Week 7 quiz Principles of nursing

A nurse is assessing a client who has a COPD. the nurse should expect the Client's chest to be which of the following shapes? Pigeon Funnel Kyphotic Barrel

Barrel Rationale: clients who have COPD use accessory muscles with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. Ill wear sandals in warm weather B I'LL put lotion between my toes after drying my feet C. I'll check my feet everyday for sores and bruises

C. I'll check my feet everyday for sores and bruises

a nurse is caring for a client who is receiving oxygen @2l via nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen (Fi02) concentration? 28% 36% 50% 27%

28%

A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. Which of the following actions should the nurse take? Keep padded portion of the restraints against the wrists Ensure enough room to fit one finger between the restraint and the wrist Attach the ties of the restraint to the bed rails use a knot that will tighten as the clients moves.

Keep padded portion of the restraints against the wrists

The nurse caring for a client with PNE related atelectasis would implement which one of the following interventions to improve oxygenation? Performing vibration and percussion Applying high flow oxygen intermittently implementing postural drainage coaching the client on the correct use of incentive spirometer

Performing vibration and percussion coaching the client on the correct use of incentive spirometer

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? Protein Calcium Vitamin B1 Vitamin D

Protein Rationale: Protein is the major structural and functional component of every cell. it is required in increases amounts during times when the body needs to heal itself and promote wound healing

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 a turning schedule every 4hr c. use pillows to keep heels off the bed surface D.Keep the clients skin dry with powder E. Minimize skin exposure the moisture

c. use pillows to keep heels off the bed surface E. Minimize skin exposure the moisture

A nurse is working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being a greatest risk for skin breakdown? 1.A young adult who has a femur Fx. and is in skeletal balanced suspension traction 2. an adolescent who has a cervical fx. and is in a halo brace 3.a middle adult who has a fracture radius and an arm cast. 4.An older adult who has a hip fx and is in Bucks traction.

4.An older adult who has a hip fx and is in Bucks traction.

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. which of the following situations should the. nurse include as an indication for placing a client in mechanical restraints? 1. Punishment for verbally abusing other clients 2. Discipline for throwing objects at staff 3.Coercion to take prescribed medications 4.Self-destruction behavior despite alternative interventions

4.Self-destruction behavior despite alternative interventions

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take?Select all the apply A. Check for personal items when changing the bed linens B. Put a clean gown on the strongest arm first C. keep the bath water temperature between 43.3C(110F) and 46.1 C (115F). D. Shave the clients hair in the direction of the hair growth E. wash the clients extremities from proximal to distal

A. Check for personal items when changing the bed linens C. keep the bath water temperature between 43.3C(110F) and 46.1 C (115F). D. Shave the clients hair in the direction of the hair growth

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. irrigate the wound with an antiseptic prior to obtaining the specimen c.swab area of skin away from the wound to identify the usual flora

A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? Nausea Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange hypotension

Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. when the client asks what the stockings during and after the procedure. When the client asks what the stockings during and after the procedure . When the client asks what the stockings do, which of the following responses should the nurse make? A. They protects your legs and heels from skin breakdown B. They help keep you warm after surgery C.They improve your circulation to keep blood from pooling in your legs

C.They improve your circulation to keep blood from pooling in your legs

A home health nurse visits client who has COPD and receives oxygen at @2L/min via nasal cannula. The client reports difficulty breathing. Which of the following action is the nurse priority? Assess the client respiratory status Call EMS for the client Have the client cough and expectorate secretions

assess the client respiratory status Rationale: The 1st action the nurse should take the nursing process is to collect data from the client. The nurse should immediately assess the clients respiratory status before determining the appropriate interventions