Exam 2
Which factors should the nurse consider when administering medications to adolescents? Select all that apply.
- Explanation of the medication administration procedure by the nurse to the client - Interactive communication regarding the procedure of medication administration - Encouragement of self-expression, individuality, and self-care
Where should the nurse place a pillow or sandbag to prevent external rotation of a lower extremity?
Lateral to the client's affected hip
Which risk is associated with estrogen therapy in a client who smokes?
Thromboembolic disorders
A nurse provides discharge teaching to an older adult about care associated with activities of daily living. Which factor should the nurse mainly consider when counseling the client on how often to take a tub bath?
condition of the skin
A client returns to work as a carpenter after surgery for carpal tunnel syndrome of the right hand. What instructions should the nurse give to help prevent further problems with the hands when the client returns to work?
do stretching exercises during breaks
The nurse is preparing to administer ear drops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply.
- allergy to med - drainage from the ear canal - tympanic membrane rupture
The nurse is teaching the mother of a 3-year-old child about techniques to promote medicine adherence. What instructions should the nurse include in the teaching? Select all that apply.
- choose the proper dosage - complete the prescribed dose - use calibrated spoons for measuring liquid formulations
A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? Select all that apply.
= leaving the bedroom when unable to sleep = exercising in the afternoon rather than in the evening = counting backward from 100-0 when the mind is racing
What are the roles of an unlicensed assistive personnel in skin care? Select all that apply.
= to assist the client in bathing = to apply wet dressings to the skin = to report changes in the skin appearance
A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially?
Arrange a referral for a thorough medical evaluation.
Which complications does the nurse anticipate in the client who has blue-colored nail beds?
Cardiopulmonary disease
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?
Elevate the head of the client's bed and obtain vital signs.
A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse do what?
Fold the client's arms across the chest
A client expresses concern about insomnia and asks, "What can I do to get better sleep?" What activities should the nurse recommend? Select all that apply.
Follow the same bedtime ritual each night Perform deep-breathing exercises.
Which nursing action is contraindicated when caring for a client with a newly applied long leg cast?
Handling the cast with fingertips
A client is receiving furosemide to relieve edema. The nurse should monitor the client for which response to the medication?
Hypokalemia
The nurse provides instructions about how to use a nebulizer to a client with chronic obstructive pulmonary disease. The nurse concludes that additional teaching is needed when the client demonstrates which technique?
Inhales with the lips tightly sealed around the mouthpiece of the nebulizer
A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the crutch walking?
Profuse diaphoresis and rapid respirations
A client has an above-the-knee amputation of the left leg because of arterial insufficiency. To prevent a hip flexion contracture, in what position should the nurse periodically place this client?
Prone position
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?
Provide perineal care
A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?
Push-ups to strengthen arm muscles
A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis?
Put on elastic stockings before arising
A client complaining of fatigue is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). What should the nurse do to prevent fatigue?
Schedule nursing activities to allow for rest
A client with severe varicose veins has surgery that involves ligation, dissection, and removal of incompetent vessels. In which position should the nurse place the client after surgery?
Supine with the legs elevated at a 15-degree angle
The nurse observes that a client has insomnia. Which intervention included in the care plan indicates a priority nursing intervention?
Teaching the client about sleep and behavioral changes
A client is ready to walk with crutches after knee surgery. Which crutch-walking technique will the nurse most likely need to reinforce after the client returns from physical therapy?
Three-point
Which assessment finding is considered the earliest sign of decreased tissue oxygenation?
Unexplained restlessness
Which condition will the nurse monitor for in a client with interruption of venous return?
Varicosity
A nurse is planning care to prevent deformities and contractures in a client with burns. When will the nurse begin range-of-motion (ROM) exercises?
When vital signs are stable
Which healthcare team member would the registered nurse state is most suitable to provide oral medication to a client?
licensed practical nurse
The healthcare provider prescribes enoxaparin to be administered subcutaneously daily to a client who had a total knee replacement. To ensure client safety, which measure would the nurse take when administering this medication?
Administer in the abdomen area only
A client with a history of occasional pain in the left foot when walking now has pain at rest. The left foot is cyanotic, numb, and painful. The suspected cause is arteriosclerosis. Which information will the nurse share with the client to help decrease the pain?
Comply with the prescribed exercise program
Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment?
a raised toilet seat
A home health nurse teaches a father how to provide oral care for his 8-year-old child who is undergoing chemotherapy. The nurse observes a return demonstration and determines that he needs further teaching when he tries to use which dental hygiene product?
an electric toothbrush
During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. The nurse should advise the client to use what sleep promotion technique?
exercise daily
A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiologic effect?
Local anesthesia
A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client?
Maintain balance to improve stability
The protein binding capacity of drugs in infants is low. Which is an implication of this physiologic process?
the free levels of a drug will increase
On the first postoperative day after a total hip replacement a client asks for assistance onto the bedpan. What should the nurse instruct the client to do?
"Flex the knee on the unoperated leg and pull on the trapeze to lift your pelvis."
The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education?
"I should administer insulin only if there are any symptoms."
The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the student nurse indicates the need for further education?
"I should advise the certified medical assistant to administer intravenous medication."
The registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a healthcare setting. Which statement made by the nursing student indicates a need for further education?
"I should avoid asking about the over-the counter medications."
The nurse is teaching a client regarding the usage of antibiotics. Which statement made by the client indicates effective teaching?
"I should not take antibiotics to treat the flu."
A nurse educates a mother about the proper administration of oral medication to her 4-year-old child. What statement made by the mother indicates effective learning? Select all that apply.
"I should use a disposable oral syringe to prepare liquid doses."
A nurse is teaching an older client about proper medication use. Which statement made by the client indicates the need for further education?
"I will use over-the-counter medicines along with prescribed drugs.
A nurse gives a teenager discharge instructions regarding cast care. The nurse concludes that the instructions have been understood when the teenager makes what statement?
"If I get itchy around the cast, I'll rub the itchy area gently.
What primary nursing actions are used to prevent pediatric medication errors? Select all that apply.
- Have full knowledge of the medication, including its on- and off-label uses. - Always confirm information about the client before delivering a dose. - Make sure all the orders are clear and well understood during a shift change.
A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do?
Advance the cane and the affected extremity simultaneously.`
A healthcare provider prescribes thigh-high antiembolism stockings for a client with varicose veins. The client's thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?
Ask the healthcare provider if an elastic bandage can be used in place of the stockings
A client is admitted to the hospital and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?
Assess for dizziness
The nurse plans to provide a back massage to a client. What should the nurse do first in this situation?
Assess the client's preference for touch and massage.
An older client has decreased blood flow to the nails. Which nursing action would be most effective for the client?
Assessing for cyanosis using oral mucosa
The nurse is planning care for an immobilized client who has suffered a stroke. The client has right-sided hemiparesis. Which activity takes priority for this client?
Assist the client in performing range-of-motion (ROM) exercises every 1 to 2 hours
A female client with a diagnosis of alcohol abuse appears disheveled and disorganized. How can the nurse best gain the client's involvement in personal hygienic care?
Assisting her in bathing and dressing by giving her clear, simple directions
Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?
Atherosclerosis
Which diagnostic study is used to detect deep vein thrombosis in the client's lower extremities?
Duplex venous doppler
After a total knee replacement, a client is using a continuous passive motion device. The nurse concludes that teaching was effective when the client states that what is the goal of this therapy?
Improve joint flexion
After an open reduction and internal fixation of a fractured hip, the nurse is helping a client to get out of bed into a chair. What should the nurse do to best accomplish this transfer?
Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair.
A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication?
Place the pill under the tongue and let it dissolve`
A stationary (nonrolling) walker has been prescribed for a client to aid in ambulation. What should the nurse teach the client to do to use the walker?
Place the walker flat on the floor with the front legs about 12 inches (30.5 cm) in front of the feet, shift the body weight to the walker, and step forward to take initial steps.
A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care?
RN
The nurse delegates the tasks of caring for a postpartum client. During assessment, the nurse observes an infection in the client caused by lack of hygiene. Which member of the health care team is most likely responsible for the client's condition? Select all that apply.
RN Unlicensed assistive personnel
A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day?
Shortening of the muscles
A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy?
Shortness of breath with crackles
A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do?
Sit on the edge of the bed so they can hold the client upright.
Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?
The client must be able to bear weight on both legs.
Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult?
The nurse should keep the client adequately hydrated.
A nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. The nurse should instruct the client to place weight on which part of the body?
The palms of the hands
While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding?
The pulse strength is barely palpable
Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?
The stockings should be applied before getting out of bed
A healthcare provider prescribes an antibiotic intravenous piggyback twice a day for a client with an infection. The healthcare provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. What reason does the nurse provide?
They determine adequate dosage levels of the drug."
According to the FDA pregnancy risk categories, which category of drugs may cause slight risks to the fetus?
b
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply.
- clean the eyelid and eyelashes - apply clean gloves before beginning the procedure - press on the nasolacrimal duct after instilling the solution
A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis?
lips
What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.
- ptosis and blurred vision - decreased auditory alertness
A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what?
Moves the walker no more than 12 inches (30.5 cm) in front of the client during use
During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing?
narcolepsy
A nurse is demonstrating to a client how to manipulate the ankles through full range of motion. Which movements should the nurse use during this process? Select all that apply.
eversion inversion dorsiflexion plantar flexion
Clients who have casts applied to the lower extremities must be monitored for complications. Which findings during assessment of the extremities of these clients are indicative of a complication? Select all that apply.
numbness prolonged capillary refill
A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?
alcohol
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate?
arterial insufficiency
A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.
rapid pulse elevated specigic gravity
A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are a result of which condition?
blood pooling in the lower extremities
After cataract surgery the nurse teaches a client how to self-administer eyedrops. The nurse reinforces the use of what technique?
Holding the dropper tip above the conjunctival sac
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply.
- chronic stress - excessive caffeine - enviromental noise
According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance?
4
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care?
Put the client in a high Fowler position
After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client?
opposition
Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process?
promoting vasodilation
