Basic Physical Care - ML5
A client asks a nurse if a large enteric-coated tablet can be cut in half. What is the best response by the nurse? "The medication becomes less effective when it is divided in half." "Cutting the medication in half alters the medication's absorption." "Dividing the tablet will not cause any problems as long as you take it with food." "Severe adverse reactions can be caused by cutting the medication in half."
"Cutting the medication in half alters the medication's absorption." Explanation: Dividing an enteric-coated tablet destroys the enteric barrier, allowing stomach secretions to act on the medication and alter its absorption.
The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching? "Use the cane when walking further than 50 feet." "Don't use the cane when climbing stairs." "Hold the cane on the same side as the injury." "Hold the cane on the opposite side from the injury."
"Hold the cane on the opposite side from the injury." Explanation: The nurse should instruct the client to hold the cane in the hand opposite the affected extremity; the only exception is when the client is physically unable to hold the cane in that hand. A cane helps maintain balance; so the client should be encouraged to use the cane when navigating stairs. The cane should be used when walking any distance to prevent injury from falls.
A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates that the client understands? "I should only have approximately 2400 mg of sodium per day." "I should avoid meat and milk." "I should schedule a visit once per week for I.V. antihypertensive medications." "I should skip my medication dose if dizziness occurs."
"I should only have approximately 2400 mg of sodium per day." Explanation: The nurse must teach the hypertensive client how to modify the diet to restrict sodium and saturated fats. In addition, the nurse should explain the actions, dosages, and adverse effects of prescribed antihypertensives. A client receiving antihypertensives also may take a diuretic as part of the drug regimen, should eat a potassium-rich diet including meats and milk, and may require dietary potassium supplements and high-potassium foods to avoid electrolyte disturbances. Instead of skipping medication if dizziness occurs, the client should notify the physician of this symptom. The client receiving antihypertensives at home takes them by mouth, not I.V.
A primary care provider prescribes morphine 4 mg IM for a client in pain. Morphine is supplied as 10 mg/mL. The nurse will administer __________ml. Record your answer using one decimal place.
0.4 Explanation: The medication is supplied as 10 mg/ml and the nurse must administer 4 mg. The nurse will divide 4 mg by 10 mg = 0.4 mg
The nurse is completing the intake and output record for a client. The client has had the following intake and output during the shift: Intake: 4 oz (120 mL) of cranberry juice, 1/2 bowl of oatmeal, 2 slices of toast, 8 oz (240 mL) of black decaffeinated coffee, tuna fish sandwich, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of 1% milk, and 16 oz (480 mL) of water. Output: 1,300 mL of urine. How many milliliters should the nurse document as the client's intake? Record your answer using a whole number.
1380 Explanation: There are 30 mL in each fluid ounce and 240 mL in each cup. The fluid intake for this client includes 4 oz (120 mL) of cranberry juice, 8 oz (240 mL) of coffee, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of milk, and 16 oz (480 mL) of water, for a total of 1,380 mL.
The nurse is gathering data from a group of clients during clinic visits. Which client does the nurse determine is at the greatest risk for the development of type 2 diabetes? 26-year old female client that exercises 4 times per week 48-year old client that had gestational diabetes with her second child 56-year-old male client that had a myocardial infarction 3 years previously 60-year-old male client with a Hemoglobin A1C of 4.8
48-year old client that had gestational diabetes with her second child Explanation: One of the risk factors for the development of type 2 diabetes is having gestational diabetes or giving birth to a child over 9 lbs (4 kg). Exercising regularly is not a risk factor and can be a preventative measure for healthy living. Regular physical activity lowers the risk factor significantly. Having a myocardial infarction does not increase the risk factors for the development of type 2 diabetes. A hemoglobin AIC of 4.8 is within normal range. A range of 5.7-6.4 indicates the client may be in a prediabetic state.
The nurse is caring for a client with a fever of 103°F (39°C) due to a respiratory infection. The client states, "I am freezing and I have a terrible headache!" What is the appropriate nursing action? Administer acetaminophen as prescribed. No intervention should be provided since the fever will kill the bacteria. Apply extra blankets to warm the client. Assist the client into a cool bath.
Administer acetaminophen as prescribed. Explanation: Acetaminophen will help to reduce the fever and relieve the pain of the headache. Placing the client into a cool bath will increase shivering which increases the metabolic rate and causes increase in fever. Applying extra blankets will increase the body temperature. The respiratory infection may be viral. The client has the right to pain relief from the headache.
The nurse is gathering data from a group of clients during clinic visits. Which client does the nurse determine is at the greatest risk for the development of type 2 diabetes? 26-year old female client that exercises 4 times per week 56-year-old male client that had a myocardial infarction 3 years previously 48-year old client that had gestational diabetes with her second child 60-year-old male client with a Hemoglobin A1C of 4.8
Clean the wound with normal saline solution. Explanation: A red, granulating foot ulcer is healing well and should be cleaned with normal saline solution or a nontoxic wound cleanser. Minimal force should be used to prevent disrupting healthy granulation tissue. A dry gauze dressing would adhere to the wound and disrupt the granulation tissue when removed. When used in a healthy, healing wound, a wet-to-dry dressing can traumatize healing tissue during removal.
A child is brought to the emergency department with life-threatening bleeding that needs immediate intervention. The child's parents cannot be reached to give consent. The nurse continues to assist with the child's care based on which understanding about consent? Consent may be given by the family health care provider. Consent must be obtained from a neighbor or close friend of the family. Consent is not needed in a life-threatening situation. The consent must be in the form of a signed document; therefore, parents or guardians must be contacted.
Consent is not needed in a life-threatening situation. Explanation: Although parents have full responsibility for the child and are required to give informed consent (either verbal or written) whenever possible, the law is clear that in an emergency, life-threatening situation, or a situation in there is the possibility of permanent injury, consent is implied. A neighbor, close family friend, or health care provider cannot legally sign consent. Treatment should not be delayed in an emergency to obtain consent.
Two nurses are working the night shift on a medical unit. The first nurse obtains vital signs on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. What should the second nurse do in this situation? Nothing; the first nurse's clients did not call for assistance. Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Ask the nurse on the day shift to report the situation to the nurse manager. Cover by gathering data from the first nurse's clients hourly.
Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Explanation: The second nurse is responsible for immediately discussing this behavior and its safety implications with the first nurse. The other options do not demonstrate behavior representative of advocating for safe and competent care.
The nurse is caring for a client who practices reflexology. When collecting client data, the nurse notes that the client's ankles are edematous. Which intervention by the nurse supports the client's beliefs in reflexology and helps reduce edema? Lowering the client's legs Elevating the client's legs Adducting the client's legs Abducting the client's legs
Elevating the client's legs Explanation: Reflexology is based on the theory that fluid in interstitial spaces blocks oxygen supply to tissues. Therefore, elevating the client's legs helps decrease fluid in the ankles, thereby increasing oxygen supply to the tissues. Lowering, abducting, or adducting the client's legs won't lessen edema or promote reflexology.
A hospitalized client has been receiving Intravenous (IV) antibiotics for the treatment of pneumonia over 3 days. The nurse observes the client having several foul smelling, loose stools during the day and suspects the client may have developed Clostridium Difficile. What is the priority action by the nurse? Insert a rectal tube so that the client will not soil the bed linens. Initiate the use of contact precautions to prevent the spread of the bacteria. Administer an antidiarrheal medication to stop the diarrhea. Notify the charge nurse that the medication should be changed.
Initiate the use of contact precautions to prevent the spread of the bacteria. Explanation: Clostridium Difficile (C. Difficile) is the most common cause of antibiotic associated diarrhea. Contact precautions should be initiated immediately to prevent the spread of bacteria to other clients as well as health care workers. Using soap and water is preferable for hand washing than an alcohol based hand sanitizer. The contact precautions can be initiated independently and does not require a health care provider order. Notifying the charge nurse that the client condition has changed is appropriate but not the priority action. Inserting a rectal tube may damage the mucosa of the rectum and is not a priority. Administering an antidiarrheal may be done as well as the initiation of a probiotic but is not a priority action at this time.
The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse plan to emphasize? Lean meats and low-fat milk Legumes and cheese Whole-grain products Fruits and vegetables
Lean meats and low-fat milk Explanation: Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk, because protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but also fat, which should be limited to 30% or less of caloric intake. Whole-grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.
When checking a client's incision one day after surgery, the nurse expects to see which finding as a sign of a local inflammatory response? Redness and warmth Clear, yellow drainage Brown exudate at incision edges Pallor around sutures
Redness and warmth Explanation: Warmth and redness are normal signs of an inflammatory response. Yellow drainage may indicate an infectious process. The nurse would expect some redness — not pallor — at the suture edges. Brown exudate is a sign of an infected wound.
A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is working with a nursing student. The student does not attempt to suction or assist with care of the client. Which action by the nurse is appropriate? Address a coworker with the concerns. Report this issue to the nurse-manager . Seek advice from the student's instructor. Talk to the student to determine the issue.
Talk to the student to determine the issue. Explanation: The nurse should approach the student first to determine feelings and experience in caring for a client with AIDS. The nurse-manager and coworkers are not familiar with the student's abilities, but the instructor may be approached if the nurse cannot communicate with the student.
The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client? body diagram number scale from one to ten questionnaire face rating scale
face rating scale Explanation: The face rating scale, which depicts five or more faces with expressions that range from happy to very unhappy, is the best way for this client to communicate level of pain because he/she can simply point to the face that illustrates how he/she is feeling. A number scale, body diagram, or questionnaire may be difficult for this client to use.
A registered nurse (RN) and licensed practical nurse (LPN) are reviewing the charts of their assigned clients. The LPN asks which clients the RN would identify as clients that may qualify for hospice care? Select all that apply. a client who's undergoing treatment for heroin addiction a client with late-stage acquired immunodeficiency syndrome (AIDS) a client with left-sided paralysis resulting from a stroke a client with cirrhosis/liver failure and encephalopathy a client who had coronary artery bypass surgery 2 weeks previously
a client with late-stage acquired immunodeficiency syndrome (AIDS) a client with cirrhosis/liver failure and encephalopathy Explanation: Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS and liver failure with co-morbidity, such as hepatorenal syndrome or encephalopathy, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who has recently undergone coronary artery bypass surgery because these health problems are not necessarily terminal.
A nurse gives the wrong medication to a client. What communication should the nurse impart to the risk manager of the facility? an order change signed by the health care provider a copy of the medication Kardex an oral report a written incident report
a written incident report Explanation: Incident reports are tools used by risk managers when a client might have been harmed. They're used to determine how future errors can be avoided. An oral report won't serve as legal documentation. A copy of the medication Kardex wouldn't be sent with the incident report to the risk manager. A health care provider won't change an order to cover the nurse's mistake.
A licensed practical nurse is caring for a client who underwent open reduction and internal fixation of a fractured left hip 1 day ago. Which intervention takes priority for this client during the first postoperative day? removing the client's surgical staples assisting the client with full weight bearing and walking assessing and controlling pain allowing the client to perform activities of daily living independently
assessing and controlling pain Explanation: During the first postoperative day, assessing and controlling pain takes priority. Recovery may be delayed by uncontrolled pain. The client must progress to full weight bearing but, during the immediate postoperative period, he requires an assistive device to avoid full weight bearing. The nurse should assist the client with activities of daily living during the immediate postoperative period. Staples are typically removed by the surgeon and shouldn't be removed for several days after surgery.
Which intervention should the nurse implement to promote adequate nutritional intake for a client with Alzheimer's disease? give the client privacy during meals assist the client with feeding help the client fill out the menu fill out the menu for the client
assist the client with feeding Explanation: Because a client with Alzheimer disease can forget how to eat, the nurse should stay and assist the client with eating to ensure adequate food intake. Allowing privacy during meals, filling out the menu, and helping the client to complete the menu don't ensure that the client will eat.
The nurse is aware that the facility follows the standard precautions recommended by the Centers for Disease Control and Prevention. Which action should a nurse perform when following standard precautions? wear gloves when giving oral medication wear a gown when bathing a client change gloves after each client contact recap needles after use
change gloves after each client contact Explanation: When following standard precautions, the nurse must change gloves and perform hand hygiene after each client contact. Used, uncapped needles and syringes should be placed in puncture-resistant containers; they should never be recapped. Standard precautions do not call for a caregiver to wear a gown or gloves when bathing a client or administering oral medication, because these activities are not likely to cause contact with blood or body fluids.
A nurse is caring for a client who just underwent a colectomy. What should the nurse do to prevent postoperative thrombus formation in the legs? keep the client supine in bed cover with warming blankets have the client use a trapeze bar to move in bed encourage the client to dorsiflex and plantar flex the feet instruct the client to turn from side to side every hour
encourage the client to dorsiflex and plantar flex the feet Explanation: Dorsiflexion and plantar flexion of the feet promote venous return to the heart for a client who just underwent a colectomy, thus reducing the risk of thrombus formation. Telling the client to turn from side to side every hour helps prevent pressure ulcers but does not help prevent a leg thrombus. Using a trapeze bar to move in bed may help the client move independently but does not enhance blood flow to the legs or prevent thrombus formation. Keeping the client flat and warm does not promote blood flow or venous return and, therefore, does not reduce the risk of thrombus formation.
A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique? recurrent circular figure-eight spiral reverse
figure-eight Explanation: The nurse should use a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee, to support the joint and limit joint movement. The circular bandaging technique is used to anchor a bandage; the recurrent technique is used to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique is used to accommodate the increasing circumference of a body part such as when in a cast.
A client arrives in the emergency department stating that the car battery exploded and acid splashed in both eyes. Which is the correct initial nursing action? apply a bandage to the eyes neutralize the acid with an alkali solution flush both eyes with sterile saline apply an antibiotic ointment to both eyes
flush both eyes with sterile saline Explanation: A chemical burn to the eyes should be flushed with copious amounts of water to neutralize the chemical. Instilling an alkali solution will cause further burns to the eyes. An antibiotic ointment may be applied after the eyes are flushed with water as well as a bandage applied.
The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: foot. ankle. lower thigh. knee.
foot. Explanation: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return.
When caring for a client with a 3-cm stage II pressure ulcer on the coccyx, which action can the nurse institute independently? applying an antibiotic cream to the area three times per day cleaning the wound three times per day with a povidone-iodine wash gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary cleaning the wound with a wound cleanser and applying a hydrogel wound dressing
gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary Explanation: Gently irrigating the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash, an antibiotic cream, and a hydrogel wound dressing require a physician's order.
A client admitted with dehydration has urinary incontinence and excoriation in the perineal area. Which action would be a priority? applying moist, warm compresses to the client's perineal area offering the urinal every 3 hours maintaining a fluid intake of 1 L/day keeping the perineal area clean and dry
keeping the perineal area clean and dry Explanation: Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority because it aids healing and prevents further breakdown. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the urinal should be offered more often. Maintaining fluid intake at 1 L/day is insufficient for a client who has been diagnosed with dehydration, and the fluids wouldn't aid healing. Continued incontinence as well as moist compresses would contribute to additional skin excoriation and breakdown.
A nurse is caring for a client with an acute head injury and is ready to begin rehabilitation. When transferring the client from the bed to a chair, what should the nurse do to ensure client safety? raise the side rails on both sides of the bed place socks on the client's feet position the chair 2 feet from the bed lock the brakes on the bed
lock the brakes on the bed Explanation: Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. Positioning the chair alongside the bed, rather than 2 feet away, helps the client to pivot into the chair. The nurse should place shoes or slippers with nonskid soles on the client's feet to help prevent slipping during the transfer.
A nurse prepares to care for a client who has just transferred from the emergency department to the medical-surgical floor. Which is the most effective action that the nurse should take to prevent microbial transmission? wearing gloves during care using aseptic technique meticulous hand hygiene disinfecting all equipment
meticulous hand hygiene Explanation: Hand hygiene is the principal means of preventing the spread of organisms among clients. Wearing gloves when they are indicated, using aseptic technique, and disinfecting equipment between clients are all important measures to prevent spread of microbes; however, none of these techniques is more effective than hand washing.
The nurse is caring for a client with a fractured hip. The client becomes combative, confused, and tries to get out of bed. His vital signs and pulse oximetry results are unchanged. The nurse should: order soft restraints from the storeroom. leave the client and get additional help. notify the nursing supervisor to see if a staff member can sit with the client. notify the physician and obtain an order to restrain the client.
notify the nursing supervisor to see if a staff member can sit with the client. Explanation: The nurse should notify the nursing supervisor to see if an available staff member can sit with the client. If staffing doesn't allow, the nurse should see if a family member is available to sit with the client. A client should never be left alone while the nurse summons assistance. The nurse should contact the physician to obtain a restraint order when all other measures fail, and the client should be restrained in the least restrictive manner possible.
A multigravida client at 34 weeks' gestation is having a non-stress test performed and begins having vaginal bleeding. Which nursing action would be the priority? obtaining maternal heart rate and respiratory rate establishing IV access and beginning fluid resuscitation preparing the client for an ultrasound with a cesarean birth to follow obtaining fetal heart rate (FHR) and maternal blood pressure
obtaining fetal heart rate (FHR) and maternal blood pressure Explanation: FHR and maternal blood pressure provide important data on the conditions of the mother and fetus. An IV line should be started after the mother and fetus are evaluated. Preparing the client for a cesarean birth before determining the cause of the vaginal bleeding would be premature. Maternal heart rate and respiratory rate, although important, are not the best indicators of maternal health status and provide no information about fetal health.
A nurse is caring for a confused, older adult client. Which action should the nurse prioritize for this client's care? identifying the underlying cause of confusion promoting safety by protecting from injury monitoring for deteriorating of neurologic status. encouraging participation in activities of daily living (ADLs)
promoting safety by protecting from injury Explanation: The nurse's first responsibility is always to protect the client from injury. Determining the cause of the confusion and protecting the older adult client's neurologic status from deterioration are the primary care provider's responsibilities. Encouraging the client to participate in ADLs is a nursing intervention, but it is not the most important consideration.
A client has an prescription for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, which action should the nurse take? aspirate after the injection always use the same injection site use the Z-track method use a 45- to 90-degree angle
suctioning a tracheostomy client with oxygen saturation of 90% Explanation: Using Maslow's hierarchy of need, the priority is maintaining airway. If the airway is not maintained, the client can die of asphyxia. Changing a dressing and colostomy are necessary but not emergent. Administering pain medication is the next priority after airway.
A nurse is caring for clients in a subacute unit. Which client care takes priority? suctioning a tracheostomy client with oxygen saturation of 90% changing a dressing on a wound with serosanguinous drainage administering pain medication to a client with a pain level of 7 out of 10 changing a colostomy bag that is full
suctioning a tracheostomy client with oxygen saturation of 90% Explanation: Using Maslow's hierarchy of need, the priority is maintaining airway. If the airway is not maintained, the client can die of asphyxia. Changing a dressing and colostomy are necessary but not emergent. Administering pain medication is the next priority after airway.
The nurse is performing a dressing change as prescribed for a client with a red, granulating foot ulcer. Which action should the nurse perform when changing the dressing? Vigorously irrigate the ulcer with ½-strength betadine. Pack the wound tightly with a wet-to-dry dressing. Apply a dry gauze dressing. Clean the wound with normal saline solution.
use a 45- to 90-degree angle Explanation: The nurse should inject at a 45- to 90-degree angle, depending on the site and the amount of subcutaneous tissue present. When injecting subcutaneously, the nurse should not aspirate after the injection and should rotate injection sites. The Z-track method is used for I.M. injections that may cause tissue irritation.
A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics? lift the client to the proper position stand several feet from the client straighten the knees and back use a wide stance for support
use a wide stance for support Explanation: When repositioning a client in bed, the nurse should stand with the feet apart (one foot in front of the other) to establish a wide base of support and good body alignment. To reduce the energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull, rather than lift the client. The nurse should flex the knees and use arm and leg muscles instead of the back. To minimize stress, the nurse should stand as close to the client as possible.
The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray? cranberry juice iced coffee chicken broth vanilla yogurt
vanilla yogurt Explanation: Yogurt is found in full liquid diets. A clear liquid diet includes clear juices, such as cranberry juice, coffee, tea, water, and broth.
The nurse is caring for a client with a Jackson-Pratt drain. While emptying the drain, the nurse is splashed with blood. Which of the following actions should the nurse take? clean the area with alcohol wash affected area with soap and water wash the area with water and apply an alcohol solution use a clean paper towel to wipe away the blood
wash affected area with soap and water Explanation: Washing the affected skin with water and soap ensures removal of the blood by rubbing the skin. Alcohol is not effective against virus and fungi. Paper towel alone, especially a dry paper towel, will not completely eliminate the blood.