Caring process

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? A. the alternative measures attempted before applying the restraints B. a verbal prescription for the restraints, renewed every 48 hours C. the type of personal protective equipment used by the nurse during restraint application D. a detailed description of the restraint application process

a

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? A. They promote venous blood return to the heart. B. They reduce the risk for impaired skin integrity. C. They eliminate peripheral edema. D. They provide a nonslip foot surface to help prevent falls.

A

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? A. To improve grasp and help provide more stability and balance. B. To provide added weight for increased client exercise and endurance. C. To increase the client's activity tolerance. D. To provide them with a better center of gravity.

A

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing. What action would be appropriate? A. Call someone to bring in the necessary item to the client's room. B. Leave the client and the room to obtain the missing item. C. Skip the part of the care that requires the missing item. D. Complete the care right up to the step of the missing item, then go get it.

A

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? A. "Ambulation helps prevent thromboembolism." B. "Ambulation helps prevent hypoglycemia after surgery." c. "Ambulation helps prevent surgical wound infection." D. "Ambulation helps prevent anesthesia related tachycardia."

A

The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves? A. The nurse touches the client's skin with one hand. B. The nurse touches one glove to the other glove. C. The nurse picks up a sterile dressing from the sterile field. D. The nurse keeps both hands above waist level.

A

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? A. Thumb and forefinger B. Thumb and fifth finger C. Index and second finger D. Second, third, and fourth fingers

A

The nurse is putting on sterile gloves. Which principle would be important to keep in mind? A. The hands should remain above waist level at all times. B. The outer edge of the cuff is used to pick up the glove to be put on. C. The cuffs of the gloves should be adjusted as each glove is applied. D. The inner package should be placed on the surface with the cuff side away from the body.

A

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take? A. Open the top and bottom folds completely. B. Slide the gloves out of the package. C. Reach under the package folds to open. D. Obtain a new pair of sterile gloves.

A

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. A. Ensure the parent engages in regular exercise. B. Provide frequent reorientation. C. Increase the parent's social interaction. D. Ensure the parent to take naps frequently. E. Ensure that the parent's routine changes frequently.

A, B, C

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. A. Pressure injuries B. Delirium C. Contractures D. Falls E. Kidney stones

A, B, C, D

The nurse considers applying restraints to an agitated client. Which actions does the nurse take? A. "Ensure the client cannot reach any objects in the room." B. "Dim the lights and speak softly about something the client enjoys." C. "Assess the client for existing injuries to the wrists and hands." D. "Call a family member to come and sit with the client."

B

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? A. Secure the wrist restraints to the side rail. B. Assess the client's need for fluids and toileting every 2 hours. C. Perform the client's activities of daily living (ADLs). D. Delegate evaluations of the restraints at 2-hour intervals to unlicensed assistive personnel (UAP).

B

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? A. mummy restraint B. extremity restraint C. elbow restraint D. waist restraint

B

What action does the nurse perform to remove gloves after performing a sterile procedure? A. Lay the first removed glove in the sterile field. B. Invert the glove as it is removed. C. Pull the glove off starting at the fingers. D. Place the first removed glove in the waste.

B

What action should the nurse take when changing a sterile dressing on a central venous access device? A. Position the sterile dressing supplies on the table between the nurse and client. B. Cleanse the central venous access device site while wearing sterile gloves. C. Place sterile gloves on before removing the existing dressing. D. Leave the bed in a low position if the side rail will need to be lowered.

B

When putting on the second sterile glove, the nurse places the gloved thumb at which location? A Under the fingers, as in a fist B. Outward away from the gloved hand C. Adjacent to the fifth finger D. Close to the palm of the gloved hand

B

While donning sterile gloves for a client's dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action? A. Place a new sterile glove over the ripped glove. B. Obtain a new pair of sterile gloves. C. Use the ripped glove for nonsterile actions. D. Continue with the dressing change.

B

While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse would be most appropriate? A. Apply a new pair of sterile gloves over the current ones. B. Replace the current gloves with a new set of sterile gloves. C. Continue the procedure using only the left gloved hand. D. Cover the contaminated glove with a non-sterile disposable glove

B

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. A. Remove any excessive hair from the legs with a depilatory B. Assist the client back to bed. C. Have the client flex and extend the legs several times. D. Elevate the client's feet and legs for about 15 minutes. E. Apply liberal amounts of lotion to the feet and legs.

B, D

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. A. help pain control B. increase joint flexibility C. decrease risk of wound infection D. improve respiratory function E. aid gastrointestinal motility

B, D, E

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform? A. Instruct the client that improved behavior results in restraint removal. B. Perform a circulation check and offer toileting and hydration. C. Ensure an as needed restraint prescription is in place and signed. D. Reassess cognitive status and the need to continue the restraints

B.

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? A. "I'm sure they are on correctly. I trust the nurse who put them on." B. "It doesn't matter if the opening is up or down, as long the stocking is smooth." C. "The opening is face up to prevent any interference with the circulation." D. "Yes, you are correct. Let me take them off and put them on again."

C

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned? A. directly behind the client with both hands on the gait belt B. in front of the client with near hand on gait belt C. to either side and slightly behind the client with near hand on gait belt D. directly beside the client with opposite hand on gait belt

C

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client's large abdominal wound. The nurse uses the extra gloves for what purpose? A. To leave in the room with additional supplies for the next change B. To be able to change gloves if the wound has copious draining C. To use if the first pair of sterile gloves gets contaminated D. To remove the existing dressing from the abdominal wound

C

The nurse has put on one sterile glove and is preparing to put on the other. What is the next step in donning the second glove? A. Use the fingers to grasp the edges of the cuff of the second glove. B. Hold the second glove in the palm of the gloved hand. C. Slide the gloved fingers under the cuff of the second glove. D. Use the thumb and index finger to grasp the cuff.

C

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? A. Restrain the client. B. Ask a family member to sit with the client. C. Use a safety monitoring device. D. Check the client every 30 minutes.

C

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? A. Raise the side rails. B. Administer a prescribed dose of lorazepam. C. Assess for the need to urinate. D. Contact the health care provider for a prescription to apply a waist restraint.

C

The nurse puts on sterile gloves in preparation for a sterile central line dressing change. The nurse realizes that the bed is too low to complete the procedure adequately. What action does the nurse take? A. Raise the bed using one finger. B. Place clean gloves over the sterile gloves. C. Ask someone to raise the bed. D. Take off the sterile gloves.

C

When removing soiled gloves, which should the nurse do first? A. Peel the glove off over the other glove B. Turn the glove inside out as it is being pulled off. C. Grasp the outside of one glove with the opposite gloved hand. D. Slide the fingers under the glove at the wrist.

C

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure? A. An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection. B. Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant. C. If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair. D. If another staff member enters the room and volunteers to assist, sterile gloves are immediately available.

C

While removing gloves after performing client care, what action does the nurse take? A. Wrap the discarded gloves inside the sterile field for waste disposal. B. Discard each glove separately into the waste receptacle. C. Ensure the skin of the hands does not touch the outside surface of the glove. D. Use hand sanitizer on the surface of the gloves prior to glove removal.

C

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. A. Ask the client, "When was the last time you ate?" B. Apply oxygen and wait several minutes for the weakness to pass. C. Firmly grasp the client's gait belt. D. Support the client's body against the nurse and gently slide the client onto the floor. E. Ask the client to lean against the wall while the nurse obtains a wheelchair.

C, D

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? A. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. B. Permit the client to remove the stockings indefinitely and speak to the health care provider about the necessity of having the client wear them. C. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. D. Tell the client he can remove them for 20 or 30 minutes during this shift.

D

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? A. Every 20 to 30 minutes B. Every 3 to 4 hours C. Every 45 minutes to 1 hour D. Every 1 to 2 hours

D

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? A. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. B. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. C. Don a second pair of sterile gloves over the first pair. D. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

D

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? A. The student rolls gloves into each other during removal for disposal in the waste can. B. The student uses one gloved hand to grab the outside surface of the other glove. C. The student reaches under the glove on one hand to peel the glove off of the other hand. D. The student pulls the gloves off starting with the fingertips prior to removal.

D

When removing soiled gloves, which action should the nurse take? A. Grab the gloved dominant hand at the wrist using the fingers of the non-dominant hand to invert the glove. B. Pull on the fingertips of the gloved non-dominant hand using the fingers of the gloved dominant hand. C. Slide the fingers of the gloved non-dominant hand between the skin and glove of the dominant hand. D. Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside.

D

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. A. Around the upper and lower aspects of the foot B. Around the widest part of the thigh C. From the bottom of the heel to the gluteal fold D. Around the widest part of the calf E. From the toes to the mid-calf F. From the bottom of the heel to the back of the knee

D, F