HURST Fundamental QBank
Which assessments will provide the nurse with the most information regarding a client's neurologic function? Select all that apply 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability
1. & 5. Correct: Yes, the most important and subtle changes are related to the client's level of consciousness, verbal ability, orientation, and ability to move to command.
What action by the nurse is most helpful when responding to a bomb threat phone call? 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others.
1. CORRECT. The nurse should keep the caller on the phone for as long as possible and try to obtain information, while being alert for voice characteristics and background noises. While keeping the caller on the line, the nurse should motion to another employee to call in the bomb threat.
A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide
2. CORRECT. A "water only" fire extinguisher is used for Class A fires, which includes solid combustibles such as wood, paper and textiles. As long as no electric equipment is plugged into a socket in the room, the water only extinguisher is most appropriate.
A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? Select all that apply 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.
2 and 5. CORRECT: The nurse must provide the client with alternatives methods to aid sleep that do not present a safety hazard. Potpourri is fragrant dried flowers or plant stems which emit a smell based on the assortment. Sprinkling a small amount inside the nightstand drawer would allow the scent to gently permeate the area next to the client's bed without presenting a safety hazard and the aroma would be consistent over long periods of time. Also, a tiny drop of an essential oil dabbed on the corner of the pillow case or sheet would also provide the client with desired needed sleep enhancement without impacting health or safety issues.
A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental". The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? 1. The right to refuse photos of the wound. 2. The right to refuse a blood alcohol test. 3. The right to refuse a tetanus injection. 4. The right to refuse police notification.
4. CORRECT: When an individual sustains a stab wound, even if self-inflicted, medical personnel are required to notify the police or proper authorities in that jurisdiction. Each facility determines the proper procedure for reporting gunshot or stab wounds, but the injury must be reported immediately while the client is still in the clinic.
A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."
3.CORRECT: The issue involves difficulty understanding the verbal phone prescriptions rom the new primary healthcare provider. Any comment by the nurse must be both professionally worded and culturally sensitive. In this statement, the nurse is asking for the orders to be repeated and indicating the need to speak slowly. This does not place blame on the healthcare provider but does suggest a process to resolve the situation in a professional manner.
The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? Stabilize cannula with one hand. Loosen tape and tegaderm cover. Clamp IV line closed securely. Wash hands and apply gloves. Apply gauze and tape tightly.
Wash hands and apply gloves. Clamp IV line closed securely. Stabilize cannula with one hand. Loosen tape and tegaderm cover. Apply gauze and tape tightly.
Which nursing statements about a client reflect correct documentation in the hospital medical record? Select all that apply 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.
1. & 2. Correct: The nurse should record findings or observations precisely and accurately. Percent of breakfast eaten is accurate documentation. An arm wound should include its exact size and location.
The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.
1. Correct: Prior to moving the client from the side of the bed to the wheelchair, assess the client for orthostatic hypotension or postural hypotension. The client may experience a sudden decrease in blood pressure after changing the position form lying down to sitting up.
While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to a keep-open rate and obtain a replacement pump.
2. CORRECT. The safest action is to stay with the client while a new infusion pump is obtained by another staff member.
A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses the procedure. What is the nurse's priority at this time? 1. Administer pre-op sedation to help the client relax. 2. Notify the primary healthcare provider of the client's refusal. 3. Remind the client that the consent is already signed. 4. Ask the family to help convince the client to re-consider.
2. Correct. The client has withdrawn consent for the procedure; therefore, the primary healthcare provider should be informed immediately to cancel the treatment. The primary healthcare provider may wish to speak with the client, but the client can legally refuse any procedure at any time.
When caring for a client on extended bedrest, which intervention should the nurse implement to decrease the risk of contractures? 1. Use a large pillow to support the head and shoulders. 2. Properly reposition every 2 hours. 3. Use a knee gatch to place knees at a 30 degree angle. 4. Place a trochanter roll along the inner aspect of each thigh.
2. Correct: Properly repositioning every 2 hours is the best way to prevent contracture.
A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would require an immediate intervention? 1. The nasogastric (NG) tube contents are pale green. 2. An abdominal dressing with the tape on 3 sides of the dressing. 3. Abdominal pain of 5 on 10 point pain scale when client coughs. 4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.
4. Correct: The JP drain should be addressed first. The purpose of the JP drain is to remove fluids adjunct to the surgical site by suction. The JP bulb should be continually compressed to create suction in the tube which will remove fluid. The compression of the bulb is released when the fluid in the bulb is emptied and then recompressed.
The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward.
4. Correct: The left shoulder should be adducted. The position of adducting the shoulder forward promotes improved chest expansion and decreases strain on the shoulder.
A client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure? 1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what to the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery.
1. Correct: Audiotapes made in the language of high volume clients who speak a language other than English is helpful to inform clients about admission procedures, room and unit orientation, and pre-surgical procedures.
Which action by a nurse requires intervention by the charge nurse? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.
1. Correct: Needles should be recapped using a one hand scoop method to prevent accidental sticks. Two-handed method increases the risk that the nurse's non-dominant hand will be punctured with the needle. Think about it. You do not want the hand holding the cap to get close to the needle. What if you miss the needle and stick your hand. The best solution is to not recap at all. Place the needle in the sharps container at once. But if the sharps container is not close by then the one hand scoop method is appropriate. You are not exposing one hand to the needle.
After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? Select all that apply 1. Provide mouth care prior to feeding. 2. Flex head forward for eating. 3. Have dietary puree foods. 4. Use crushed ice as a stimulant for swallowing. 5. Offer thickened liquids to drink. 6. Position client in semi fowler's position after feeding.
1., 2., 4., & 5. Correct: These interventions will stimulate sensory awareness, salivation, swallowing, and decrease the risk of aspiration.
A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."
2. Correct: For intermittent catheterization in the home, the client should follow clean technique. Wash rubber catheters thoroughly with soap and water after use, then dry and store in a clean place.
During evening rounds on a medical unit, a client is discovered in cardiac arrest. After activating the code button, the nurse initiates chest compressions. A second nurse enters the room to assist. What priority task could be delegated to the second nurse? 1. Retrieve the crash cart. 2. Document the code events. 3. Notify the primary healthcare provider 4. Begin oxygenating the client.
4. Correct: The chest compressions, airway, and breathing (CAB) sequence is always of primary concern. The first nurse correctly activated a code and then began chest compressions. The second nurse will assist by oxygenating the client, using a bag valve mask.
The nurse is observing a new LPN insert an indwelling foley catheter for a client. The nurse knows it is necessary to intervene when the new LPN initiates what action? 1. Applies sterile gloves prior to opening catheter kit. 2. Pours iodine solution over the sterile cotton balls. 3. Lubricates catheter by dipping into water-soluble gel. 4. Identifies client and elevates bed to waist height.
1. CORRECT: A catheter kit is removed from the plastic bag and opened up without any gloves at all. The use of sterile gloves would not be necessary and would be a waste of money as the outside of the kit is not sterile.
Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed. 2. Daily intake of at least 85 percent of food offered. 3. Occasional forgetfulness. 4. Continent of bowel and bladder.
1. Correct: Immobility or weakness puts a client at risk for skin breakdown, particularly if combined with other indicators such as inadequate nutrition, confusion, incontinence, or limited sensory perception.
A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? Select all that apply 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast
2 and 5. CORRECT: A high protein, calcium rich diet is most important for the preeclampsia client who is losing protein in urine. Grilled cheese is an excellent selection for lunch, especially since it contains tomato slices, which adds another level of nourishment and vitamins. Additionally, a chicken sandwich, particularly on whole wheat toast, is very appropriate for this preeclampsia client.
A home care nurse is making an initial visit to an elderly client recently discharged following hip surgery. When evaluating the home environment, what environmental hazard is most concerning to the nurse? 1. Lamp plugged into extension cord. 2. Throw rugs on kitchen tile floor. 3. Gas fireplace in the living room. 4. Non-working wall socket in hall.
2. CORRECT: It is quite common to find throw rugs, or "scatter rugs" in homes to protect carpets and absorb moisture or dirt. However, throw rugs are a common hazard, posing the potential for tripping or catching on wheels. In this situation, a tile floor is generally smooth, making it even more likely to slip on the rugs.
The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.
2. CORRECT: The purpose of an incident report is to document any incident or unusual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability, for clients, family, or staff. The nurse has violated HIPAA regulations by discussing a client's medical prognosis with family members. The primary healthcare provider is responsible to discuss prognosis with client and only those individuals designated by the client.
A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.
2. Correct: Including a daytime exercise program is a sleep hygiene recommendation that will increase the quality of sleep. The exercise program increases metabolism and reduces stress. Activities after 1700 should be avoided if they a strenuous.
The nurse should wear gloves when administering which medication? Select all that apply 1. Lorazepam 1mg orally. 2. Nitroglycerin ointment 2% 0.5 inch to chest. 3. Ceftriaxone 250mg intramuscularly. 4. Metronidazole 500mg intravenous piggyback. 5. Humalog 8 units subcutaneously.
2., 3., & 5. Correct: You do not want to get nitroglycerin on your hands. The medication would be absorbed into your skin. When giving a medication intramuscularly or subcutaneously, there is a chance of being exposed to blood. Remember to wear gloves when there is a chance for you to encounter body fluids.
The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? Select all that apply 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.
2., 4., & 6. Correct: The wheelchair should be placed on the right side of the bed where the equipment is located. It needs to face the head of the bed so the client can reach the chair with the strong left arm to help with the transfer. The client should grab the wheelchair arm with the strong left arm.
A client diagnosed with glaucoma is being instructed on self-instillation of eye drops. What statement by the client would indicate to the nurse that teaching was successful? 1. "I should look into the mirror to be sure I am getting the drops in." 2. "I will put all drops in my eyes and then close eyes for 5 minutes." 3. "I have to be sure not to touch the dropper to any part of my eye." 4. "I have to pull down the upper lid when putting the eye drops in."
3. CORRECT: The client is correctly stating the importance of not contaminating the eye drop bottle by touching it to the eye. This statement indicates teaching was successful.
Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).
3. Correct: Avoiding eating meat on Fridays during Lent is a practice of those of the Catholic faith; this action demonstrates cultural sensitivity and spiritual support.
A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.
3. Correct: Caffeine and some medications may interfere with sleep.
A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.
3. Correct: Phantom limb pain (PLP) may be experienced in the amputated part after surgery. The client may describe the PLP as crushing, cramping, and burning. Complementary therapy is a non-pharmacological comfort measure that can be utilized to reduce the client's PLP. Instructing the client to implement guided imagery techniques will assist the client in reducing PLP.
A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.
3. Correct: When helping to feed a client with dysphagia, the nurse should monitor for signs of aspiration such as frequent throat clearing during and after meals. The client is trying to move the bolus of food down esophagus. Aspiration is a condition where food, liquids or saliva moves into the lungs instead of the esophagus during eating.
A client who has right sided weakness and weighs 280 pounds (140 kg) needs to be transferred from the bed to the chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1. Stand at the client's right side. 2. You are physically fit and at lesser risk for injury. 3. Using proper body mechanics will prevent you from injuring yourself. 4. Use the mechanical lift and with another UAP, transfer the client to the chair.
4. Correct: Mechanical lifts are used to transfer clients who are unable to assist with the move or is large in size. The client weighs 280 pounds (140 kg). Because the client weighs 280, another UAP should assist with the transfer.
A client from a long-term care facility arrives in the emergency department by ambulance with altered level of consciousness. The primary healthcare provider instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client's wrist during the initial assessment. Which immediate action should the nurse take to advocate appropriately for this client? 1. Assist the respiratory therapist to prepare the client for immediate intubation. 2. Attempt to contact the client's family. 3. Notify the primary healthcare provider immediately of the client's DNR bracelet. 4. Notify the charge nurse immediately of the client's DNR bracelet.
3. Correct: The nurse should immediately notify the primary healthcare provider upon discovering the client's DNR bracelet. The DNR bracelet is an indicator that the client or their healthcare surrogate decision maker wants the client's wishes be known regarding healthcare treatment and resuscitation.
A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."
4. CORRECT: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently.
Which nursing action represents measures taken to protect the client from a mode of infection transmission in the chain of infection? Select all that apply 1. Donning personal protection equipment. 2. Administering the Haemophilus influenzae type B (HIB) immunization to a child. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 5. Teaching importance of long pants and sleeves and insect repellent to reduce the risk of West Nile Virus. 6. Performing hand hygiene after removal of soiled gloves.
1., 3., 4., & 6. Correct: In this question, can you identify the nursing actions that represent prevention of the spread of infection to other clients at the point of mode of transmission on the chain of infection? The first one identified is the donning of personal protection equipment. This prevents the infectious agent from coming into contact with the nurse's hands that could then spread the infection to other clients. Next, disposing of soiled gloves in the appropriate receptacle assures that the infectious agents are not carried outside of the infectious client's room and then transmitted to other clients. Gloves should always be worn when there is a possibility that the nurse could come into contact with the client's secretions. Hand hygiene is a crucial part of infection control. Hand hygiene by washing the hands and/or using alcohol based sanitizer before and after glove removal reduces the risk of the spread of infection. Both the use of gloves when secretions are present and proper hand hygiene help to prevent the nurse's hands from becoming a mode of infection transmission to other clients.
A client scheduled for a bronchoscopy and possible lung biopsy tells the nurse, "I don't know what a bronchoscopy is." Which nursing intervention should the nurse implement? 1. Explain the bronchoscopy procedure to the client and inform the client of the risks, benefits, and treatment alternatives. 2. Immediately inform the primary healthcare provider that the client requests additional information about the bronchoscopy procedure. 3. Give the client an information pamphlet on the bronchoscopy procedure, and tell the client to sign the consent after reading the pamphlet. 4. Instruct the client to sign the informed consent form. The primary healthcare provider will answer any additional questions right before the procedure is performed.
2. Correct: The primary healthcare provider performing the procedure should explain the risks and benefits, recovery time, and reasonable alternatives, as well as the consequences of refusing treatment.
A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money? 1. Insist the money go home with the client's visitor. 2. Place the money in the client's bedside table drawer. 3. Put itemized cash in envelope and place in hospital safe. 4. Lock money up in narcotic cabinet with client's identity and room number.
3. Correct: It is best to have two witnesses (preferably hospital staff) sign the inventory list. The best action by the nurse would be to itemize the valuables, place in an envelope with the record of the inventory, and have it put in the hospital safe. If you fail to properly safeguard the client's property, the trust of the healthcare team for medical care can also be lost. Liability waivers should be signed if for whatever reason, the valuables must remain at the hospital.
The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an intrauterine device (IUD) is most appropriate for what individuals? Select all that apply 1. A mother of a toddler who wants another child in three years. 2. The client with a recent exacerbation of sickle cell anemia. 3. A client with stage II breast cancer who has finished chemotherapy. 4. An adolescent who has recently become sexually active. 5. The client with a double mastectomy seven years ago.
1 & 5. CORRECT: An IUD is a surgically placed method of birth control in which a small, t-shaped piece of plastic, or even copper, is inserted into the uterus to decrease the chance of pregnancy. The client must be very healthy, emotionally amenable to a foreign body to prevent pregnancy, and aware that an IUD is not 100% fail-proof. The mother of a toddler who would like to have another child in a few years is an excellent candidate for the use of an IUD. Also, a client who had a double mastectomy over seven years ago is a good candidate, since treatment that long ago means the client would no longer be receiving any type of immunosuppressant therapy.
The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.
1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs.
What should the nurse check when assessing a client's balance? Select all that apply 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses
1., 3., & 4. Correct: Asking the client to walk on the tips of the toes assesses foot strength and balance. Muscle strength is needed to maintain balance and a Romberg's test asks the client to stand erect with arms at their side and feet together. The nurse notes any sway or unsteadiness. Then the client does the same thing with their eyes closed for 20 seconds again noting imbalance and sway. A positive Romberg is seen with swaying and moving feet apart to prevent a fall. It indicates a problem with balance.
A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? Select all that apply 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.
1.,2. & 3: Correct: Having a person directly monitor the client will decrease the possibility of the client getting out of the bed. In addition, a familiar person in the room can have a calming effect on the client. Bed alerts will notify the healthcare team that the client is moving in the bed. This will result in a quicker response time to evaluate, if the client is trying to get out of bed. The intervention of moving the client closer to the nursing station will increase the observation of the client. This increased visualization can allow the healthcare team to intervene if the client tries to get out of the bed.
The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so independently. What statement by the nurse is appropriate? 1. "Many spouses have been able to learn this procedure." 2. "Which part of this procedure has you most concerned?" 3. "Don't you have any family to help you with this procedure?" 4. "Are you worried about caring for your spouse?"
2. CORRECT. The nurse's question is open-ended since it allows the spouse to elaborate on any specific areas of concern or doubt. This approach encourages the spouse to express feelings with any care after discharge, and not just the log rolling technique.
A home health nurse is visiting an adolescent with a myelomeningocele. The nurse realizes more instruction is needed when the client makes what statement? 1. "I might need to get glasses." 2. "I catheterize myself twice a day." 3. "I drink bottled water all day long." 4. "I do upper arm exercises every day."
2. CORRECT: The nurse is looking for a statement that indicates the need to do further instruction for this client. Self-catheterization should be completed every four to six hours. Allowing urine to remain in the bladder longer than six hours greatly increases the risk of infection. This comment indicates that the adolescent needs more instruction on the importance of timing catheterization.
The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? 1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward." 2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg." 3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand." 4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg, and advance affected leg and the crutches to the step."
2. Correct: This client will need additional instruction. The client should place their crutches on the step below first. Then move the affected leg down to the next step. The client should follow with the unaffected leg.
The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. "I will soak my feet for 30 minutes a day." 2. "I will avoid using a heating pad on my feet." 3. "I can use scissors to remove the corns on my toes." 4. "I enjoy walking without my shoes around the house."
2. Correct: One of the long-term complications of diabetes is peripheral neuropathy. As the neuropathy progresses the feet have reduced sensation and may eventually become numb. The client should avoid using heating pads and hot water bottles. Due to the decrease sensation of the feet, the client is in danger of blistering and burning the feet.
What action should the nurse take when testing a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.
3. Correct: The nurse can get a general idea of near visual acuity by asking the client to read from a newspaper. The newspaper should be held 14 inches from the eyes. This exam can also be done with the Jaeger chart containing a few short lines or paragraphs of printed text. The size of the print gradually gets smaller. The client is asked to hold the card about 14 in. (36 cm) from the face and read aloud the paragraph containing the smallest print he/she can comfortably read. Both eyes are tested together, with and without corrective lenses. This test is routinely done after age 40, because near vision tends to decline as one ages (presbyopia).
A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.
3. Correct: You should not bend at the waist. This will injure your back. Lower your knees, and stay close to the object to use thigh muscles.
How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.
4. Correct: This maintains the client's horizontal center of gravity.
After applying sterile gloves, what process should the nurse use to remove interrupted sutures from a client's surgical wound? Place in the correct order. Moisten dried crust with sterile 0.9% sodium chloride solution Gently grasp the knot with forceps and raise it slightly Gently cut the suture Make certain all suture material is removed Apply sterile wound strips Document date, time, and number of sutures removed Clean suture line with antimicrobial solution Place the curved tip of suture scissors directly under the knot Put suture on clean gauze Pull suture out with forceps
Moisten dried crust with sterile 0.9% sodium chloride solution. Clean suture line with antimicrobial solution. Gently grasp the knot with forceps and raise it slightly. Place the curved tip of suture scissors directly under the knot. Gently cut the suture. Pull suture out with forceps. Make certain all suture material is removed. Put suture on clean gauze. Apply sterile wound strips. Document date, time, and number of sutures removed.