Exam 2 Sims

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client?

Manipulation of the client's ear to straighten the auditory canal

. A nurse is placing a client in Fowler's position. What should she teach the family about this position?

"Do not raise the knees with the knee gatch."

A nurse is teaching an older adult at home about taking newly prescribed medications. Which information would be included?

"I have written the names of your drugs with times to take them."

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?

"Tell me about what you do to take care of your skin."

The mother of a child 2 years of age tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother?

"That is dangerous; you might puncture the eardrum."

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed?

Client restrictions

A physician has ordered peak and trough levels of a medication. When would the nurse schedule the trough level specimen?

30 minutes before the next dose

What would a nurse instruct a client to do after administration of a sublingual medication?

"Try not to swallow while the pill dissolves."

A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give?

1

The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3.

1, 5, 4, 2, 3, 6

A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which of the following is the most suitable angle when administering an intradermal injection?

10-degree angle

The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed?

45 to 60 degrees

Which client is most likely to require hospitalization related to problems associated with the feet?

A client with peripheral vascular disease

Which of the following clients receives a drug that requires parenteral route?

A woman who has been ordered intravenous antibiotics

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care?

Cleanse to remove secretions from less-soiled to more-soiled areas.

A nurse is assessing the activity level of an infant age 5 months. What normal findings would be assessed?

Ability to sit and head control

A client who is taking an oral narcotic for pain relief tells the nurse he is constipated. What is this common response to narcotics called?

Adverse effect

A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of which of the following?

Allergic reaction

A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which of the following instructions are stated on the label of a vial container?

Amount of diluent to be added

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?

Lying flat

A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process?

Apply cream to area to be shaved in a layer about 1/2-inch thick.

The nurse and nursing aid are providing perineal care for an incontinent client. What information is important for the nurse to consider when providing perineal care?

Apply moisture barriers to the skin of the perineal area.

A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order?

Ask the physician to write out the order.

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to do what?

Assess the client's safety

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart?

Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms."

Medications administered that are renal toxic should have frequent assessments of which blood values?

BUN and creatinine

A nurse is administering a liquid medication to an infant. Where will the nurse place the medication to prevent aspiration?

Between the gum and the cheek

A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty do immediately upon detection of the medication error?

Check the client's condition.

What does the nurse do to verify an order for a medication listed on a medication administration record (MAR)?

Compare it with the original physician's order.

Student nurses are turning a client in bed. In order to move the client to the edge of the bed, which positioning instruction is best to give the client when using the friction-reducing sheet?

Cross the arms across the chest and cross the legs.

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what?

Cut the nail straight across

Which clent would be at greatest risk for injury to the skin and mucous membranes?

Man 77 years of age with diabetes

A student nurse is administering medications through a nasogastric tube connected to continuous suction. How will the student do this accurately?

Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30 minutes.

A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle?

Do not recap the needle; place it in a puncture-resistant container.

A nurse is providing oral care to a client with dentures. What action would the nurse do first?

Don gloves.

Which client would be most at risk for alterations in oral health?

Man with a nasogastric tube

A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, and after) while preparing the medication for administration?

Ensures that the right medication is given at the right time by the right route

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

Every two hours

An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. Which of the following actions should the nurse perform first?

Explain to the client how the nurse will assist her.

A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly?

Face the direction of movement.

A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following?

Facilitates oil distribution

Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them.

False

The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate for the nurse to follow when administering a drug via this route?​

Flush the tube with water between each drug administered.

Which of the following is a correct guideline to follow when providing a bed bath for a client?

Fold the washcloth like a mitt on your hand so that there are no loose ends.

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth?

From the pubic area toward the anal area

A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges?

Gauges range from 18 to 30, with 18 being the largest.

Which of the following factors does not affect personal hygiene practices?

Gender

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following actions will be most effective to transfer the client safely into the chair?

Have the client sit on the side of the bed for several minutes before moving to the chair.

A physician has ordered that a medication be given "stat" for a client who is having an anaphylactic drug reaction. At what time would the nurse administer the medication?

Immediately after the order is noted

A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which of the following precautions should the nurse take when storing narcotic medications?

In a double-locked drawer

A client with allergy has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which of the following injection routes is most suitable for allergy testing?

Intradermal

While performing a physical examination on a client, the nurse observes that the client has scoliosis based on which of the following?

Lateral deviation of the thoracic spine

The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which of the following represent these five rights? Select all that apply.

Medication Client Dosage Route

A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care?

Middle-age woman with a Foley catheter

A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan?

Minimize stress on the wife's joints

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice?

No, douching removes normal bacteria.

The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate?

Obtain a mechanical lateral transfer device to move the client onto a stretcher.

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely affecting the client?

Orthostatic hypotension

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following?

Paralysis of the legs

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?

Partial care

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate?

Periodontitis

What is the name of the process by which a drug moves through the body and is eventually eliminated?

Pharmacokinetics

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do?

Wash hair daily

What function of the skeletal system is essential to proper function of all other cells and tissues?

Producing blood cells

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do?

Provide supplies and assist with hard-to-reach areas

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene?

Provide the client with an electric shaver.

A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which of the following nursing actions is most likely to promote safe handling of this client?

Provide to the client brief, clear instructions that are phrased positively.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which of the following actions is correct?

Remove the antiembolism stockings during the bath.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?

Return the client to the bed.

A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. Which of the following points should the nurse tell the client in order to avoid lipoatrophy and lipohypertrophy?

Rotate the site with each injection.

A physician writes an order for ampicillin 1 gram every 6 hours for a client. What is missing in this order?

Route

A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment?

Rubbing the ointment into the skin

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?

Sacrum

Which medication system allows for client independence?

Self-administered medication system

What type of bath is preferred to decrease the inflammation after rectal surgery?

Sitz bath

A homeless person uses the soap and towels in a public restroom to wash up. This is an example of which type of factor affecting personal hygiene practices?

Socioeconomic class

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?

Spreading feet shoulder-width apart to broaden the base of support

The nurse is preparing to move a patient up in bed with the assistance of another nurse. In what position would the nurse place the patient, if tolerated?

Supine

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 of the following initial actions by the nurse is appropriate?

Support the client's body against yours and gently slide the client onto the floor.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

The client's ability to assist

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made?

The head for nits on hair shafts

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

The nurse should gently slide the client down his or her body to the floor.

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect?

Therapeutic range

While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurses's best response?

They promote venous blood return to the heart.

A nurse is bunching the tissue of a client when administering a subcutaneous injection to that client. The nurse knows that which of the following is the reason for bunching when injecting subcutaneously?

To avoid instilling medication within the muscle

A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets

To prevent gastric irritation

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position?

To prevent hyperextension of the neck

Why is it important for the nurse to teach and role model proper body mechanics?

To promote health and prevent illness

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the patient. What is the rationale for using a transfer board in this procedure?

To reduce friction as the client is pulled laterally onto the stretcher.

A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs. What is the nurse's best choice of transfer equipment for this client who cannot bear weight on either leg?

Transfer chair

A clinic nurse is preparing for a tuberculosis screening. Knowing the injections will be administered intradermally, what size needles and syringes will the nurse prepare?

Tuberculin syringe, 1/2-inch 26-gauge needle

An older adult resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?

Use a nonsoap cleaning agent.

A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care?

Use an antifungal powder on the client's feet if necessary.

A nurse is conducting an interview for a health history. In addition to asking the client about medications being taken, what else should be asked to assess the risk for drug interactions?

Use of herbal supplements

The medical chart of a newly admitted client notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the client's wound culture and sensitivity. How should the nurse respond to this situation?

Withhold the medication until the potential drug allergy has been addressed by the care team.

Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device?

an alert client after knee replacement surgery who is being assisted to ambulate

Before a long-term care resident goes to sleep at night, his dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water?

to prevent drying and warping of plastic

The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle baby powder in the perineal area. Which of the following actions is correct?

inform the client that baby powder is not used because it may become a medium for bacterial growth.