Basic Physical Care Passpoint

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." -"Severe adverse reactions can be caused by cutting the medication in half." -"Dividing the tablet will not cause any problems as long as you take it with food." -"Cutting the medication in half alters the medication's absorption."

-"Cutting the medication in half alters the medication's absorption."

A nurse is presenting nutritional information to a client with a wound and encourages the client to consume foods high vitamins A and C to facilitate wound healing. The nurse determines the client understands which food products to incorporate when the client makes which statements? Select all that apply. -"I love eating cherries and strawberries, so I will make sure to add them to my diet." -"I love almonds, so I will eat more of them." -"Since I love mushrooms, I will cook more often with them." -"I will make sure to add sweet potatoes to my diet." -"It is a good thing I love oysters."

-"I love eating cherries and strawberries, so I will make sure to add them to my diet." -"I will make sure to add sweet potatoes to my diet."

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 schedule a visit once per week for I.V. antihypertensive medications." -"I should skip my medication dose if dizziness occurs." -"I should avoid meat and milk."

-"I should only have approximately 2400 mg of sodium per day."

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital and later tells the nurse, "I want to have everything possible done to help me get better." Which response by the nurse would be most appropriate? -"It's too late to change your mind now." -"We'll have to ask your health care provider if the DNR can be changed." -"It isn't a problem to rescind your DNR order. -"You should talk with your family before making this decision."

-"It isn't a problem to rescind your DNR order.

A client stepped on a piece of sharp glass while walking barefoot and comes to the emergency department with a deep laceration on the bottom of the foot. Which question is the mostimportant for the nurse to ask? -"When did you have your last tetanus shot?" -"Was the glass dirty?" -"How many diphtheria-tetanus-pertussis (DTaP) shots did you receive as a child?" -"Are you immune to tetanus?"

-"When did you have your last tetanus shot?"

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

The nurse is working on an ethics committee that is reviewing client/nurse interactions. Which of the following actions indicates negligence? -A nurse substituted a generic drug with a brand name drug. -A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue necrosis. -A nurse crushed medication ordered for oral administration and gave it through the peg tube. -A nurse administered medication a half hour before the scheduled time.

-A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue necrosis.

A client is diagnosed with cellulitis of the lower leg from a spider bite. What information can the nurse reinforce to help relieve the pain and inflammation? -Administer aspirin as ordered. -Wrap the leg snugly with an Ace wrap. -Apply warm compresses to the leg. -Apply cold compresses to the leg.

-Apply warm compresses to the leg.

Which assessment finding would be most supportive of the nursing diagnosis, Impaired skin integrity? -Area of skin with persistent redness -Dry and intact wound dressing -Heart rate of 88 beats/minute -Wound healing by first intention

-Area of skin with persistent redness

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take? -Making the client comfortable -Clearing the client's airway -Stopping the feeding and removing the NG tube -Starting cardiopulmonary resuscitation

-Clearing the client's airway

A nurse changes the wet-to-dry dressing of a client who has an open abdominal incision. Which nursing intervention is appropriate? -Label the dressing with the date, time, and nurse's initials. -Pack the wound tightly with wet-to-dry gauze sponges. -Irrigate the wound vigorously with sterile saline solution. -Use a plastic moisture resistant barrier to cover the dressing.

-Label the dressing with the date, time, and nurse's initials.

A client had gastric bypass surgery, is on nothing-by-mouth (NPO) status, and is in pain. The nurse gives morphine 4 mg as ordered. In 20 minutes, the client reports feeling nauseous. What would the nurse suspect as the most likely cause? -Morphine, which was given for pain, has a tendency to cause nausea. -It is a reaction to blood still remaining in the mouth after extubation. -Being NPO, the increase in gastric secretions is precipitating this symptom. -The surgery is causing nausea.

-Morphine, which was given for pain, has a tendency to cause nausea.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take? -Asking the physician to give the client a tranquilizer -Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client -Placing bilateral wrist restraints on the client -Delaying I.V. fluid administration until the client's confusion ceases

-Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

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? -Brown exudate at incision edges -Pallor around sutures -Clear, yellow drainage -Redness and warmth

-Redness and warmth

A nurse is providing home care to a client who has failing vision. The nurse is concerned about the client's safety. Which action should the nurse take to help reduce the client's risk of a fall? -Arrange pieces of furniture close together so the client can use them for guidance and support. -Contact the disability association to install a flashing light to indicate when the phone or doorbell rings. -Request that the family have handrails installed on the stairs, in hallways, and in bathrooms. -Encourage the client to wear a medical identification bracelet that describes the client's visual deficit.

-Request that the family have handrails installed on the stairs, in hallways, and in bathrooms.

The nurse is caring for a client with stomatitis. To make eating less painful, which foods should the nurse suggest? -Liquid foods -Soft, bland foods -Hot foods -Dry foods

-Soft, bland foods

A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention? -Increasing fluids to 2,500 ml/day -Improving airway clearance -Suctioning the client every 2 hours -Teaching the client how to deep-breathe and cough

-Teaching the client how to deep-breathe and cough

A nurse is reinforcing discharge instructions to the parents of a child who had a tonsillectomy. Which instruction is the most important? -Orange juice should be given to provide pain control. -The child shouldn't drink from straws. -The child should drink extra milk. -The mouth should be rinsed with salt water to provide pain relief.

-The child shouldn't drink from straws.

During a teaching session, the nurse demonstrates how to change a tracheostomy dressing. Then, the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? -The client cleans around the incision site, using gauze squares moistened with normal saline. -The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. -The client applies cotton-filled gauze squares as the sterile dressing after cleaning. -The client cleans around the incision site, using gauze squares moistened with tap water.

-The client cleans around the incision site, using gauze squares moistened with normal saline.

The nurse has been accused by a client with assault and battery. Which action did the nurse perform that caused the client to make this allegation? -The nurse took a necklace belonging to the client. -The nurse discussed the client's medical information with another nurse. -The nurse entered the client's room several times during the course of treatment. -The nurse performed a procedure without obtaining consent from the client.

-The nurse performed a procedure without obtaining consent from the client.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? -Sterile objects are held above the waist of the technician. -Sterile packages are opened with the first edge away from the technician. -Wetness in the sterile cloth on top of the nonsterile table has been noted. -The outer inch of the sterile towel hangs over the side of the table.

-Wetness in the sterile cloth on top of the nonsterile table has been noted.

A nurse is caring for a client who's receiving enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as for residual volume. The purpose of the nurse's actions is to prevent which life---threatening complication? -gastric ulcers -aspiration -diarrhea -abdominal distention

-aspiration

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? -allowing the client to perform activities of daily living independently -assessing and controlling pain -assisting the client with full weight bearing and walking -removing the client's surgical staples

-assessing and controlling pain

Which intervention should the nurse implement to promote adequate nutritional intake for a client with Alzheimer's disease? -fill out the menu for the client -help the client fill out the menu -assist the client with feeding -give the client privacy during meals

-assist the client with feeding

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? -change gloves after each client contact -wear a gown when bathing a client -recap needles after use -wear gloves when giving oral medication

-change gloves after each client contact

A client on bedrest with an indwelling urinary catheter informs the nurse of having discomfort in the lower abdomen. What is the first action by the nurse? -obtain a urine specimen to see if the client has a urinary tract infection -check to see if the catheter is kinked -irrigate the catheter -remove the catheter and reinsert another

-check to see if the catheter is kinked

A nurse is removing an indwelling urinary catheter. Which nursing action reflects the besttechnique? -cut the lumen of the balloon -wear sterile gloves -document the time of removal -position the client on his left side

-document the time of removal

A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should: -turn the client every 2 hours. -encourage increased fluid intake. -elevate the head of the bed 30 degrees. -maintain a cool room temperature.

-encourage increased fluid intake.

After a surgical procedure, the health care provider orders a clear-liquid diet for a client. The nurse advises the unlicensed assistive personnel (UAP) to check the client's food tray for which of the following allowable items? Select all that apply. -orange juice, farina, and coffee -pineapple juice, a bran muffin, and milk -ginger ale, jello, and a fruitless popsicle -apple juice, chicken broth, and gelatin -orange juice, custard, and tea

-ginger ale, jello, and a fruitless popsicle -apple juice, chicken broth, and gelatin

A nurse is providing care to a client after surgery. The nurse must practice surgical asepsis when performing which procedure? -colostomy care and irrigation -irrigation of a nasogastric (NG) tube -insertion of an indwelling urinary catheter -mouth care

-insertion of an indwelling urinary catheter

The nurse is caring for a client on the medical-surgical unit who has an acute attack of vertigo. What intervention should the nurse provide for safety of the client? -place the client in a modified Trendelenburg position -keep the client on bed rest with the side rails elevated -administer meclizine 50 mg po daily -start an IV with lactated Ringers solution at 125 mL/hr

-keep the client on bed rest with the side rails elevated

A client in the long-term care facility sustains a fall when trying to get out of the bed. What is the priority action by the nurse? -assist the client back into the bed -find out from the unlicensed assistive personnel (UAP) what happened -complete an incident form -obtain subjective and objective data to determine injury

-obtain subjective and objective data to determine injury

A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which nursing action would best serve the hospital in this disaster situation? -perform duties as outlined in the disaster plan -offer advice about how to run the facility smoothly -implement tasks that are beyond the scope of practice -volunteer to help where assistance is most needed

-perform duties as outlined in the disaster plan

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action? -considering a 1-inch edge around the sterile field as contaminated -pouring solution directly onto a sterile field barrier -opening the outermost flap of a sterile package away from the body -holding sterile objects above the level of the waist

-pouring solution directly onto a sterile field barrier

A nurse walks into a client's room and sees the trash smoldering. What should the nurse do first? -remove the client from the room -contain the fire by closing the door -extinguish the fire -activate the fire alarm

-remove the client from the room

A nurse is assigned to care for an older adult client who is confused and repeatedly attempts to climb out of bed. While the nurse is out of the room, the client climbs out of bed and falls, but does not sustain injuries from the fall. This situation would most likely present as which type of occurrence? -quality-improvement issue -ethical dilemma -risk-management incident -informed-consent problem

-risk-management incident

A nurse working in the emergency department (ED) is caring for several clients. The nurse determines that obtaining informed consent for treatment would be unnecessary for which client? -the client who is diagnosed with a mental illness -the client who asks the nurse to give substituted consent -the client who is bleeding profusely from a car crash -the client who refuses to give informed consent

-the client who is bleeding profusely from a car crash

A nurse wants to use a waist restraint for a client who wanders at night. Which intervention should be considered before applying the restraint? -the lack of unlicensed assistive personnel (UAP) on the night shift -the nurse's convenience -the client's reason for getting out of bed -a sleeping medication ordered as needed at bedtime

-the client's reason for getting out of bed

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? -use the Z-track method -always use the same injection site -aspirate after the injection -use a 45- to 90-degree angle

-use a 45- to 90-degree angle

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? -vanilla yogurt -chicken broth -iced coffee -cranberry juice

-vanilla yogurt

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? -wash the area with water and apply an alcohol solution -wash affected area with soap and water -clean the area with alcohol -use a clean paper towel to wipe away the blood

-wash affected area with soap and water