inner to outer areas and, if the catheter is soiled, cleans it with soap and water using the proximal-to-distal technique. These actions will help prevent moving pathogens from the outer areas into the urinary opening. Although a clean wash cloth with soap and water is acceptable, the nurse may use premoistened, rinse-free, disposable washcloths to clean the perineal area of client's urinary catheter. Reference:

The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home? Place throw rugs in high traffic areas. Install 60 watt light bulbs in stairways. Use night-lights in bedrooms and bathrooms. Use ladders and step stools to reach high items.

Use night-lights in bedrooms and bathrooms. The risk of falls increases with a person of advanced age, impaired mobility, or both. Ways to prevent falls include the use of night-lights in bedrooms and bathrooms to provide light if the client needs to get up in the night. Other interventions include removal of throw rugs, making sure that stairways are well-lit (100 watt bulbs), and never attempting to reach items that are beyond reach or physical ability.

a nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain? Use of nonpharmacologic methods can diminish the emotional component of pain. Nonpharmacologic methods do not require a health care provider's prescription. Nonpharmacologic methods are less expensive. Nonpharmacologic methods are more effective.

Use of nonpharmacologic methods can diminish the emotional component of pain. Nonpharmacologic methods of pain management can diminish the emotional components of pain, strengthen coping abilities, give clients a sense of control, contribute to pain relief, decrease fatigue, and promote sleep. Although it is true that nonpharmacologic methods do not require a health care provider's prescription, it is not the best rationale for their use. Many nonpharmacologic methods are more expensive than pain medications, especially if nursing staff are needed to implement the methods. Nonpharmacologic interventions lessen the emotional impact of pain but may not diminish the sensation of pain. A combined approach is often most effective.

The nurse is trying to obtain a temperature and the client continues to bite down on the oral thermometer. The nurse determines a rectal thermometer should be used. What actions demonstrates the nurse's understanding of the client's well-being and safety during this procedure? Using a digital thermometer, the nurse inserts the covered, lubricated probe 1.5 in (3.75 cm) into the rectum for 1 minute. The nurse positions the client in a prone position for comfort before inserting the probe into the rectum 0.5 in (1.25 cm) holding it between two fingers for stability. The nurse inserts the covered lubricated probe into the rectum, gently pushes until probe is at 1 in (2.5 cm) and leaves in the rectum for 30 seconds. The nurse selects the blue probe, places a disposable cover on it, and applies water-soluble lubricant to the probe tip.

Using a digital thermometer, the nurse inserts the covered, lubricated probe 1.5 in (3.75 cm) into the rectum for 1 minute. The nurse will ask the client to assume the Sim's position with upper leg flexed. The red probe is for rectal use. The probe should not be mercury or glass; therefore, a digital probe is a safer option. Ensuring that the rectal probe is used prevents cross-contamination, even when a disposable cover is used. In adults the covered, lubricated probe should be inserted 1.5 in (3.75 cm) for adults and left in for 1 minute. The probe should never be forced into the rectum.

The nurse is making an unoccupied bed. What action is most appropriate?

When changing a client's bedding, it is important to maintain appropriate body mechanics. The bed should be raised, and the nurse should avoid reaching over from one side of the bed to the other. An absorbent pad would go under the top sheet, not on top of it.

A nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which strategy(ies) does the nurse include about how the spouse can maintain proper body mechanics and prevent injury to oneself? Select all that apply. When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer. Use the hip flexors to rotate the client to the designated position. Use the muscles in your legs to lift and/or pull.

When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer Use the muscles in your legs to lift and/or pull. When teaching the spouse about his or her safety while providing care for the client who had a stroke, the nurse will explain that when the caregiver supports the spouse during dangling, the caregiver should tighten the gluteal and abdominal muscles to avoid back strain or self-injury. In addition, the nurse will tell the caregiver to use a gait belt to help the spouse transfer from bed to chair to prevent the caregiver injuring one's own shoulders and back. The caregiver will also be advised to always keep the spouse close to one's body to prevent shoulder and back strain to self. The caregiver will be told to use the muscles in the legs to lift and/or pull rather than using the shoulders and back. When transferring a client, the body should turn with the client and there should not be a rotation movement as this will cause back injury.

A nurse is providing care for a client recovering from a stroke and teaches the spouse about caring for the client. Which strategy(ies) does the nurse include about how the spouse can maintain proper body mechanics and prevent injury to oneself? Select all that apply . When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer. Use the hip flexors to rotate the client to the designated position. Use the muscles in your legs to lift and/or pull.

When supporting your spouse during dangling, tighten your gluteal and abdominal muscles to avoid back strain or self-injury. Grip the gait belt as your spouse walks so that you can provide aid if your spouse begins to fall. Use a gait belt to help your spouse transfer from bed to chair. Always keep your spouse close to your body during the transfer. Use the muscles in your legs to lift and/or pull. When teaching the spouse about his or her safety while providing care for the client who had a stroke, the nurse will explain that when the caregiver supports the spouse during dangling, the caregiver should tighten the gluteal and abdominal muscles to avoid back strain or self-injury. In addition, the nurse will tell the caregiver to use a gait belt to help the spouse transfer from bed to chair to prevent the caregiver injuring one's own shoulders and back. The caregiver will also be advised to always keep the spouse close to one's body to prevent shoulder and back strain to self. The caregiver will be told to use the muscles in the legs to lift and/or pull rather than using the shoulders and back. When transferring a client, the body should turn with the client and there should not be a rotation movement as this will cause back injury.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device? The client should hold the cane in the hand on the same side as the leg with the most severe deficit. The client should stand with as much weight as possible placed on the feet, using the cane for balance. When taking a step, the client should advance the stronger leg forward ahead of the cane and follow with the weaker leg. When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane. When stepping forward, the heel should be slightly beyond the tip of the cane. The client should hold the cane on the opposite side of the foot with the deficit and evenly distribute weight between the feet and the cane. The client should step first with the weaker leg.

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began measuring the BP after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client? This is called hypotension and may be caused by your medications. You may have orthostatic hypotension and should be seen by your health care provider as soon as you can. You should change the batteries in your BP monitor. You should not lay down for a nap during the day to prevent your BP from dropping.

You may have orthostatic hypotension and should be seen by your health care provider as soon as you can Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? a dose of an antipsychotic side rails a geriatric chair with a tray a dose of an analgesic

a dose of an antipsychotic Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid: adduction of the affected leg. hip abduction. flexion of the knee on the affected leg. extension of the knee on the affected leg.

adduction of the affected leg. For some types of hip surgery, dislocation can result from movement of the leg toward (adduction) or past the midline of the body(abduction). Thus, to prevent injury, it is important to avoid hip adduction on clients who have had hip replacement surgery.

5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply. four-point soft restraints isolation administration of sedation four side rails up having a parent stay with the child

administration of sedation four side rails up having a parent stay with the child The use of four-point restraints and isolation would likely increase agitation. These would be appropriate if behavior was violent or if behavior posed an immediate threat to self or others, such as trying to climb out of the bed.

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action? ask the client to stand while assessing the BP ask the client to make a fist after cuff inflation wait a few minutes and then try to assess the BP contact the primary care provider for further instruction

ask the client to make a fist after cuff inflation Korotkoff sounds result from the vibrations of blood within the arterial wall and changes in blood flow. These sounds occur in phases and correlate with blood pressure measurement. They can be increased by asking the client to make a fist after cuff inflation. Standing for BP assessment is not appropriate, as blood volume changes. Waiting to assess the BP could be problematic if the client is experiencing low BP or an acute change. Contacting the PCP is not appropriate, as there is further nursing action that can be taken.

The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care? Encourage the client to dress oneself using assistive devices Suggest the client have a family member assist him or her Offer techniques first and have client return demonstration Assist the client in dressing oneself after offering alternative techniques

assist the client in dressing oneself after offering alternative techniques Self-care refers to a person's ability to perform primary care functions in bathing, feeding, toileting, and dressing without the help of others. Nurses play an important role in helping clients learn or relearn self-care. The ability for the client to independently perform appropriate self-care improves a person's health status and emotional well-being. After a CVA, an adult client would need help relearning how to dress, not learning to dress. Encouraging the client to use assistive devices is not an appropriate intervention for dressing and undressing. Suggesting a family member assist may not be appropriate and cause the client to feel embarrassed or helpless. Likewise, having the client return demonstration is not appropriate as the client knows visually how to do this task, but is unable to perform dressing themselves.

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of: ataxia. tremors. chorea. athetosis.

ataxia. Ataxia refers to a lack of muscle coordination. Tremors are rhythmic, repetitive movements. Chorea is spontaneous, brief, involuntary muscle twitching of the limbs or facial muscles. Athetosis refers to movement characterized by slow, irregular, twisting motions.

A 90-year-old widower lives alone in her home. The nurse knows that older clients are at increased risk for falls. What other factors contribute to increased risk for falls in clients? Select all that apply. ataxic gait history of a fall 5 years ago diuretics installed carpeting

ataxic gait history of a fall 5 years ago diuretics Gait disturbances, history of falls, certain medications, and weakness are highly predictive of a fall. Installed carpeting can help prevent a fall in a home, while hardwood floors or loose rugs present a fall risk.

Over the course of a day, a nurse encounters many different clients whose pulse rates she must measure. For which client(s) will the nurse measure the apical pulse? Select all that apply. client who is on a medication that has arrhythmia as a side effect healthy 2-year-old toddler older adult client, whose pulse when measured peripherally is found to be extremely rapid young, athletic adult whose resting heart rate tends to be lower than normal middle-aged adult who has a fever young adult client who is pregnant

client who is on a medication that has arrhythmia as a side effect healthy 2-year-old toddler older adult client, whose pulse when measured peripherally is found to be extremely rapid An apical pulse is assessed when giving medications that alter heart rate and rhythm. In addition, if a peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, assess the apical rate. In adults, the apical rate is counted for 1 full minute by listening with a stethoscope over the apex of the heart. Apical pulse measurement is also the preferred method of pulse assessment in children up to 2 years of age.

During discharge planning, the nurse is assessing home safety for a client who has repeatedly fallen. Which condition increases the client's risk for falls? Select all that apply. climbs two flights of stairway to get to his bedroom prefers to use the bathtub when taking a bath drinks 2 shots of alcoholic beverages before dinner takes a diuretic pill early in the morning uses non-skid socks all day

climbs two flights of stairway to get to his bedroom prefers to use the bathtub when taking a bath drinks 2 shots of alcoholic beverages before dinner takes a diuretic pill early in the morning Unintentional injuries at home are common for the older adult. Safety habits, no longer reinforced by watchful adults, can become rusty; disregard of judgment, overconfidence, or ignorance can place adults in danger's path. In addition, adults may consume alcohol, which interferes with judgment to interpret the environment and with physical capabilities to operate machinery, thus contributing to injuries.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? deep in the posterior sublingual pocket superior to the tongue, with the tip touching the hard palate in the inferior buccal space on either side of the tongue along either upper gum line, adjacent to an incisor

deep in the posterior sublingual pocket

There have been an increase of needlestick injuries in the intensive care unit. When preparing to address this occurrence in a staff meeting, what should the nurse manager include in an education presentation to prevent needlestick injuries? Select all that apply. disposing of used needles in sharps container recapping all needles after use using self-retracting safety needles wearing gloves for performing venipuncture Using needleless adapters for medication administration

disposing of used needles in sharps container using self-retracting safety needles Using needleless adapters for medication administration To avoid needlestick injuries, the nurse should dispose of needles in appropriate sharps containers, should not attempt to recap needles, and should utilize self-retracting safety needles when performing venipuncture. Use needleless adapters whenever possible for all other IV maintenance and medication administration. Although observing Standard Precautions limits provider exposure to bloodborne pathogens, especially hepatitis B and HIV, gloves do not help to avoid needlestick injuries.

A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate to decrease the risk of falls? Select all that apply. encourage oral fluid intake encourage slow movement from the bed to the chair encourage intake of protein-rich foods encourage removal of compression stockings encourage the client to use the call light prior to getting out of bed encourage the use of the call light for help to the bathroom

encourage oral fluid intake encourage slow movement from the bed to the chair encourage the client to use the call light prior to getting out of bed encourage the use of the call light for help to the bathroom The nurse can reduce the fall risk associated with postural hypotension by restoring adequate hydration, making sure the client stays seated and moves slowly from sitting to standing, and encouraging the client to use the call light for help when ambulating. Protein-rich foods have no bearing on postural hypotension. Compression stockings should be applied to reduce the pooling of blood in the extremities when the client is standing.

The nurse is caring for two clients with the same ethnic background. The nurse notices some differences between the two in the religious practices and the slang used for communicating. What is most likely the etiology of these differences? cultural norms cultural relativity ethnicity ethnocentrism

ethnicity Ethnicity or ethnic identity refers to the differences among a group who share the same cultural and/or ancestral heritage. Cultural norms are the actions that are expected by others within the culture. Cultural relativity refers to the differences between cultures in the meaning of various behaviors. Ethnocentrism is the belief that one's own practices are the only correct practices

The nurse is caring for a 72-year-old client who has a history of asthma and hypertension and recently had some medication changes. Which action should the nurse prioritize after noting the client has a diminished appetite with reports of nausea as well as dizziness upon standing? evaluate new cardiovascular medications monitor for weight changes assess for an infection institute precautions against falling

evaluate new cardiovascular medications Older adults generally have more profound responses to cardiovascular medications than younger adults. Changes such as dizziness or fainting, diminished appetite, nausea, or visual changes may indicate the need for evaluation of cardiovascular medications. The nurse must know potential adverse reactions to all medications his or her client is receiving and monitor each client for these potential reactions. The other actions could be performed if needed; however, evaluating the possibly adverse effect to the medication would be the priority.

The nurse is admitting a client who practices the Jewish faith to the acute care unit and calls the dietary department to order a kosher dietary tray without consulting the client about food preferences. Which behavior is the nurse demonstrating when performing this action? ethnocentrism generalization ageism stereotyping

generalization The nurse is demonstrating generalization by ordering a kosher dietary tray when not all Jewish people keep kosher. The nurse is assuming that all Jewish people only eat kosher foods or all hold the same behaviors and beliefs. Stereotyping prevents seeing and treating another person as unique while generalizing suggests possible commonalities that may or may not be individually valid. The nurse is not demonstrating ethnocentrism, which is a belief that one's own culture or religion is superior to another. Ageism is the discrimination of a person due to their age and treating them differently.

When moving a client up in bed with the assistance of another caregiver, the nurse should: ask another nurse about the plan of care. elevate the head of the bed. maintain a pillow under the client's head. have the client fold the arms across the chest.

have the client fold the arms across the chest. Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assists in determining the best plan for client movement. The head of the bed should be flat or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate? identifies client's last name and room number identifies client's date of birth and last name identifies client's full name and date of birth identifies client's room number and full name

identifies client's full name and date of birth National Patient Safety Goals require that two methods for identification (e.g., the client's name and date of birth) be confirmed prior to administration of medications or treatments. Room numbers should not be used, since clients may be assigned to different rooms throughout a stay. Identifying a last name is not enough information to thoroughly confirm identification.

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? To ensure safety, do not allow the client to assist with the transfer. Use assistive devices if either of the nurses will need to lift more than 60 lb (27.2 kg). If the client is in pain, administer analgesics in advance of the transfer. Avoid using handling aids unless absolutely necessary.

if the client is in pain, administer analgesics in advance of the transfer. If the client is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the client to participate in the move comfortably. Clients should be encouraged to assist in their own transfers. During any client-transferring task, if any caregiver is required to lift more than 35 lb (16 kg) of a client's weight, then the client should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and client.

Which body system effects would the nurse state as occurring due to immobility? Select all that apply. increased cardiac workload increased depth of respiration increased rate of respiration decreased urinary stasis increased risk for renal calculi Increased risk for electrolyte imbalance

increased risk for renal calculi Increased risk for electrolyte imbalance increased cardiac workload Increased cardiac workload, increased risk for renal calculi, and increased risk for electrolyte imbalance occur from immobility. The client would have decreased depth of respiration, decreased rate of respiration, and increase in urinary stasis with immobility.

The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply. There is a large pillow under the client's head. The client's forearms are supported on pillows. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. There is a rolled towel beside the client's hips.

The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. There is a large pillow under the client's head. In the Fowler position, the client's head should be against the mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture of the neck. The knee gatch should be avoided to prevent pressure on the popliteal artery that could compromise lower extremity circulation. When the client's foot is in the plantar flexion position, the client is at risk for foot drop. A foot board, high-top sneakers, or improvised firm foot support should be used. It is appropriate to place the client's forearms on pillows. This will prevent pull on the shoulders and help prevent dislocation of the shoulder. A rolled towel or trochanter roll will help prevent external rotation of the hips.

When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply. The head is held erect. The feet are at right angles to the lower legs. The arms are bent at the elbows. The chest is held upward and forward. The knees are bent.

The knees are bent. The arms are bent at the elbows. Correct alignment permits optimal musculoskeletal balance and operation and promotes optimal physiologic function. With the client standing, the nurse would be concerned if the arms were bent at the elbows. The arms should hang comfortably at the sides. Also, the nurse would be concerned if the knees were bent. The knees should be in a slightly flexed position, not bent and not in the knee-locked position. It is a normal finding for the head to be held erect and in the midline position. It is also a normal finding for the feet to be at right angles to the lower legs. It is a normal finding for the chest to be held upward and forward.

Which action by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs? The nurse teaches the client's family members how to administer the client's tube feeding. The nurse facilitates a family meeting to elicit support for the client's return to home following a stroke. The nurse caring for a Native American/First Nations client arranges for the client's medicine man to perform a healing ceremony. The nurse arranges for the client's clergy to visit after visiting hours.

The nurse arranges for the client's clergy to visit after visiting hours Self-actualization needs encompass the intellectual and spiritual dimensions of the individual, which is reflected in the nurse arranging for the client's clergy to visit after visiting hours. Arranging for the client's medicine man and teaching how to administer the client's tube feeding meet the physiologic needs of the individual. Love and belonging needs are met by eliciting support from the family.

A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency? The nurse works with other health care team members to provide care for a client diagnosed with Alzheimer's disease. The nurse manager holds an in-service for staff to teach them the safe operation of a new piece of equipment. The nurse researches best current practices for prevention of the spread of infection in physician offices. The nurse uses computer-generated care plans for client care.

The nurse researches best current practices for prevention of the spread of infection in physician offices. The QSEN model specifies the integration of best current evidence with clinical expertise, along with client and family preferences and values, for delivery of optimal health care. Researching current practices for prevention of the spread of infection demonstrates this competency. Working with others to provide care demonstrates collaboration of care. The nurse manager holding an in-service demonstrates education of the staff. Use of computer-generated plans for client care demonstrates the use of nursing informatics.

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse? leave the friction-reducing sheet in place once the client is transferred keep the client covered with the top covers and bedsheets instruct the client to hold on to the side rails for support and reach for the stretcher grasp the friction-reducing sheet at the hips and knees of the client

leave the friction-reducing sheet in place once the client is transferred Safe client handling and transfers involve the use of client assessment criteria, algorithms for client handling decisions, and proper use of client handling equipment. The client should be kept in good alignment and protected from injury while being moved. Once the client is transferred, the friction-reducing sheet should be left in place for the return transfer. In preparation for the transfer, a bath blanket should be placed over the client and the top covers removed from underneath. The client should be instructed to fold the arms against the chest and move the chin to the chest. This provides assistance in the transfer and prevents hyperextension of the neck. The nurse on the side of the bed without the stretcher should grasp the friction-reducing sheet at the head and chest areas of the client. The nurse on the stretcher side of the bed should grasp the friction-reducing sheet at the head and chest, and the nurse on the other side should grasp the friction-reducing sheet at the chest and leg areas of the client. This allows for even support of the client.

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? back arm chest leg

leg The nurse would tighten gluteal and abdominal muscles, flex the knees, and use the leg muscles to do the pulling. This saves strain on the nurse's lower back. The arms and chest are part of the accessory muscle groups used in pulling a client.

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce their risk for injuries incurred while working with clients. Which action(s) would contribute to this risk? Select all that apply. using uncoordinated lifts using assistive devices lifting when tired engaging in repetitive movements standing for long periods

lifting when tired engaging in repetitive movements standing for long periods using uncoordinated lifts Variables that can lead to back injuries or back pain for health care workers include performing uncoordinated lifts, manual lifting and transfer of clients without assistive devices, lifting when fatigued, repetitive movements, and standing for long periods.

During the time a client is on a hypothermia blanket, the nurse turns and positions the client every 30 to 60 minutes. What assessment(s) will the nurse make with each turn? Select all that apply. skin color change neurological changes lip and nail bed changes facial muscle twitching sensory impairment

lip and nail bed changes skin color change sensory impairment On each client turn, the nurse assesses the client's skin, looking for any color changes to the skin, lips, and nail beds, as well as any areas where there is sensory deficit. A neurological assessment is completed every 15 minutes regardless of whether or not the client is repositioned, as per the facility policy, until the body temperature is stabilized. Additional assessments would include evaluating for shivering and facial muscle twitching, but these are to be evaluated each time the client is assessed, not just when the client is repositioned.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? listen with the stethoscope at the fifth intercostal space left mid-clavicular line listen with the stethoscope at the fifth intercostal space at the sternum listen with a stethoscope at the neck to the right of the coracoid process listen with a stethoscope at the second intercostal space left sternum

listen with the stethoscope at the fifth intercostal space left mid-clavicular line To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostal space, left mid-clavicular line.

A client is hospitalized with orthostatic hypotension from dehydration. A nurse must delegate the task of hygiene and morning care to an unlicensed assistive personnel (UAP). What type of bath should the nurse instruct the UAP to provide to the client? complete bed bath partial bath independent showering The client should not be bathed.

partial bath Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash the lower extremities. Even while hospitalized, independence is encouraged, so allowing the client to receive a partial bath with assistance is appropriate. The client is likely stable enough to allow hygiene measures.

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? instruct the client to place arms on the side rails place a small pillow under each arm elevate the head of the bed place a trochanter roll under the arms

place a small pillow under each arm A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning? plantar flexion of the feet flexion contracture of the neck skin breakdown of the sacrum hyperextension of the hips

plantar flexion of the feet It is important to be aware of client positioning and nursing actions required to prevent complications. The client who is in the prone position is at risk for foot drop (plantar flexion of the feet) because of the pull of gravity on the feet—unless the legs and feet are positioned carefully. The client in the prone position is not at risk for flexion contracture of the neck, because the body is straight—the shoulders, head, and neck are in an erect position. The client would be at risk for flexion contractures of the hips when in the supine or Fowler position. The client in the prone position is lying on his abdomen and therefore would be at risk for skin breakdown of the sacrum. The client in the Fowler position would be at risk for skin breakdown of the sacrum. When in the prone position, the hips are prevented from flexing or hyperextending.

The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use? lateral assist device friction-reducing device powered full-body lift powered stand-assist device

powered full-body lift Many devices are available to aid in transferring, repositioning, and lifting clients. It is important to choose the right equipment and appropriate device on the basis of client assessment and desired movement. Although this client can bear weight on the unaffected side, the client is uncooperative. A powered full-body lift device should be used. A lateral assist device is used during side-to-side transfers to make transfers safer and more comfortable for the client. A friction-reducing device can be used under clients to prevent skin shearing when moving clients in bed and when assisting with lateral transfers. A powered stand-assist device can be used with clients who can bear weight on at least one leg, can follow directions, and are cooperative.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in the movement of secretions in the respiratory tract increase in circulating fibrinolysin predisposition to renal calculi increased metabolic rate

predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group? selecting toys for the developmental level providing drug, alcohol, and sexuality education teaching stress reduction techniques providing close supervision to prevent injuries

providing drug, alcohol, and sexuality education The school-age child should be taught drug, alcohol, and sexuality education. Selecting toys for the developmental level applies to infants. Teaching stress reduction techniques applies to adults. Providing close supervision to prevent injuries applies to toddlers. - school age is around 6 to 12

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which sign(s) and symptom(s) will the nurse assess related to this condition? Select all that apply. report of feeling dizzy when sitting up from a supine position report of feeling palpitations when rising from a supine to a standing position erythema on the bilateral lower extremities temperature of 100.4°F report of feeling lightheaded when sitting up syncope

report of feeling dizzy when sitting up from a supine position report of feeling palpitations when rising from a supine to a standing position report of feeling lightheaded when sitting up syncope Orthostatic hypotension occurs when the client's blood pressure decreases when moving from a sitting or lying position to a standing position. The systolic pressure drops by at least 20 mm Hg or the diastolic decreases by at least 10 mm Hg within 3 minutes of rising to the standing position. Common signs and symptoms of orthostatic hypotension include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, syncope and headaches.

A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply. respiratory rate 30/min headache hunger cold, clammy skin red or flushed skin

respiratory rate 30/min headache red or flushed skin The following are clinical signs associated with a fever: pinkish or red skin (skin that is warm to the touch), headache, and above-normal pulse or respiratory rates. Clients who are febrile may or may not be hungry. Clients who are febrile have warm, not cold and clammy, skin.

The nurse is preparing an education session on injury prevention for parents with toddlers. What will the nurse prioritize during this session to help parents to reduce the risk of injury for toddler, given their developmental stage? Select all that apply. safety with stairs water safety electric outlet safety childproof latches bike safety

safety with stairs water safety electric outlet safety childproof latches Infants and toddlers are vulnerable and often the victims of accidental poisoning, falls from stairs or high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning. As children do not begin to learn how to ride a bike independently until at least the preschool age (more commonly during the school-aged years), the nurse will not prioritize teaching the parents about bike helmet safety.

A nurse assists the client in the development of a healthy lifestyle. The adoption of these lifestyle changes in the client's life is considered: adaptation. self-care. self-esteem. health management.

self-care. Self-responsibility is paramount in Dorothea Orem's nursing theory, which focuses on self-care so that the person can maintain life, health, and well-being. Self-esteem is one's own sense of one's worth. Adaptation is how one responds to one's environment and to disease. Health management is one's efforts to maintain one's health.

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding? hypertrophy. atrophy. flaccidity. spasticity.

spasticity Adequate skeletal muscle mass, tone, and strength are prerequisites to appropriate body movement and work performance. Spasticity, or hypertonicity, is defined as increased tone that interferes with movement. Spasticity is caused by neurologic impairments, and is often described as a stiffness, tightness, or pulling of the muscle. Hypertrophy refers to increased muscle mass resulting from exercise or training. Atrophy describes muscle mass that is decreased through disuse or neurologic impairment. Flaccidity, or hypotonicity, results from disuse or neurologic impairments, and is described as a weakness of paralysis.

The staff at a day-surgery clinic are meeting because there have been two significant medication errors committed over the past few weeks. To prevent future medication errors, what is the priority action for the nurse's to take? take measures to ensure that nurses are not disturbed when obtaining and administering medications have each medication administered checked and co-signed by another nurse collaborate with the health care providers to determine whether clients are being prescribed any nonessential medications cluster the timing of medication administration to reduce the number of times that a client is given medications

take measures to ensure that nurses are not disturbed when obtaining and administering medications Distraction is a major cause of medication errors. In general, it is not necessary to have two nurses co-administer medications for them to be given safely. Performing a medication reconciliation with health care providers may reveal that some medications are nonessential, but this does little to enhance overall medication administration safety. Clustering the administration of medications does not equate with improved safety and reduction of errors.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered? temporary application of devices that reduce the client's ability to move arms administration of an antipsychotic agent to alter the client's behavior delegating to the unlicensed assistive personnel (UAP) to sit with the client providing a sleep agent to help the client rest instead of pulling IV lines and the catheter

temporary application of devices that reduce the client's ability to move arms If diversion behaviors and chemical (drug) restraints have failed, the nurse anticipates that the provider may order temporary application of devices to reduce the client's ability to move arms, which will prevent the behavior. The other actions are not appropriate, so the nurse would not anticipate them.

A client has been discharged from the hospital after being treated for a myocardial infarction. The client has been asked to evaluate the care received by completing the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The results of this survey may affect: the client's future qualification for Medicare and/or Medicaid. the amount of money the hospital receives from the Centers for Medicare & Medicaid Services. the hospital's evaluation by the Occupational Safety and Health Administration (OSHA). the hospital's standing in the Magnet Recognition Program.

the amount of money the hospital receives from the Centers for Medicare & Medicaid Services. A portion of the value-based purchasing program is based on clients' responses to satisfaction surveys such as HCAHPS. This survey is irrelevant to the client's enrollment in Medicare or Medicaid. OSHA is not privy to HCAHPS results. HCAHPS results are not used in the determination of Magnet designation.

A client reports having a history of gingivitis. The nurse correctly recognizes that this condition may be caused by which? Select all that apply. thermal extremes poor oral hygiene diet with soft fruits and cooked vegetables adverse reaction to medications bacteria

thermal extremes poor oral hygiene adverse reaction to medications bacteria The gums are made up of the oral mucosa, which covers the bone supporting the tooth; the alveolar bone, which forms sockets around the teeth; and the periodontal ligament, which joins the teeth to the bone. Inflammation in these tissues, called gingivitis or periodontitis, can be caused by local irritation from bacteria, plaque, tartar, and food impaction. Mechanical, chemical, or thermal extremes may also contribute to inflammation of the oral mucosa. Soft foods would not cause the plaque or tarter buildup that can lead to gingivitis.

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? transfer belt transfer boards mechanical lift roller sheet

transfer belt A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

The health department is reviewing community health initiatives for the year. During the summer, the health department focuses infection control implementation activities on which program? administering influenza immunizations administering free antibiotics using pesticides for mosquitoes delivering fans to older adult residents

using pesticides for mosquitoes Community problems such as water supply contaminated with sewage or tick infestations near residential areas also can result in infection. Influenza immunization is concentrated in the fall and winter. Antibiotic administration is not a prevention program but one geared to disease treatment. Fans may be delivered to older adults but this intervention will not reduce infection.

A nursing student is caring for a client with dentures. Which action by the nursing student would require intervention by the nurse? using ungloved hands to remove an unconscious client's dentures cleaning dentures with tepid water from the sink encouraging the client to leave the dentures in their mouth overnight holding dentures over a plastic basin or towel when cleaning them

using ungloved hands to remove an unconscious client's dentures Gloves should always be used to remove an unconscious client's dentures. Dentures should be cleaned in cold or tepid water, and then replaced into the client's mouth so the gum lines do not begin to change. Holding dentures over a plastic basin or towel when cleaning them is appropriate, so if dentures are dropped, they will not break.

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?" The client will demonstrate safety measures to prevent falls. The client will establish safety priorities with family members. The client will identify resources for safety information. The client will identify unsafe situations in his or her environment.

The client will demonstrate safety measures to prevent falls. Because this client has been assigned a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment," the nurse should determine that the client is at risk for falls and, therefore, a good outcome would be to prevent falls.

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client? The client will not experience a fall and remains free of injury. The client will stay in bed. The client will wear nonskid footwear The client will not ambulate without assistance.

The client will not experience a fall and remains free of injury. Many accidental injuries and deaths are preventable. Consider the various factors and the environment that affect the client's safety and formulate expected outcomes uniquely suited to each situation and circumstance. Some expected outcomes for clients that promote safety and prevent fall injuries include:• demonstrate safety measures to prevent falls and other accidents• remain free of injury during hospitalization

The nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply. Restraints may be used to prevent a client from falling if the facility is short-staffed. The client's family must be involved in the decision and care plan. Alternatives to restraints and less restrictive interventions must have been implemented and failed. The benefit gained from using a restraint must outweigh the known risks for that client. A physician or licensed independent practitioner must reevaluate and assess the client every 48 hours. The client's vital signs must be assessed and the medical client must be visually observed every 4 hours.

The client's family must be involved in the decision and care plan. Alternatives to restraints and less restrictive interventions must have been implemented and failed. The benefit gained from using a restraint must outweigh the known risks for that client. The client has the right to be free from restraints that are not medically necessary. Restraints are not used for the convenience of staff or to punish a client. The client's family must be involved in the care plan and must be consulted when the decision is made to use restraints. Alternatives to restraints and less restrictive interventions must have been implemented and failed, and all alternatives used must be documented. The benefit gained from using a restraint must outweigh the known risks for that client. A physician or licensed independent practitioner must reevaluate and assess the client every 24 hours. The client's vital signs must be assessed and the medical client must be visually observed every 2 hours.

A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints? Chemical restraints should be tried before using physical restraints. The restraints can be ordered by the nursing supervisor in emergency situations. The client's vital signs must be assessed every hour. The client's order for restraints must be renewed by the health care provider every 4 hours.

The client's vital signs must be assessed every hour. The client's vital signs must be assessed every hour when restrained. Restraints must be ordered by a health care provider. Orders for restraints may be renewed every 4 hours for adults 18 years of age or older but must be renewed every 24 hours. Chemical restraints do not necessarily have to precede the use of physical restraints.

The nurse is caring for a client diagnosed with asthma. The client reports drinking herbal tea to treat illnesses. Which additional question(s) will the nurse ask during the assessment? Select all that apply. "Do you take any other supplements?" "Is there a specific brand of tea that you prefer?" "Can your family bring some tea to the hospital for you?" "How many cups of herbal tea do you drink in one day?" "Have you shared this information with your health care provider?"

"How many cups of herbal tea do you drink in one day?" "Have you shared this information with your health care provider?" "Do you take any other supplements?" Culture influences a client's dietary choices and the nurse should accommodate these preferences as long as it is safe to do so. Herbs are a common medicinal treatment in many cultures. If a client traditionally drinks herbal tea to alleviate symptoms of an illness, it would be appropriate for teas and prescribed medications to be used together as long as there are no contraindications. The nurse will need to determine how many cups of herbal tea are ingested each day along with any other supplements the client takes. The nurse does not need to determine the specific brand of tea the client prefers. It may be appropriate for family to bring the client herbal tea, but only after the nurse has determined there are no interactions with the client's prescribed medications. It is important to ask the client if he or she has discussed the use of the tea or any other supplements and alternative therapies with the primary health care provider. Since many alternative treatment modalities are not federally approved for use, there may be drug interactions that the client is unaware of.

A school nurse is teaching a group of adolescents about safe driving. What behavior(s) should the nurse encourage to promote safe driving? Select all that apply. Always wear a seat belt. Drive at night when fewer people are on the road. Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit.

Limit the number of other adolescents in the car. Never text while driving. Obey the speed limit. Always wear a seat belt. (? marked wrong but within the rationale it's included as right) Safe driving behaviors that help limit occurrences of motor vehicle accidents and help keep passengers safe should an accident occur. These behaviors include reducing the number of other adolescents in the car, never texting while driving, obeying the speed limit, and always wearing seat belts. Driving at night should be limited, not encouraged.

A client has a nasogastric tube following abdominal surgery. Which intervention(s) does the nurse perform to prevent an alteration in the client's oral health? Select all that apply. Apply lubricant to the lips and nostrils Offer water to rinse the mouth every hour Encourage the client to swallow saliva naturally Assist the client to brush teeth at least every 4 hours Swab oral mucosa with lemon-glycerin swabs as needed.

Apply lubricant to the lips and nostrils Offer water to rinse the mouth every hour Encourage the client to swallow saliva naturally Assist the client to brush teeth at least every 4 hours To prevent an alteration in the client's oral health, the nurse applies lubricant to the lips and nostrils of the client. The nurse offers water or mouthwash to rinse the mouth every hour. The nurse also encourages the client to swallow saliva naturally and assists the client to brush teeth at least every 4 hours. Assisting the client to brush the teeth at least once every day is not frequently enough to maintain optimal oral care for the client with a nasogastric tube. Lemon glycerin swabs and other alcohol-based mouthwashes and products are drying agents and should not be used

The nurse assesses a 68-year-old client being treated for heart failure who reports dyspnea with mild activity, sitting at a desk most of the day while working, and preferring an orthopneic position. Recognizing that the client is at risk for disuse syndrome, which intervention(s) will the nurse initiate? Select all that apply. Instruct the client to sit upright to prevent dyspnea. Offer activity options and their benefits that match the client's interests and address the client's needs. Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program. Encourage active range-of-motion exercises. Encourage the client to elevate legs instead of standing up at times in the day.

Instruct the client to sit upright to prevent dyspnea. Offer activity options and their benefits that match the client's interests and address the client's needs. Collaborate with physical, occupational, and recreational therapists to implement an individually tailored exercise program. Encourage active range-of-motion exercises. The consequences of inactivity are referred to as disuse syndrome and, because the client is at risk for the condition, the nurse will teach the client to initiate a high Fowler position when dyspnea occurs. This will help alleviate the dyspnea and allow the client better oxygenation and energy to increase activity level. The nurse also offers activity options and their benefits to the client that match the client's interest and address the client's needs, so the client can understand the reasons for the activities and make good choices. The nurse collaborates with physical, occupational, and recreational therapists to implement an individually tailored exercise program, so that each professional can contribute from his or her area of expertise and the different types of activities that can motivate the client and enhance adherence to the program. Whenever possible, it is important to encourage the client to stand up from the sitting position even for brief periods throughout the day, as repositioning can improve circulation that prevents disuse syndrome. Although elevating the legs is an effective way to prevent edema of the lower legs, it is not as effective as standing to prevent muscle atrophy associated with disuse.

A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries in the toddler. Which instruction is the priority to provide to the mother? Instruct the toddler about the consequences of burns. Keep coffee cups on the counter above the child's reach. Teach the toddler about fire safety. Cool hot liquids before giving them to the child.

Keep coffee cups on the counter above the child's reach. The mother should be told to always keep her coffee cup on the counter so that it is out of reach of the toddler. Toddlers are naturally inquisitive and more mobile than infants, and they fail to understand the dangers of looking into a cup, which can have hot contents. Consequently, they are often the victims of accidental poisoning, falls down stairs or from high chairs, burns, electrocution from exploring outlets or manipulating electric cords, and drowning. The toddler may not understand fire safety or the consequence even after he has been given instructions. A parent feeding the child is not a usual cause of accidental thermal injury.

A new mother has brought her infant into the pediatric clinic. The infant has a red rash on the buttocks. What should the nurse instruct the mother? Leave the baby's buttocks open to air for 2 hours each day. Apply gentian violet to the buttocks with every diaper change. Change diaper as soon as it is soiled and apply cornstarch. Keep the diaper and buttocks clean and dry and apply zinc oxide.

Keep the diaper and buttocks clean and dry and apply zinc oxide Keeping the skin as dry and clean as possible helps preserve its integrity. The diaper area should be inspected with each change. Skin barrier products, such as those containing zinc oxide, are used to protect skin at risk for damage caused by excessive exposure to water and irritants, such as urine and feces. Application of one of these products forms a thin layer on the surface of the skin to repel potential irritants.

The nurse is caring for a client who has a large furuncle in the right axillae. What education will the nurse provide? Squeeze the lesion to release pus. Launder personal bath items in hot water and bleach. This chronic skin disorder is noninfectious. Nits may be present on hairs under the axillae.

Launder personal bath items in hot water and bleach. A furuncle (boil) is a raised pustule, usually in the neck, axillary or groin area that feels hard and painful. The nurse will teach the client to keep hands away from the infection lesion, to use separate cloths and towels from the rest of the family, to wash hands thoroughly before and after applying medication, and to launder personal bath items in hot water and bleach to prevent the transmission of infection. The nurse will not teach the client to squeeze the lesion, nor will tell the client that the skin disorder is noninfectious or that nits may be present on hairs under the axillae.

The nurse is providing discharge teaching to a family member of a client who has recently developed right sided weakness post-stroke. Which information will the nurse provide when educating the family member on how to assist the client to mobilize? Select all that apply . Have the client dangle legs on the side of the bed before standing. Support the client on the stronger side of the body when preparing to stand. Rock the client to standing position based on an agreed signal. Have the client stand for 1 minute before trying to take steps. Encourage the client to slowly take small steps.

Rock the client to standing position based on an agreed signal. Have the client stand for 1 minute before trying to take steps. Encourage the client to slowly take small steps. Have the client dangle legs on the side of the bed before standing. The caretaker should have the client sit on the side of the bed prior to ambulation to help prevent significant drops in blood pressure and help ensure that the client is safely moved to a standing position. Then, the client should stand for a few minutes to ensure blood pressure has stabilized and balance will not be lost. Rocking the client in the sitting position before assisting them to stand provides momentum and reduces the need to lift the client. The client should also move slowly and take small steps to avoid falls. Moving the legs and feet prior to standing may feel comfortable but is not needed to assist in ambulation. The client should always be assisted on the weaker side in order to allow them to use the stronger side to lead. This promotes independence with a focus on the client's ability rather than on their deficits.

When performing health education regarding hygiene, the nurse should advise female clients to avoid the use of which products/activities? Select all that apply. Routine douching Vaginal deodorants Tampons Commercial soap Unscented sanitary napkins

Routine douching Vaginal deodorants Douching has also been linked to vaginal irritation, bacterial vaginosis, pelvic inflammatory disease, and sexually transmitted infections (STIs). Deodorants to control odor around the vaginal orifice are unnecessary. There is no need to avoid the use of tampons, soap, and unscented sanitary napkins unless the client has a specific contraindication.

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? Nurse-client relationship Privacy Confidentiality Safety

Safety When moving a client, the nurse's key concerns are safety and client comfort. Privacy should be provided, as with any other nursing action, but this is not a key concern. Assisting a client with activity strengthens the nurse-client relationship. Confidentiality is not a major concern with activity.

The nurse is caring for a client who wears contacts. The client who states, "I sometimes sleep with my contact lenses and go 48 hours before removing them, even though I should take them out and disinfect them nightly." What education about contacts and eye care is most important to teach the client? Select all that apply. Secretions, dust, and pollen accumulate under the lenses as they are worn and increase the risk of an eye infection. A reddened conjunctiva, excess tearing, and burning pain are symptoms of wearing contacts too long. Contact lenses should be removed nightly and cleaned and disinfected after removal. Hand hygiene should be performed before and after insertion and removal of contact lenses. Contact lenses can cause corneal damage if left in place for too long.

Secretions, dust, and pollen accumulate under the lenses as they are worn and increase the risk of an eye infection. A reddened conjunctiva, excess tearing, and burning pain are symptoms of wearing contacts too long. Contact lenses should be removed nightly and cleaned and disinfected after removal. Hand hygiene should be performed before and after insertion and removal of contact lenses. Contact lenses can cause corneal damage if left in place for too long. All answers are factual and, in this situation the client knows the contact lenses need to be removed, cleaned, and disinfected nightly but may not know why. Explaining the signs of wearing lenses too long and the possible consequences ensures that the client can make an informed decision about caring for the eyes.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? supine prone Sims' Fowler's

Sims' Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply. The care team meets with the client and family promptly to identify their preferences for treatment. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. Each member of the care team uses the best available technology to organize and provide care. Treatments are chosen with the goal of minimizing the financial burden on the health care institution.

The care team meets with the client and family promptly to identify their preferences for treatment. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. Each member of the care team uses the best available technology to organize and provide care. According to the ANA, there are six focus-area competencies in QSEN: 1) client-centered care, 2) evidence-based practice, 3) teamwork and collaboration, 4) safety, 5) quality improvement, and 6) informatics. Meeting with the family exemplifies client-centered care. Evidence-based practice includes research evidence as well as client preferences. Safety is a QSEN competency, as is informatics (the effective use of technology). Financial concerns of the health care institution are not included among the six QSEN competencies.

The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed? The client uses the arms of the chair as support when standing up to use the walker. The client steps into the walker before moving the walker forward. The client pushes the walker ahead, following behind it. When arising from a chair, the client puts one hand at a time on the walker.

The client pushes the walker ahead, following behind it. Clients can have a tendency to push the walker out in front of them as they lean slightly forward and "follow" the walker. This makes the client and walker unstable and may result in a fall. The remaining statements reveal correct walker technique.

The nurse has provided instruction to the client concerning the use of the sitz bath. After the instruction the nurse is evaluating the client's understanding of the education. Which findings indicate the need for further instruction? Select all that apply. The client uses cool water for the treatment. The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C). The client reports that the treatment will take approximately 20 minutes. The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. The client reports the treatment will promote circulation to the problem area.

The client uses cool water for the treatment. The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C). The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth, rectal surgery, or to decrease the inflammation of hemorrhoids. Immersing only the pelvic region allows for application of local heat without widespread vasodilation that results when the entire body is placed in warm water. A sitz bath can be given in a special chair or tub in which the client sits. A portable device placed in the toilet also can be used. Warm water circulates gradually into the disposable device through tubing attached to a bag of warm water. The sitz bath usually lasts 20 minutes; the temperature of the water should be maintained at 105°F (40.5°C) to 110°F (43.3°C), with care taken not to burn the client.

The nurse is assessing a client's brachial artery blood pressure. Which nursing actions are performed correctly? Select all that apply . The nurse centers the bladder of the cuff over the brachial artery about midway on the arm. The nurse places the cuff over the client's bulky clothing and fastens it snugly. The nurse notes the point on the gauge at which the first faint but clear sound appears, and increases in intensity as the diastolic pressure. The nurse repeats any suspicious reading before 1 minute has passed since the last reading. The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. The nurse wraps the cuff around the arm smoothly and snugly and fastens it.

The nurse centers the bladder of the cuff over the brachial artery about midway on the arm. The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. The nurse wraps the cuff around the arm smoothly and snugly and fastens it. Pressure in the cuff applied directly to the artery provides the most accurate readings. If necessary, thick or bulky clothing is removed to allow for audible sounds of the blood pressure. The cuff should be centered over the site of the brachial artery, midway up the client's upper arm. Blood pressure measured with the arm below the level of the right atrium of the heart may produce a falsely high reading; if above the level of the heart the readings may be falsely low. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. The first faint but clear sound is the systolic (not diastolic) pressure. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings that are less than 1 minute apart.

The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply. The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark. The nurse checks to see that the manometer is in the horizontal position. The nurse opens the valve to the sphygmomanometer once the pulse if found.

The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark. Lying or sitting in a comfortable position allows for a more accurate measurement. Pressure in the cuff applied directly to the artery provides the most accurate readings. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. An aneroid gauge must be at zero when beginning to measure the blood pressure to help in ensuring accuracy. The manometer must be in the vertical position for BP measurement. Once the pulse is found with the Doppler the nurse should close the valve on the sphygmomanometer to allow for inflation of the BP cuff bladder.

The nurse is performing a safety belt fit test for a young client at a well-child check-up. What criteria confirms that the child may sit in the back seat of a vehicle with a lap and shoulder belt in place? The knees do not bend at the edge of the seat when child's back is against vehicle's seat back. The seat belt stays low on the hips and is not resting on the soft part of the stomach. The shoulder belt does not lay on the collarbone or shoulder when fastened. The child's feet touch the floor of the car when belted in with the lap and shoulder belt.

The seat belt stays low on the hips and is not resting on the soft part of the stomach. The child must meet all of the following criteria to be allowed to sit in the back of a vehicle with a lap and shoulder belt:• The child must sit in the back seat with the entire back against the vehicle's seat back.• The buckled seat belt must stay low on the hips and is not resting on the soft part of the stomach.• The shoulder belt must lay on the collarbone and shoulder.• The child must maintain the correct seating position with the shoulder belt on the shoulder and the lap belt low across the hips.

The health care provider tells the nurse that the desired body temperature for the client is 99.8°F (37.7°C). When does the nurse turn off the blanket? When the client reports feeling cold and uncomfortable. When the client's temperature reaches 99.8°F (37.67°C). When the client reports feeling nauseated and dizzy. When the client's temperature reaches 100.8°F (38.22°C).

When the client's temperature reaches 100.8°F (38.22°C). The blanket is turned off 1 degree above reaching the desired temperature because the body will continue to cool further, and it is desired to avoid hypothermia. The desired temperature is 99.8°F (37.7°C), so the blanket is turned off when the client's temperature is 100.8°F (38.2°C). The client who experiences hyperthermia may have nausea, vomiting, and dizziness due to the elevated temperature, but this is not an indication to discontinue therapy. Therapy is not discontinued secondary to feeling cold or uncomfortable, but it is discontinued if the client shivers, hyperventilates, or demonstrates other signs of overcooling.

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