Module 1

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow." Rationale: If a client asks to use baby powder it is most appropriate for the nurse to explain that baby powder is not recommended for use because it creates a medium for bacteria to grow, putting the client at risk for infection. The nurse would not want to use the baby powder from home because of this increased risk of infection, not because it increases costs or increases the risk for allergic response.

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

"Powder in the genital area can create a medium for bacterial growth." Rationale: Powder can create an environment for bacterial growth. This is a teaching moment for the nurse with the client and is the best response, addressing the client request and the reasons not to accommodate it. There is some evidence suggesting that ovarian cancer may result from excessive talcum powder exposure. However, there are talcum-free powders available. Powder can sometimes create additional redness, because it gathers moisture and sticks to groin folds and is no longer routinely recommended for care.

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse?

"The health care provider will see the client and assess whether the restraint prescription should be renewed." Rationale: After restraints have been worn for 24 hours, the health care provider who is responsible for the care of the client must see and assess the client before writing a new prescription for the use of restraint or seclusion for the management of violent or self-destructive behavior. The health care provider will indicate that the client should remain in restraints if violent or self-destructive behavior continues. The client must be taken out of restraints before discharge, but the nurse would not know whether the health care provider would continue to renew the prescription for restraints for each 24-hour period until the client's discharge. If tests were needed to determine why the client is violent, the health care provider would have prescribed them before this time.

The nurse is caring for a client who has had colon surgery. The client asks the nurse "How do pneumatic compression devices decrease risk of thromboemboli?" What is the best response by the nurse?

"They increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart." Rationale: Pneumatic compression devices decrease risk of thromboemboli by increasing the velocity of blood flow in the superficial and deep veins and improving venous valve function in the legs, promoting venous return to the heart. They are not used for muscle massage. The goal of pneumatic compression devices is to improve venous, over arterial. Pneumatic compression devices do not increase fluid volume.

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"Use of special bathing products and avoidance of scrubbing help keep your skin intact." Rationale: Nurses should examine bathing practices and consider the effect on the client's skin. In general, they should avoid using soap and hot water and avoid excessive friction and scrubbing, as these can compromise the integrity of the client's skin, especially that of an older client, whose skin tends to be more fragile.

The nurse must apply a mummy restraint to a small child. Place the steps in the correct order. Use all options.

1)Secure a prescription from the health care provider. 2)Explain the reason for use to the client and family. 3)Open the blanket or sheet and place the child on the blanket. 4)Position the child's right arm alongside the body and pull the right side of the blanket tightly over the child's right shoulder and chest. 5)Secure the blanket under the right side of the child's body. 6)Fold the lower part of the blanket up and pull over the child's body.

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100oF Rationale: Although water temperature should be adjusted to 100oF (38oC) to less than 120o to 125oF (49oC to 52oC), the lower temperature limit of 100oF (38oC) is suggested for children and adults older than 65 years of age. A temperature of 90oF (32oC) would cause chilling.

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading?

105oF Rationale: Warm water is comfortable and relaxing for the client. It also stimulates circulation and provides for more effective cleaning. Adjusting the water temperature to 100oF (37.8oC) to less than 120o to 125oF (48.9o to 51.7oC) decreases the risk of burns and drying of the skin. Water temperatures below 100oF (37.8oC) could lead to chilling the client whereas water temperatures above 135oF (57.2oC) could burn the client.

The nurse is caring for a client wearing a pneumatic compression device. The nurse has set the device properly when the pressure is in what range?

35 to 55 mm Hg Rationale: The normal pressure range of a pneumatic compression device is 35 to 55 mm Hg. The other pressure ranges are incorrect.

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client?

Ask for help from a staff member. Rationale: The nurse obtains helps from a fellow staff member so that the client can be properly cleaned and safely turned. The nurse protects the client's alignment and observes personal safe body mechanics. A hydraulic lift is not very useful for the client who is soiled. Placing pillows behind the client's back is done after the client has been cleaned. The nurse should not attempt to clean and position a client without assistance so that the client can be rolled without injury.

The nurse is assessing a client with a figure-eight bandage on the right ankle. The client has returned from the bathroom and the bandage is loose and has migrated over the tips of the toes. What action does the nurse perform next?

Discard the bandage and replace with a new bandage following the figure-eight pattern Rationale: The bandage has lost the elasticity and needs to be replaced. Apply a new bandage following facility policy. Some bandages will regain elasticity after being washed, but the extremity must have a bandage placed while the old bandage is being washed and becomes completely dry. Pulling a loose bandage up will only allow a loose bandage to migrate again.

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

Disposable gloves, Toothbrush, Toothpaste, Emesis basin, Towel Rationale: 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 preparing to apply a pneumatic compression device for a client. Which statement accurately describes a contraindication for this device?

Do not place the sleeves of the device above the knee. Rationale: A pneumatic compression device may be used in combination with anticoagulant therapy and antiembolism stockings. The sleeves may cover the entire leg or may extend from the foot to the knee. A skin assessment would be performed to identify any skin conditions that may get worse by applying the device.

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed?

Ease the clean linens under the client, from the top to the bottom of the bed. Rationale: The recommended procedure for applying new linens on an occupied bed is to apply the bottom sheet securely to the top of the bed, ease the clean linens under the client from the top to the bottom of the bed, and secure the linens at the bottom of the bed.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency?

Every 1 to 2 hours Rationale: The nurse would plan on increasing the frequency of client observation and surveillance, conducting client/nursing rounds every 1 to 2 hours. These rounds would include assessing for pain, assisting with toileting, providing client comfort, ensuring that personal items are within reach, and meeting client needs. Client care rounds/nursing rounds improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.

How should the nurse open the bottom sheet when making an unoccupied bed?

Fanfold to the center Rationale: The nurse would place the bottom sheet with its center fold in the center of the bed, open the sheet and fanfold to the center of the bed. Opening items on the bed reduces strain on the nurse's arms and diminishes the spread of microorganisms. Centering the sheet provides sufficient coverage for both sides of the mattress.

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens?

Fold the linens in fourths on the bed and then hang them over a clean chair. Rationale: The nurse would fold reusable bedding, such as a sheet, blanket, or spread, in fourths on the bed and then hang it over a clean chair. Folding the reusable linens saves time and energy when they are replaced on the bed. Folding bedding while it is on the bed reduces strain on the nurse's arms. Having another nurse assist may not be an effective use of time. The overbed table should be reserved for client items. The nurse would want to place the reusable lines on the bed after the client has returned to the bed.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation. Rationale: The nurse should warm the unopened package in the microwave, according to manufacturer's directions. The other methods are not as effective or efficient.

A nurse is caring for a 3-year-old who has just been admitted to the hospital due to a severe case of influenza. The child experiences a seizure. The nurse should suspect which as the most likely cause of the seizure?

High Fever Rationale: Most seizures in children are caused by disorders that originate outside of the brain, such as high fever, infection, head trauma, toxins, or cardiac arrhythmias. Febrile seizures are the most common type during childhood and are usually benign. Moreover, we know from the scenario that the child likely has a fever due to having influenza. There is no indication that the child has epilepsy or has experienced head trauma from a fall or intracranial hemorrhage.

Where should the nurse roll soiled linens when removing them from an unoccupied bed?

Inside the bottom sheet Rationale: The nurse should snugly roll all the soiled linen inside the bottom sheet and place it directly into the hamper to help prevent the spread of microorganisms. The floor is heavily contaminated, and soiled linens would further contaminate the furniture. Rolling the used lines inside the top sheet is not efficient.

The nurse is caring for a client, after hip replacement, and receives a prescription to apply a pneumatic compression device. On what part of the body would the nurse place this device?

Legs Rationale: A pneumatic compression device is placed on the client's legs to enhance blood flow and venous return in the legs.

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens?

Lying on one side Rationale: The nurse would position the client on one side of the bed, lying on the side, and reposition the pillow under the client's head. This allows the linens to be removed and new linens to be placed on the vacant side. The nurse would then have the client roll to the opposite side to make the opposite side of the bed. Sitting up, lying flat, and lying prone would not facilitate the removal of the soiled linens while the client remains in bed.

The nurse is caring for a hysterical child who requires assessment of a dog bite near the eye. The parent is in emotional state that is not appropriate for helping to immobilize the child. The nurse should implement which restraints to best enable the health care provider to examine the client's injury?

Mummy Restraint Rationale: The mummy restraint is appropriate during an examination or while providing care for the head or neck, because it provides short-term restraint designed to control all movement. The vest restraint, extremity restraint, and elbow restraint are not appropriate in this situation.

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 wearing contact lenses. What is the priority action by the nurse?

Notify the emergency department health care provider the client is wearing contact lenses. Rationale: 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 client has decreased strength in the left leg. How should the nurse instruct the client to hold a cane for assistance?

On the right side Rationale: The cane should be held in the hand opposite of the weakened leg.

A nurse is shaving a male client's face. Which should the nurse do?

Pull the skin taut and shave in the direction of hair growth using short strokes. Rationale: The skin on the face is more sensitive and needs to be shaved with the direction of hair growth in short strokes to prevent discomfort. The skin should be pulled taut so that the razor can cut the hair more effectively.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action?

Remove gloves, unless indicated for transmission precautions. Rationale: After placing the soiled linens in the laundry hamper, the nurse would remove gloves, unless indicated for transmission precautions, and then place the bottom sheet with its center fold in the middle of the bed. This can be done without gloves, because the linens are clean. If the mattress is soiled, it should be cleaned according to facility policy. Scrubbing the mattress with antimicrobial cleanser is not necessary.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

Scrotum Rationale: When performing perineal care for a male client it is important that the nurse be particularly gentle and avoid pressure when handling the scrotum, because pressure on the scrotum may cause pain for the client. Gentle, but firm handling of the penis including the meatus, glans penis, and shaft reduces the chance of the client having an erection, which can be embarrassing for the client and the nurse.

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

Sitting at the edge of the bed Rationale: To prevent aspiration, it is best to assist the client to a sitting position. If the client is unable to sit, the side-lying position is also acceptable. The other options would place the client at risk for aspiration.

The nurse should document the time, date, and location of the figure-eight bandage when applied or changed in the nursing record. What other information should the nurse record in the procedure documentation?

Size of bandage Rationale: The nurse should record the size of the bandage. Medication allergies should be recorded elsewhere in the record and not necessary with this procedure. Client position upon leaving the room such as extremity elevated, in bed, or in chair could be documented, but size of dressing is more important for procedure. This procedure does not require informed consent. Verbal consent and agreeing to the dressing change/application is sufficient for this non-invasive procedure.

The nurse is caring for a client in the postanesthesia care unit (PACU) who has just undergone a third foot surgery. Which gate is best for the nurse to teach this client?

Swing-to gait Rationale: The swing-to gait utilizes the client swinging both legs to the crutch position in front of them. This eliminates the client bearing all the weight on the affect foot. The four-point gait utilizes "four" legs; one crutch, then one leg, the other crutch, and then the other leg. The two-point gait utilizes "two" legs; one crutch and the opposite leg move together, then the other crutch and opposite leg move together. The three-point gait utilizes "three" legs; both crutches and the affected leg at the same time, then followed by the unaffected leg.

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

The UAP begins cleansing from the anus toward the pubic bone. Rationale: When performing perineal care, it is important to wash from the area that is least likely to be contaminated to most likely to be contaminated (front to back) to prevent contaminating of bacteria from the anal area to the urethra. Cleansing form anus to pubic bone would be cleaning "back to front" and put client at risk for urinary tract infection. The other options are appropriate when performing perineal care.

A nurse is explaining to a client's caregiver the purpose of antiembolism stockings, which the client has received a prescription to wear. Which best explains their purpose?

They promote venous blood return to the heart. Rationale: By applying pressure, antiembolism stockings increase the velocity of blood flow in the superficial and deep veins. The purpose is not to treat edema, but to promote blood return to the heart. They have a smooth surface and can increase the risk for falls. They can increase the risk for impaired skin integrity if not applied correctly.

The nurse wraps the sleeves of a pneumatic compression device around the legs of a client. How would the nurse determine if the fit is correct?

Two fingers should fit between the leg and the sleeve. Rationale: When wrapping the sleeves of a pneumatic compression device around a client's legs, the nurse would ensure that two fingers can fit between the leg and the sleeve.

A nurse is directed to apply a pneumatic compression device for a client, after surgery. What postoperative complication would this device help to prevent?

Venous Thrombus Rationale: The pneumatic compression device is applied to a client's legs to enhance blood flow and venous return to prevent deep-vein thrombosis. Coughing exercises help to prevent pneumonia, and frequent dressing assessments help to detect infection and hemorrhage.

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first?

Warm the cap in the microwave Rationale: Shampoo caps are commercially prepared, disposable caps that contain a rinseless shampoo product. The cap is warmed in the microwave or stored in a warmer until use. The cap is then placed on the client's head and the hair and scalp are massaged through the cap, to lather the shampoo. After shampooing for the manufacturer's suggested length of time, the cap is removed and discarded. The client's hair is towel dried and styled.

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching?

"I will pull the skin taut to reduce the risk for ingrown hairs." Rationale: Pulling the skin taut while shaving increases the risk for ingrown hairs. When shaving the face, the client should use warm water and shave cream to soften the hair, begin shaving using smooth, short strokes in the direction of the hair growth while holding the skin steady to prevent the razor from pulling on the skin and causing discomfort.

A nurse is preparing to shampoo a client's hair while the client is in bed. Place the steps below in the order that the nurse would perform them? Use all the steps listed.

1)Place a protective pad under the client's head and shoulders after removing the pillow. 2)Fill the pitcher with water at an appropriate temperature. 3)Place the shampoo board under the client's head. 4)Position a drain container underneath the drain of the shampoo board. 5)Put on gloves and give the client a folded washcloth to hold over the forehead. 6)Saturate the client's hair with water from the pitcher.

A client wearing bilateral pneumatic compression devices reports pain and tingling in the left leg. After removing the pneumatic compression device, what is the next intervention by the nurse?

Assess the extremities for peripheral pulses, edema, changes in sensation, and movement.

The nurse making an occupied bed. Under which body part of the client would the nurse place the drawsheet?

Midsection Rationale: When making an occupied bed, the nurse would place the drawsheet under the midsection of the client. If the client soils the bed, the drawsheet can be changed without changing the other linens and the drawsheet may aid in moving the client. A drawsheet under the head, feet, or buttocks will not facilitate movement of the client in bed.

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action?

Provide client comfort Rationale: The main purpose for changing the linens on a client's bed is to provide client comfort. Tidying up the room, preparing for visitors, and removing soiled linens are also benefits of this action, but the main objective is to make the client comfortable and free of skin alterations due to wrinkled linens.

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action?

Raise the side rail Rationale: After tucking in the bottom linens on one side of the bed, the nurse would raise the side rail on that side and then assist the client to roll over the folded linen. The nurse would then reposition the pillow and bath blanket and move to the other side of the bed. The linens are loosened from both sides of the bed before they are removed.

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

Start with cleanest areas and end with most soiled areas Rationale: The nurse should start with cleanest areas and end with most soiled areas, to avoid transferring microorganisms from soiled areas to the clean areas. The other approaches are not valid

What would be most important to document after shaving a client?

That the chin was nicked with the razor Rationale: Shaving a client does not usually require documentation. If the skin is broken while shaving, it is important to document the occurrence and any assessment findings. Otherwise, the time, the type of shaving cream and aftershave are not important to document.

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms?

Wiping down the handles of the walker once the client has returned to bed Rationale: Proper cleaning of equipment between client use prevents the spread of microorganisms. While washing the client's hands upon return to bed will decrease the possibility of infection, the walker would remain contaminated and at risk being touched by many people passing by the walker.

A nurse is providing nail care for an older adult client. Which actions should the nurse take? Select all that apply.

> Cut the nail straight across > Round the tips of the nails in a gentle curve using a file > File the nail straight across > Gently clean under the nails using an orangewood stick

The nurse is teaching a client with peripheral vascular disease about foot care. What will be included in the teaching plan? Select all that apply.

> Schedule foot exams with podiatrist at least once per year. > See a podiatrist for treatment for bunions. > Wear appropriate footwear.

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures?

Apply gentle pressure with a 4 × 4 gauze to grasp the denture plate. Rationale: Applying gentle pressure with a 4 × 4 gauze prevents slippage and discourages the spread of microorganisms. Asking the client to take a deep breath and exhaling and using a tongue blade are not effective for removing denture plates. Sterile gloves are not necessary for providing oral care.

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure?

Apply gentle pressure with a piece of gauze to remove the upper dentures. Rationale: Providing denture care for a client, the nurse would apply gentle pressure with a piece of gauze to remove the upper dentures, place them in a denture cup, line the sink with a paper towel to prevent breakage when cleaning the dentures with a toothbrush and toothpaste, rinse them, and return the dentures to the client.

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take?

Change to a clean wipe after each stroke Rationale: The nurse changes wipes after each stroke to avoid spreading feces to noncontaminated areas. Wipes are not flushable. Using multiple wipes at one time is wasteful. Wash cloths are harsh to perineal skin and are not used for incontinence care or after bowel movements.

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint?

Pad bony Prominences Rationale: Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. The nurse should remove PPE after applying the restraint.

The nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint. The elbow restraint should not impede circulation. Which pulse will the nurse assess to decide if circulation is compromised?

Radial Rationale: The nurse should determine if circulation is compromised by assessing the radial pulse and the circulation to the fingers and hand. Assessing the apical, carotid, and jugular pulses will not help the nurse decide if the elbow restraint is compromising circulation.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height. Rationale: Proper bed height helps reduce back strain while performing the procedure. A protective pad keeps the sheets from getting wet. Placing a drain container under the shampoo board prevents a mess on the floor. Closing the curtains around the bed and closing the door to the room provides for client privacy..

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

Remove the antiembolism stockings before the bath. Rationale: Antiembolism stockings should be removed before the bath to allow for assessment during the bath

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. Rationale: In an uncircumcised male client (teenage or older), retract the foreskin (prepuce) while washing the penis but pull it back into place over the glans penis immediately afterwards to prevent constriction of the penis, which may result in edema and tissue injury. However, it is not recommended to retract the foreskin for cleaning during infancy and childhood, because injury and scarring could occur. The nurse should clean the tip of the penis first, not soak it in water, by moving the washcloth in a circular motion from the meatus outward.

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

The client should use an electric razor. Rationale: A client who is prescribed anticoagulant therapy is at risk for bleeding; therefore, it would be important to use an electric razor rather than a blade. Before shaving a client, it is important to assess shaving preferences and this information should be shared with the UAP, but these are not as important as preventing bleeding.

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why he or she needs to ambulate in halls three times a day. What is the correct response by the nurse?

"Ambulation helps prevent thromboembolism" Rationale: Regular ambulation can decrease the risk of thromboembolism in the postsurgical client. It does not affect risk of surgical wound infection or hypoglycemia. This client should no longer be experiencing any acute effects of anesthesia.

A client with diabetes asks the nurse what should be done for a large callus on the right great toe. What is the best response by the nurse?

"I encourage you to see your podiatrist to get a recommendation for your callus." Rationale: Clients with diabetes are at risk for poor circulation and at increased risk for infection. For these clients, a callus should be treated by a podiatrist. Cutting, filing and callus removers increase the risk of injury and infection in clients with diabetes and should not be used.

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

"Microbial contamination can occur when cleaning the anal area first." Rationale: The nurse needs to teach the staff member that wiping "front to back" is done to avoid carrying germs, like Escherichia coli, from the anus to the urinary meatus, causing a urinary tract infection. Telling the staff member that this action can prolong the hospital stay is correct but doesn't help the staff understand why the action was incorrect. Changing washcloths between the genitals and the rectal area is ideal, but it is more important to ensure cleaning is done in the proper sequence, whether with disposable or washable cloths.

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond?

"Mouth care during this time helps prevent complications." Rationale: The best response by the nurse is to explain that mouth care for the unconscious client prevents dental problems such as decay and prevents pneumonia due to bacterial growth in the oropharynx. This most completely addresses the spouse's question. Bacteria would normally be partially washed away by saliva, dental care does remain important, and moist oral mucosa does feel good to the client. However, these responses do no completely address the spouse's concern.

The nurse has instructed the client with a knee injury on how to perform crutch walking with a four-point gait. Which statement clarifies client understanding?

"The four-point gait uses one crutch, then one leg, followed by the other crutch, and then the other leg." Rationale: The four-point gait utilizes "four" legs: one crutch, then one leg, the other crutch, and then the other leg. The two-point gait utilizes "two" legs: one crutch and the opposite leg move together, then the other crutch and opposite leg move together. The three-point gait utilizes "three" legs: both crutches and the affected leg at the same time, then followed by the unaffected leg. The swing-to gait utilizes the client swinging both legs to the crutch position in front of them.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear." Rationale: All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching?

"When I eat, I will remove my dentures and place them in a napkin." Rationale: Clients should be encouraged to wear dentures to assist with eating. Dentures should not be wrapped in a napkin or paper towels, because they may be mistaken for trash. This statement indicates a need for further teaching. Dentures should not be placed in the bedclothes or linens, because they may be lost in the laundry. Storing dentures in cold water prevents warping. Special cleaners may be used to soak dentures and remove remaining food or other debris.

The nurse is caring for a 2-year-old child for whom elbow restraints have been prescribed. The nurse should remove the restraints and assess the child every how many hour(s)? _______

1 Hour Rationale: Children under 9 years of age should have elbow restraints removed at least once every hour to make sure the restraints are not too tight and are not impeding circulation.

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens?

Keep the blanket in place over the client to provide privacy and remove the top sheet Rationale: To change the linens in an occupied bed when the client cannot be turned on the side, the nurse would first cover the client with a bath blanket and remove the top linens. Then, the nurse would help the client up to a sitting position in the bed (as tolerated), roll the soiled linens from the top of the bed until they meet the client's backside, and remove the soiled sheets by working them out from under the client down to the foot of the bed.

After applying a restraint to a client, the nurse is required to stay with the client while it in use. Which type of restraint has the nurse applied?

Mummy restraint Rationale: A mummy restraint restricts all movement, and thus the nurse should stay with the client while it is in place. The other types of restraint do not restrict the client's movements as completely and thus require checks at specified intervals, but not the constant presence of the nurse.

The nurse is applying a pneumatic compression device to a client's legs. Where would the nurse place the inflation pump?

On then bottom of the bed Rationale: When applying a pneumatic compression device to a client's legs, the nurse would hang the inflation pump on the bottom of the bed.

The nurse is observing the client's caregiver apply a figure-eight bandage to the client's ankle. The caregiver begins wrapping the elastic bandage around the ankle and unrolls the entire bandage before wrapping the ankle in figure-eight fashion. What should the nurse instruct the caregiver?

Re-roll the bandage, wrap twice around the ankle, and then alternate with the bandage rolled ascending and descending with every turn. Rationale: The figure-eight bandage is applied best with the bandage rolled to control tension/compression of the bandage as it is applied. The bandage should be wrapped twice over the joint to hold in place then alternate ascending and descending with every turn. The bandage should start at the ankle to ensure stability. By keeping the bandage rolled up and unrolling it as it goes down the foot, it is easier to keep the bandage in place more tightly.

The nurse has delegated contact lens removal to the unlicensed assistive personnel (UAP) for a client in the preoperative area. Which action by the UAP requires intervention by the nurse?

The UAP has placed the client in a side-lying position. Rationale: Placing the client in the side-lying position is incorrect. The supine position with the bed raised and side rail down is the least stressful position for removing contact lenses. Clean gloves are worn during the removal to prevent the spread of microorganisms. To remove contact lenses, one hand is used to retract the lower lid while using the pads of the thumb and index finger of the other hand to remove the lens. A storage case marked left and right should be placed on the overbed table or other surface within reach.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

The alternative measures attempted before applying the restraints Rationale: Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

A toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint. The procedure is expected to take about 10 minutes. Which approach might the nurse suggest as an alternative to using a mummy restraint?

Therapeutic Holding Rationale: An alternative approach for temporary restraint is therapeutic holding, which makes use of a secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 minutes or less. A vest or mitt restraint would not be an alternative to a mummy restraint. Straddling the child would be inappropriate.

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

Tip of the penis Rationale: The nurse would always clean from the least contaminated area to the most contaminated area. The nurse would clean the tip of the penis first, from the meatus outward, washing the shaft of the penis using downward strokes toward the pubic area. The scrotum would be cleaned next, followed by the anal area.

The nurse is changing the figure-eight bandage on the client's hand after hand surgery. In addition to the gauze bandage, a small gauze pad is placed in between each finger to prevent what complication?

To pad between fingers so there is no skin to skin contact under the bandage. Rationale: The client's fingers/toes should have gauze or cotton applied between them when being wrapped with a figure-eight bandage. This keeps the skin from coming in contact and decreases risk for skin breakdown. If bleeding is noted as a dressing is removed, the dressing should be reinforced, and the health care provider should be notified. The gauze between fingers is used for padding and should not have any bearing on risk for wound infection. The gauze between fingers is not used to position fingers.

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth?

Twice a day

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.

A client's health care provider has prescribed the use of knee-high graduated compression stockings. To ensure that the correct size is obtained for the client, the nurse would measure which area? Select all that apply.

> Around the widest part of the calf > From the bottom of the heel to the back of the knee Rationale: To ensure that the correct size is obtained, the nurse would Measure the client's legs to obtain the correct size stocking. For knee-high length stockings, the nurse would measure around the widest part of the calf and the leg length from the bottom of the heel to the back of the knee, at the bend. For thigh-high length stockings, the nurse would measure around the widest part of the calf and the thigh and the leg length from the bottom of the heel to the gluteal fold.

The nurse is providing nail care to a client. Which assessment findings require notification of the client's health care provider? Select all that apply.

> Bleeding under the nail bed and from the sides of the toes > Red and swollen skin around the great toe > Nails curled around the tip of the toes > Blackened great toe nail Rationale: When providing nail care, the nurse should report assessment findings such as changes to the color or shape of the nail, bleeding, or signs of inflammation. It would also be important for the nurse to report thinning or thickening of the nail or separation of the nail from the surrounding skin. It is not important to report the presence of nail polish to the health care provider.

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

Uncover only the area being cleaned Rationale: Performing perineal care is personal, so it is important for the nurse to maintain privacy and dignity. This is achieved by being sensitive to the client and uncovering only the area that is necessary for cleaning. Cleansing from "front to back" and using a clean portion of the washcloth are important to prevent infection. It is not necessary to obtain two identifiers before performing perineal care.

Which describes an accurate step taken by the nurse when applying a pneumatic compression device on a client?

Unfold the sleeves and place them on the bed with the inner lining facing up. Rationale: When applying pneumatic compression device sleeves, the nurse would remove the sleeves from the packaging (sterile gloves are not used), unfold the sleeves and place them on the bed with the inner lining facing up, place the sleeves under the client's legs with the tubing toward the heel, and place the end of the knee-high sleeve above the back of the ankle.

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply.

> Check the walker for signs of damage, frame deformity, or loose or missing parts before use > Wear nonskid shoes or slippers > Choose a walker with wheels on the front legs if you have a faster gait Rationale: The nurse should instruct the client to wear nonskid shoes or slippers when using a walker to prevent falling. The nurse should instruct the client to inspect the walker for damage or missing parts to make sure that it is safe to use each time. The client should choose a walker with wheels if the client has a faster gait, as the wheels allow the person to move more quickly. The client should never use a walker on the stairs, which is dangerous. The client should use the arms of the chair or a stand-assist device for leverage when getting up from a chair and should not pull on the walker to get up, as the walker could tip or become unbalanced. A walker with wheels, not a standard walker, is better for clients who have difficulty lifting.

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?

Use a safety monitoring device Rationale: A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance. Restraining the client takes away independence and can increase agitation and confusion. Asking a family member to sit with the client may help calm the client, but inappropriately transfers the nurse's responsibility to the family member. Checking on the client every 30 minutes is insufficient, because the client could fall and sustain injury during the unobserved intervals.

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply.

> Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible. > Put on gloves before removing soiled linens. > Place a bath blanket over the client.

A client with a history of diabetes is demonstrating nail care to the nurse. Which action by the client requires teaching by the nurse?

Using a nail clipper to cut the nail straight across Rationale: Clients with diabetes and other circulatory problems should only file, not cut nails to avoid injury to the nail or surrounding tissues, which may have delayed healing. Using a cuticle stick to gently push cuticles back reduces hangnail formation, filing the nail prevents injury to the nail and surrounding area, and thoroughly drying between the toes prevents fungal infections.

The nurse is caring for a postsurgical client. The client asks the nurse why he needs to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factors? Select all that apply.

> Increase joint flexibility > Improve respiratory function > Aid gastrointestinal motility Rationale: Ambulation helps the client increase joint flexibility, improve respiratory function and aid gastrointestinal motility. It does not necessarily help with pain control. In fact, clients may need pain medication prior to ambulation, especially if they are postsurgery. Ambulation is not related to wound infection risk.

The nurse is assigned a client for whom an elbow restraint is prescribed. Which general principles of correct placement of the elbow restraint will the nurse follow? Select all that apply.

> Pad bony prominences > Confirm the restraint does not extend below the wrist or place pressure on the axilla > Ensure the restraint is the correct size for the client

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply.

> Polypharmacy > Clutter > Extension Cords Rationale: In the home of an older adult, the use of extension cords and clutter in the walkways are environmental hazards that increase the risk of falls in the home. Polypharmacy is common risk in the home of an older adult client. Placing objects in familiar places helps to decrease the risk in the home of an older adult. Using ambulation devices helps to decrease the risk of falls in the home of the older adult.

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

> Provide privacy while the client removes dentures from the mouth. > Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. > Use a toothbrush and paste to gently brush all surfaces.

The nurse is demonstrating proper ambulation technique with crutches to a child with a fractured ankle. What is priority assessment should the nurse perform?

Weight bearing status Rationale: The nurse should assess the client's weight to help determine which crutch gait to demonstrate. The nurse should consider pain, neuromuscular, and neurovascular status when ambulating a client; however, ignoring weight bearing status could cause increased injury to the client as well as impair the client's safety with crutch ambulation.

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate? Select all that apply.

> Support the client's body against the nurse and gently slide the client onto the floor > Firmly grasp the client's gait belt Rationale: Firmly grasping the client's gait belt ensures a safe hold on the client. Supporting the client's body against the nurse's and gently sliding the client onto the floor enables the nurse to support the client's weight with large muscle groups and protects the nurse from back strain. The client should not be left alone. The cause of the weakness in unknown and it may not pass. Oxygen is not indicated. Assessing for the potential causes of the weakness should occur after client safety is assured.

Which methods can be used to remove a client's soft contact lenses? Select all that apply.

> Use the pads of the index finger and thumb to gently pinch and remove the lens. > Ask the client to remove them, if able.

A nurse is providing care to several clients who are extremely weak and need to have their hair shampooed while remaining in bed. When gathering the necessary supplies, the nurse would anticipate needing to adapt the shampoo board for the client with which condition?

Acute spinal cord injury Rationale: If the client has a spinal cord or neck injury, use of the shampoo board may be contraindicated. In this case, a makeshift protection area can be created to wash the client's hair without using the board. The other conditions would not contraindicate the use of the shampoo board.

After monitoring the client during a seizure, the nurse determines the seizure has ended and the client is stable. Which action does the nurse take?

Allow the client to sleep Rationale: The client will likely sleep after the seizure during the postictal state. Because the client was stable at the conclusion of the seizure (secure airway, normal vital signs), the nurse allows the client to sleep until he or she naturally awakens, at which time the nurse can orient the client to the situation. It is not necessary to awaken the client in 30 minutes and assess the neurological status, nor is it necessary to obtain frequent vital signs during the postseizure period.

Which action does the nurse perform to institute seizure precautions for a client after a subdural hematoma?

Apply padding to the bed side rails bilaterally Rationale: Rail padding decreases the risk for injury. Depending on facility protocol, this may involve having three or four bed side rails raised. A bite guard is not used as a precautionary measure. Clients may be given lorazepam or another medication for seizures, but this is not included in seizure precautions. The nurse may raise the bed while applying the rail pads, but must ensure, as a part of seizure precautions, that the bed is in the lowest possible position while not at bedside.

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse?

Apply pressure with a gauze pad for 2 to 3 minutes. Rationale: If a client is cut during shaving and is bleeding, the nurse should apply pressure with a gauze pad or a towel for 2 to 3 minutes, and then check for continued bleeding. After the bleeding has stopped, it is safe to resume shaving. The priority is to stop the bleeding. Applying pressure does this, but it typically does not need 7 to 8 minutes. Rinsing with water will not aid in stopping bleeding, nor will a transparent dressing.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

Assess both eyes for contact lenses. Rationale: Upon noting the history of contact lenses, it would be most appropriate to assess both eyes for the presence of contact lenses. Some people wear contacts in only one eye. Removal of contact lenses may be delegated to the UAP, but only after proper assessment by the nurse. Contacting the client's caregiver would not provide the nurse with the needed information. The health care provider does not need to be contacted unless an injury is present.

A client who is wearing soft contact lenses is unable to remove the lenses before bedtime. What action should the nurse take?

Assist the client to remove the lenses using a small pair of rubber grippers. Rationale: For soft contact lenses that cannot be easily removed, a small rubber gripper is a tool that can be used to aid in removal. A small suction cup would be used for hard contact lenses. Sleeping with lenses in increases infection risk and is not recommended. The health care provider should be contacted only after other means of removal have failed.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures Rationale: Brushing the dentures is within the scope of practice for the UAP and therefore it is appropriate to delegate this aspect of denture care. Assessment, planning and teaching fall within the scope of practice for the nurse and are not appropriate for delegation to the UAP.

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath Rationale: The gown should be removed without disconnecting the IV equipment or cutting the gown. This provides uncluttered access during the bath and prevents the destruction of the gown, while maintaining IV fluids at the prescribed rate. Leaving the gown in place is inappropriate, as a fresh gown is part of a routine bath.

The nurse cleans the client after a bowel movement and notes stool on the gloves. The nurse has not finished cleaning the client. What action should the nurse take?

Change into a new pair of gloves. Rationale: The nurse stops and changes into new gloves when they become soiled. This action will avoid contaminating the clean linen being placed under the client. Using a wipe to clean the gloves still leaves the chance of contamination, as does continuing without changing gloves. It is unlikely the nurse will be able to avoid touching the clean linen when placing under the client.

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client?

Change the bed linens from the top to the bottom. Rationale: When a client cannot be turned on the side, the nurse, with assistance from a coworker, would change the linens from the top to the bottom.

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure?

Check the client's chart Rationale: The first action taken by the nurse before changing the linens on an occupied bed is to check the client's chart for limitations on physical activity. The nurse would then gather the equipment, perform hand hygiene, identify the client, and provide for client privacy.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home Rationale: The nurse should recommend that the client's family ensure that walking paths and floors in the home are free of clutter, which is an environmental hazard that increases the risk of falls in the home. Changing routines, taking walks outside, and using the stairs will not reduce the risk of falling in the home.

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 Rationale: 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.

The client is 1 day postsurgery with a figure-eight bandage in place after an open reduction internal fixation (ORIF) of a left wrist fracture. How often should the nurse check the neurovascular status of the left wrist and hand?

Every 4 Hours Rationale: The distal neurovascular status should be checked at least every 4 hours while a figure-eight bandage is in place. This includes capillary refill, pulses, movement, skin integrity and skin temperature. Status can be checked more frequently based on client condition or facility policy.

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

Every 60 Minutes Rationale: If a client who is at high risk for falls has no access to an activated bed or chair alarm, a nurse should observe the client every 60 minutes. Unless the client is on one-to-one observation, every 30 minutes is too frequent. Once a shift, or at 2- or 4-hour intervals, is too infrequent.

How often should skin integrity be assessed for a client who is using pneumatic compression devices?

Every 8 hours Rationale: Skin integrity for a client who is using pneumatic compression devices should be assessed every 8 hours. Four hours would be too short and 12 and 24 hours are too long in between assessments.

How would the nurse remove the top linens when making an occupied bed?

Have the client hold onto the bath blanket and reach under it to remove the linens. Rationale: The nurse would place a bath blanket over the client and have the client hold onto it while reaching under it and removing the top linens. The nurse would leave the top sheet in place if a bath blanket is not used. Fanfolding the linens at the bottom of the bed does not assist in removing the top linens. The bath blanket or top sheet, if a bath blanket is not used, provide privacy and warmth more effectively than the client's gown.

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted?

Insert the fist between the restraint and the client. Rationale: The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

How should the nurse teach the client who is ambulating with a cane?

Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next Rationale: A full bed bath every day may cause excessive dryness in many older adults, and a continent client may not require a bath every day. If dry skin is a problem, water and skin lotion or bath oil may be used on alternate days with a bed bath. Do not use bath oil in tub water, as it can cause tub surfaces to become slippery. Bed baths should not be avoided altogether but simply given every other day.

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment?

Cognitive function level Rationale: Assessment of cognitive function is most important to assure safety for the client with using the walker. A client unable to follow or retain direction would be at risk for injury. Vital signs should be reviewed and checked if the client is at risk for orthostatic hypotension. Muscle strength is an appropriate assessment but not the priority assessment in this situation. Medication allergies should not affect teaching proper ambulation technique with a walker.

When providing oral care to an unconscious client, the nurse takes which action?

Ensure there is a towel and basin positioned for drainage Rationale: The nurse ensures that liquids can be easily captured and cleaned by placing a towel and basin beneath the unconscious client's head during oral care. The unconscious client should not be placed in an upright position during oral care due to risk of aspiration. The tongue and teeth must be brushed adequately, but multiple times is not necessary. Oral suction should be set up to collect drainage in the oral cavity or the posterior oropharynx, but endotracheal suction will not be needed if oral care is done correctly.

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?

Perform a circulation check and offer toileting and hydration Rationale: Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids. Restraints are not used on an as needed basis but are used for a 24-hour period with breaks only for basic needs, like toileting. Even if the client suddenly seems calm, removal of the restraints is not permitted. Once this is done, a new prescription must be obtained and there are legal issues to consider. Bargaining with the client for restraint removal is not an acceptable nursing action. Restraint use is a safety measure, not a punishment.

The nurse is caring for a middle-aged adult who has been prescribed elbow restraints. The nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. What is the best action by the nurse?

Remove restraints more frequently and perform range of motion (ROM) Rationale: If a client cries or reports discomfort or pain when elbow restraints are removed, the nurse should remove the restraints more frequently and perform active or passive ROM. Eliminating the restraints would alleviate the client's pain only if the reason for which the restraints were prescribed has resolved. The nurse could reassess and consider another type of restraints, but it is better to continue with the type of restraints prescribed by the health care provider. A padded dressing will not alleviate the client's pain, because the restraints are already padded.

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

Retract the foreskin when washing the prepuce of adolescents and older Rationale: The nurse would retract the foreskin and wash the area under it when providing perineal care for an uncircumcised male who is an adolescent or older. The nurse would then pull the foreskin back into place over the glans penis to prevent constriction of the penis, which could result in edema and tissue injury. It is not recommended to retract the foreskin for cleaning during infancy and childhood because injury and scarring could occur.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place Rationale: In an uncircumcised male client (teenage or older), retract the foreskin (prepuce) while washing the penis but pull it back into place over the glans penis immediately afterwards to prevent constriction of the penis, which may result in edema and tissue injury. However, it is not recommended to retract the foreskin for cleaning during infancy and childhood, because injury and scarring could occur. The nurse should clean the tip of the penis first, not soak it in water, by moving the washcloth in a circular motion from the meatus outward.

The nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint. The infant's parent asks the nurse what will be used to implement the mummy restraint on the infant. What is the best response by the nurse?

Sheet or blanket Rationale: A small blanket or sheet is applied and folded to construct the mummy restraint. A vest restraint is made for adult clients. Towels are too small to be able to fold in the prescribed manner around the child. There are no manufactured mummy restraints.

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client?

Side-lying Rationale: Putting the unresponsive client in a side-lying position while performing oral care facilitates the drainage of any liquid from the client's mouth and prevents aspiration. Prone position would not be conducive to oral care. Supine and semi-Fowler's position would increase the risk for aspiration in the unresponsive client.

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. Rationale: 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 is teaching proper cane use to a client who has had ankle surgery. The client has been cleared to begin bearing weight on the affected leg. What outcome would be unexpected?

The client reports increased strength in the weaker leg Rationale: Increased strength in the weaker leg is not considered a projected outcome for proper cane usage. Rather, the cane is used for balance and support to increase safety and independence.

What should the nurse teach the client about climbing stairs with a cane?

The client should advance the stronger leg up the stair first, followed by the cane and weaker leg. Rationale: The client should advance the stronger leg up the stair first, followed by the cane and weaker leg. This helps support the weaker leg. The other techniques could increase client fall risk.

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds Rationale: Skin-fold areas may be sources of odor and skin breakdown if not cleaned and dried properly. Although all the areas listed should be bathed, they do not require the same level of attention as do the skin-folds.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers Rationale: Moisture barriers and special perineal skin cleansers will help prevent skin breakdown and excoriation. Do not use antibiotic or other antimicrobial cleaners or betadine at the urethral meatus. Decreasing the frequency of bathing is unnecessary to preserve skin integrity, as long as special precautions are taken. A full bed bath may not be necessary each time the client has an episode of incontinence. A partial bed bath may be given in some instances.

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?MC

Waiting outside of the closed bathroom door while the client uses the toilet Rationale: To prevent falls for a client who is at high risk for falls, the nurse should not wait outside the closed bathroom door but should remain with the client in the bathroom and assist the client in toileting. The other actions are appropriate measures for a client who is at high risk for falls and would not require the charge nurse to intervene.

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse?

"Allow me to show you how to use your walker again." Rationale: The nurse should correct any inappropriate use of assistive devices immediately upon observing improper use. Asking the client to activate the call light does not prevent the client from ambulating independently in an unsafe manner. Utilizing a wheelchair is a safe option but does not correct the improper use of the walker for future use. The best action is to re-demonstrate the proper walker use.

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

"Consult with your health care provider about beginning an exercise program." Rationale: The nurse should advise the client to consult with the health care provider to create a plan for an exercise program. Regular exercise, including cardiovascular exercise, helps maintain strength and flexibility and can help slow bone loss, all of which aid in fall prevention. However, the type of exercise and equipment should be determined by the health care provider or another qualified health care professional, not by the nurse.

A client has been out of bed, sitting in the chair for the past hour. The nurse is preparing to apply knee-high length graduated compression stockings as prescribed by the client's health care provider. Which action would be appropriate for the nurse to do? Select all that apply.

> Assist the client back to bed. > Elevate the client's feet and legs for about 15 minutes. Rationale: If the client is sitting or has been up and about, 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. Flexing and extending the legs would be inappropriate. The nurse could apply powder to the leg lightly unless client has a respiratory problem, dry skin, or sensitivity to the powder. If the skin is dry, a small amount of lotion may be used. Powders and lotions are not recommended by some manufacturers, so the nurse should check the package material for manufacturer specifications. Flexing and extending Hair does not need to be removed.

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply.

> Use a night light > Avoid climbing on a chair or table to reach items that are too high to reach > Keep electrical and telephone cords against the wall and out of walkways > Remove clutter from walkways Rationale: A teaching plan for fall prevention in the home should include the recommendations: avoid climbing on a chair or table to reach items that are too high to reach; use a night light; remove clutter from walkways; and keep electrical and telephone cords against the wall and out of walkways. Considering the use of an electronic personal alarm would not help prevent a fall, but it may be used to help alert others to the fact that one has fallen.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?

Asses the client's need for fluids and toileting every 2 hours Rationale: Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance. According to the UAP Nurse Practice Act, the duties of a UAP do not include performing assessments. The nurse should assist with the client's ADLs but allow the client the independence of performing as many as possible for oneself. The restraints should be secured to a non-movable part of the bed frame, and, thus, not to the side rail.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate?

Assess for the need to urinate Rationale: Client needs should be assessed before considering physical or pharmacologic restraint.

The nurse is talking to a client who has been using crutches for ambulation. The client reports intermittent numbness of the upper arms. What should the nurse instruct the client to avoid?

Leaning for prolonged periods by the axilla on the crutches Rationale: Leaning on the crutches can create pressure on the axillary nerves, creating numbness, tingling, and pain down the arms. The client should not be leaning on the crutches for long periods of time. The crutches should have been fit to the client's height upon being dispensed. No additional padding should be necessary because it could alter the fit of the crutches. Likewise, adjustments made to the height without professional assistance increases risk of injury. The type of gait used with crutches does not contribute to numbness of the arms.

The nurse applies a gait belt to a client prior to ambulation. For what reason might the nurse use a gait belt when ambulating certain clients?

To improve grasp and help provide more stability and balance Rationale: A gait belt helps to improve the nurse's grasp and help provide stability and balance. It does not help with center of gravity. It is not used as a weight for added exercise. A gait belt alone does not increase the client's activity tolerance.

Proper application of a pneumatic compression device includes which step?

Place a sleeve under the client's leg with the tubing toward the heel. Rationale: Proper application of a pneumatic compression device includes placing a sleeve under the client's leg with the tubing toward the heel. The sleeve is applied properly when two fingers can fit in between the tube and client's leg. The tubing should not be wrapped around client's bedrail, but it should be free of kinks. The cotton liner of a pneumatic compression device is applied facing up.

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate?

Tying the restraint behind the chair Rationale: The nurse should run the restraint under the arm rests and tie it behind the chair. Tying the restraint out of the client's reach promotes security. Tying the restraint to the side rail or in the front of the chair would allow the client to untie the restraint. Tying the restraint under the chair would not provide the nurse with swift access to the quick-release knot.

The health care provider has prescribed application of total-leg pneumatic compression device sleeves to a client's legs. Where would the nurse place the opening in the sleeve?

At the popliteal space behind the knee Rationale: When applying total-leg sleeves, the nurse would place the opening in the sleeve behind the knee at the popliteal space to prevent pressure behind the knee.

The nurse considers applying restraints to an agitated client. Which actions does the nurse take?

"Dim the lights and speak softly about something the client enjoys." Rationale: The nurse attempts multiple techniques before restraining a person, even when the person is agitated. Among those techniques is providing a calming environment and distraction. The nurse can assess the client for injuries anytime he or she is agitated, but this is not immediately relevant. The client must at least be able to reach the call bell to request assistance and water, if allowed. Family members are not always helpful for someone with agitation, and a family member may find it difficult to accept that level of responsibility.

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

"Let me assess the patches. They may indicate the development of a fungal infection." Rationale: The yellow or white patches in the oral cavity may indicate a fungal infection called thrush. They are not normal, nor are they the result of ineffective brushing or of drinking whole milk.

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need?

"Place all four feet of the walker on the ground before stepping forward." Rationale: The client should move the walker 6 to 8 in (15 to 20 cm) in a forward direction and set all four feet down and ambulate to the walker. All four walker feet should always be on the ground before the client ambulates. The client should lead with the leg he is most comfortable with. Setting only two walker feet on the ground creates a risk for falling for the client.

A nurse delegates the application of graduated compressions stockings to a licensed practical nurse. A while later, the client's spouse pulls the nurse aside and says, "I think the other nurse put the stockings on backwards. The opening is facing up." Which response by the nurse would be most appropriate?

"The opening is face up to prevent any interference with the circulation." Rationale: When applying graduated compression stockings, the heel pocket is down and the client's heel is centered in the pocket. If the stockings have a toe window, it is positioned correctly when it faces up. Proper positioning ensures toe comfort and prevents interference with circulation. The toe window should face up and the stocking should be smooth to prevent uneven pressure and interference with circulation. The statement about trusting the nurse is inappropriate and does not address the spouse's concern.

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Place the following instructions in the correct order. Use all options.

1)"Place both crutches under your left arm." 2)"Grasp the stair railing with your right arm." 3)"Place your unaffected leg on the first stair tread." 4)"Transfer your weight to the unaffected leg." 5)"Move up onto the stair tread." 6)"Move your crutches and the affected leg up onto the stair tread." Rationale: Crutches can be used when climbing stairs. The client grasps both crutches as one on one side of the body and uses the stair railing. Have the client stand in the tripod position facing the stairs. The client transfers his or her weight to the crutches and holds the railing. The client places the unaffected leg on the first stair tread. The client then transfers his or her weight to the unaffected leg, moving up onto the stair tread. The client moves the crutches and affected leg up to the stair tread and continues to the top of the stairs. Using this process, the crutches always support the affected leg.

The nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply.

> Bath blanket > Towels > Linen > Gown > Protective pads Rationale: Prior to giving a client a bed bath, the nurse would gather the following supplies not found in the client's room: bath blanket, towels, gown, linen, and protective pads. The basin is located in the side cabinet in the client's room.

The nurse has just transferred a client to the chair. The client begins to experience a tonic-clonic seizure. Which actions are appropriate for the nurse to take? Select all that apply.

> Ease the client to the floor > Loosen constricting clothing > Move furniture and other objects out of the immediate area > Place a folded blanket under the client's head Rationale: Getting the client to the floor prevents injury that might occur if the client falls to the floor. Removing objects and loosening clothing prevents possible injury. A blanket placed under the head prevents injury from striking the head against a hard surface, such as the floor. Restraint can injure the client. Attempting to open the mouth and/or insert anything into the mouth can result in broken teeth and injury to the mouth, lips, or tongue.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply.

> Ensure the parent engages in regular exercise > Provide frequent reorientation > Increase the parent's social interaction Rationale: The nurse should instruct the adult child to provide frequent reminders of person, place, and time to help keep the client oriented in the environment and decreases the chance that the client will wander. The nurse should also instruct the adult child to ensure the parent engages in regular exercise and to work to increase the parent's social interaction, both of which help clients with dementia channel stress more appropriately. Taking naps frequently does not help to reorient the client with dementia or to channel energies. Changing the parent's routine frequently can disorient a client with dementia and increase the chance that the client will wander.

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply.

> Falls > Contractures > Delirium > Pressure injuries Rationale: Restraint-free care is the standard of practice and an indicator of quality care in all health care settings. Physical restraints do not prevent falls, and they increase the possibility of serious injury due to a fall. Restraint use in older adults is associated with falls and injurious falls, pressure injuries, and other adverse outcomes. Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, and even death.

A client who is recovering from surgery is beginning to ambulate. This client is strong enough to walk without assistance but has poor balance. Which type of mobility aid would be most appropriate for this client?

A cane with four prongs on the end (quad cane) Rationale: The quad cane provides a wide base of support and thus is recommended for clients with poor balance. A single-ended cane with a half-circle handle is recommended for clients requiring minimal support and for those who will be using stairs frequently. A single-ended cane with a straight handle is recommended for clients with hand weakness because the handgrip is easier to hold but is not recommended for clients with poor balance. A walker with four fixed legs must be completely lifted off of the floor between steps and is not recommended for clients with poor balance.

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

Apply a thin barrier of skin protectant to the perineal area Rationale: The nurse would apply a thin barrier of skin protectant to the perineal area to protect the skin from breakdown associated with contact with stool or moisture. Baby powder is a medium for bacterial growth and should not be used in the perineal area. Antibiotic ointment and betadine ointment are not indicated at this time.

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure. Which intervention should take priority?

Assess the circulation to the client's fingers and hands. Rationale: In this situation, assessing the circulation to the client's fingers and hands should be the priority intervention, because elbow restraints can impair circulation if applied too tightly. Keeping a call bell within easy reach would be a lower priority intervention, because the client is undergoing a procedure and is already in the company of the provider or other health care professionals. Assessing respirations to help prevent asphyxiation would be a priority intervention if the client were prescribed a waist restraint, not an elbow restraint. Encouraging the client to wear low-heeled, rubber-soled shoes would be a pertinent intervention for a client at high risk for falls.

After assisting a bed-bound client with oral care, what action does the nurse take?

Assist the client to a comfortable position in the bed Rationale: During oral care, the client either sits straight up in the bed or must lean toward the bedside. After completion of oral care for the bed-bound client, the nurse assists the client to a comfortable position. Oral care supplies are recapped or rinsed, stored in a drawer, cabinet, or on a shelf, and reused when needed to avoid unnecessary waste. Inspection of the oral cavity should occur prior to care to minimize oral trauma and to correctly assess for hydration.

For the client at risk of seizures, which action does the nurse take?

Attach an oxygen regulator at the head of the bed Rationale: If the client has a seizure, the client is at risk for hypoxia and aspiration. An oxygen and vacuum regulator must be attached at the wall with the correct supplies for delivery of oxygen and suctioning of secretions or vomitus. Also, an oral airway and resuscitation bag, a bag-valve mask device, must be at the wall behind the bed. Intubation supplies are ready on the crash or code cart for emergencies if needed. Unless the client already demonstrates hypoxia, placing an oxygen mask on the client is not warranted. The client may lie in any position that is comfortable and does not aggravate existing conditions, as long as the client is not actively having a seizure.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity Restraint Rationale: The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client?

Suction toothbrush Rationale: A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration. A regular toothbrush and an oral suction catheter may also be used. An emesis basin, towel, and toothpaste would be expected for use for any client during oral care.

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

The client continually tries to move from head of the bed toward the foot of the bed Rationale: Research suggests that waist restraints pose the same risks for asphyxial death as vest restraints. When the client is very mobile in the bed or chair, the risk for asphyxiation increases. The nurse should pad skin and bony prominences that will be covered by the restraint to reduce friction and pressure to skin and underlying tissue. Restraints ground a client's center of gravity, thus helping to prevent injuries and falls such as rolling off a stretcher or falling out of bed. Because the nurse should be following the removal schedule (every 2 hours), the client is at less risk for incontinence and dehydration because these needs are being met every 2 hours.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can Rationale: 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 let the client bathe himself to the extent that he can effectively do so. Bathing is performed in a matter-of-fact and dignified manner. If this approach is followed, clients generally do not find care by a person of the opposite gender to be offensive or embarrassing. Just because the man has dementia does not mean that he is not capable of bathing himself, at least in part. Calling a family member to bathe the client is both unnecessary and impractical.

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned?

To either side and slightly behind the client with near hand on gait belt Rationale: When ambulating a client with a gait belt, the nurse should stand to either side and slightly behind the client with near hand on gait belt. The other positions do not allow the nurse to properly use the gait belt to help provide stability and balance.