NS102 Module 5

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased fiber in the diet E. Increased activity

A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL , and 8 oz broth. The nurse should record how many mL of intake on the client's record?

740 mL

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter.

A. Apply a moisture barrier ointment to the client's skin.

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A. A reddened area over the sacrum

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? A. Apply the bag for 30 min at a time. B. Reapply the bag 30 min after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin.

A. Apply the bag for 30 min at a time.

A nurse is caring for a client who is immobile. Which of the following actions is a priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion (ROM) exercises at least two to three times daily. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply antiembolic stockings.

A. Auscultate breath sounds at least every 2 hr.

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to AP? (Select all that apply.) A. Bathe a client who had an amputation 2 days ago. B. Assist a client to ambulate using a gait belt. C. Review a low-sodium diet for a client who has hypertension. D. Explain oral hygiene to a client receiving chemotherapy. E. Feed a client who had a stroke 3 months ago.

A. Bathe a client who had an amputation 2 days ago. B. Assist a client to ambulate using a gait belt. E. Feed a client who had a stroke 3 months ago.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.) A. Contractures of the extremities B. Polyuria C. Diarrhea D. Crackles in the lungs E. Pressure ulcers

A. Contractures of the extremities D. Crackles in the lungs E. Pressure ulcers

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? A. When the client has the urge to defecate B. Every 2 hr while the client is awake C. Immediately before the client has a meal D. After the client feels abdominal cramping

A. When the client has the urge to defecate

A nurse is preparing to administer a cleansing edema to a client. Which of the following actions should the nurse take first? A. Keep the container of solution at a level to maintain client comfort. B. Hold the container of solution 30 cm (12 in) above the anus. C. Hold the container of solution level with the client's upper hip. D. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus

B. Hold the container of solution 30 cm (12 in) above the anus.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying

C. Atelectasis

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? A. Inspecting the site for reduced swelling B. Monitoring the client's pulse rate C. Asking the client to rate the pain D. Having the client perform range-of-motion of the affected arm

C. Asking the client to rate the pain

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? A. Bear down hard when defecating. B. Drink four to five glasses of water daily. C. Increase dietary intake of raw vegetables. D. Limit activity.

C. Increase dietary intake of raw vegetables.

A nurse is assessing a client's notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Reflex incontinence

C. Overflow incontinence

A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate? A. Needs assistance raising her legs to put on socks B. Demonstrates mild dyspnea when eating breakfast C. Performs active range-of-motion (ROM) exercises of all extremities D. Develops fatigue when assisting with morning hygiene care

C. Performs active range-of-motion (ROM) exercises of all extremities

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client' skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

C. Provide the client with a diet high in protein.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse notify as an indication for discontinuing the application due to a systemic response? A. Hypotension B. Numbness C. Shivering D. Reduced blood viscosity

C. Shivering

A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? A. Remind the client to tell the nurse when he has to urinate. B. Use adult diapers to prevent frequent clothing changes. C. Take the client to the bathroom every 2 hr. D. Request a prescription for an indwelling urinary catheter.

C. Take the client to the bathroom every 2 hr.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep the client's skin dry with powder. E. Minimize skin exposure to moisture.

C. Use pillows to keep heels off the bed surface. E. Minimize skin exposure to moisture.

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection to the client's ventrogluteal muscle? A. 45 degree B. 60 degree C. 75 degree D. 90 degree

D. 90 degree

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals.

D. Establish a plan of care with the client that sets attainable goals.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? A. Trochanter roll B. Sheepskin heel pad C. Abduction pillow D. Footboard

D. Footboard

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? A. Increased insulin production B. Decreased RBC production C. Decreased sodium excretion D. Increased calcium excretion

D. Increased calcium excretion

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle? A. Locate the center of the arm between the elbow and the shoulder. B. Find the center of the anterior aspect of the thigh. C. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. D. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

D. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous

D. Serosanguineous