NCLEX basic care and comfort

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

"Apply ice packs for the first 24 to 48 hours, then apply heat packs."; The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing.

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply.

"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain." "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the spouse speaking for the client and finishing the client's sentences?

"Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse."

The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full-strength formula with water? Record your answer as a whole number.

375

The nurse is caring for a client who has a prescription for antiembolism stockings. The client is confused and begins kicking at the nurse during the measurement of the client's legs. What is the next action by the nurse?

Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings.

The parent of a child with autism tells the nurse that her child is only sleeping 2 to 3 hours per night. When educating the parent about treatment for the child's sleep disturbance, the nurse should include what information?

Behavioral interventions including sleep-hygiene measures are often effective in treating sleep disturbance.

The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What interventions will the nurse include in the client's plan of care? Select all that apply.

Change tubing and bag every 24 hours. Ensure patency of the tube prior to enteral feedings; The PEG tube should be flushed in between every feeding and access. Formula should not hang longer than 4 to 8 hours. Initial feedings should start out slowly, monitor client comfort, and change tubing/bag every 24 hours. Verification of patency prior to each feeding is essential to prevent aspiration.

A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first?

Inquire about the client's sleeping habits.

The nurse is teaching a pregnant client about exercises that may be helpful during pregnancy. Which points should the nurse include in the instruction? Select all that apply.

Pelvic rocking may help relieve lower back pain. Abdominal breathing lifts the abdominal wall off of the uterus. Kegel exercises help improve vaginal contractility and bladder control.

The nurse evaluates the client's understanding of nutritional modifications to manage hypertension. The nurse knows the teaching was successful when the client makes what statement?

"Limiting my salt intake to 2 grams per day will lower my blood pressure."

The nurse teaches the mother of a child newly diagnosed with insulin dependent diabetes about the principles of a healthy eating plan. Which statement by the mother indicates effective teaching?

"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device?

"The splint immobilizes the body part in a functional position."

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin

enhances protein synthesis.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough

Which intervention should the nurse suggest to a parent to relieve itching in a child with chicken pox?

oatmeal preparation baths; Calamine lotion can be also be used if there are no open lesions.

When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate which type of feeding?

oral electrolyte solution; When a child is ready to take fluids by mouth postoperatively, clear liquids are given initially. If clear liquids are tolerated, the concentration and amount of oral feedings are gradually increased. This means advancing to half-strength and then to full-strength formula while increasing the amount given with each feeding.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

vesicle

A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned?

vinegar

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client?

Raise the hips using trapeze.

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void; Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of returned fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency.

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?

abduction

A client has refused to take a shower since being admitted 4 days earlier and tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

accepting these fears and allowing the client to take a sponge bath

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.

bacon pepperoni pizza soft drinks cheese

A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. What is the nurse's best response?

"Let us try this until you can have acupuncture."

The nurse is assisting a healthcare provider with suturing an arm laceration on a school-age client. What relaxation strategy will the nurse instruct the client to use during this painful procedure?

"Take a deep breath, and blow out until I say to stop."

The nurse finds it difficult to relieve a client's pain satisfactorily. Which measure should the nurse take next when continuing efforts to promote comfort?

Increase the client's confidence in the nurse.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application.

In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery?

can persist for several months.

Parents of a 4-year-old child with acute leukemia ask a nurse to explain the concept of complementary therapy. The nurse should tell the parents that

complementary therapy is an alternative to conventional medical therapies; The nurse should tell the parents that complementary therapy is a form of alternative medicine. This type of therapy can include diet, exercise, herbal remedies, and prayer.

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?

current medications

After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching?

"I will eat two large meals daily with frequent protein snacks."; The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting.

A client with schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

Assist the client with feeding.

For a client with anorexia nervosa, which goal takes the highest priority?

The client will establish adequate daily nutritional intake.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that

clients with terminal cancer may develop tolerance to opioids.

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client:

verbalizes the importance of small, frequent feedings; Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action?

Elevate the ankle; Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury.

The client with type 1 diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." What is the best response by the nurse?

"A person with diabetes should monitor their eating of proteins, fats, and carbohydrates."

An anxious client is admitted for treatment of an exacerbation of irritable bowel disease. The client asks the nurse if biofeedback will help after reading about biofeedback online. What is the best response by the nurse?

"Biofeedback will help reduce stress."

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she makes which statement?

"I need to reduce my caloric intake to 1,200 calories a day."; Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating more frequent, smaller meals decreases heartburn resulting from the reflux of acidic secretions into the lower esophagus. Pregnant women need adequate hydration (fluids) and fiber to prevent constipation.

Which statement indicates that the client understands the home care of a colostomy?

"I should be able to establish a regular pattern of elimination with my colostomy."

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. The nurse knows that the client understands the management of the disorder when the client says

"I will eat five or six small meals each day and have some protein with each meal."

The nurse has taught a client with a history of chronic upper respiratory infections (URIs) about the appropriate use of Echinacea. Which client statement indicates that the nurse's teaching has been successful?

"I will use Echinacea as a tea several times a day."; Echinacea can be prepared as a cup of tea and used several times a day. All the other statements are incorrect as Echinacea can be used throughout the year as indicated, it cannot be a substitute for appropriate antibiotic use for a client with chronic URIs, and it should only be used up to 2 weeks as prolonged use is not advised.

A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch?

"I'll empty my pouch when it is about one-third full."; The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal.The client with an ileostomy must wear a pouch at all times to collect stool.The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time.A pouch can be worn for 3 to 7 days before being changed.

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which statement indicates the client's understanding of the nurse's instructions?

"I'll increase my intake of unrefined grains."; To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids.

A school-age child loses their appetite secondary to side effects of chemotherapy. What will the nurse teach the parents about nutritional choices for the child?

"Let your child eat any foods that appeal to them right now."

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask?

"What were you doing when the pain started?"

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an intravenous line with dextrose in 5% water infusing at 40 ml/hour and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters would the nurse calculate as urine? Record your answer as a whole number.

1180; During 8 hours, 1,600 ml of bladder irrigation has been infused (200 ml X 8 hour = 1,600 ml/8 hour). The nurse would subtract this amount from the total volume in the drainage bag to determine the urine output (2,780 ml - 1,600 ml = 1,180 ml).

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500

The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. What should the nurse do next?

Allow the client to rest for a few minutes, then re-assess; The client is experiencing activity intolerance which is common following the first ambulation following surgery. The nurse should allow the client to rest and continue to monitor vital signs. Since the client is not dizzy or in pain, the nurse should wait to see if the client recovers from ambulating and reports having pain prior to administering pain medication.

After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema?

Apply cold compresses to the area.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first?

Assess the pain using a pain scale and compare to the previous assessment.

A nurse is caring for a client with a hiatal hernia who states that abdominal and sternal pain occurs after eating and when lying down. Which instructions would the nurse recommend when teaching this client? Select all that apply.

Avoid constrictive clothing around the abdomen. Decrease intake of caffeine and spicy foods. Sleep in semi-Fowler's position. Maintain a normal body weight.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently; These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.

A client with pneumonia has a temperature of 102.6° F (39.2° C), is diaphoretic, and has a productive cough. The client is able to ambulate. What should the nurse do?

Change the bed sheets frequently.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?

Change the tube feeding administration set at least every 24 hours; The nurse should change tube feeding administration sets at least every 24 hours. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings.

A client is admitted to the hospital with an exacerbation of chronic gastritis. What recommendation should the nurse make when evaluating the client's nutritional status?

Consume yogurt with probiotics daily; Factors that have been associated with reduced risk of gastritis or ulcer disease include probiotics (e.g., Lactobacillus caseii), which interfere with H pylori adhesion to epithelial cells, attenuate H pylori-induced gastritis, and inhibit growth of H pylori in humans. Increasing soluble fiber (oats, legumes, barley, certain fruits, and vegetables) has been found beneficial. Fiber in the form of wheat bran has no effect. Alcohol should be eliminated from the diet. Coffee, both caffeinated and decaffeinated, aggravate gastritis by stimulating acid production.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Deficient fluid volume

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse?

Discontinue the graduated compression stockings and notify the healthcare provider; When a client has prescribed graduated compression stockings, the nurse would remove the stockings and inspect the skin at least every 8 hours. If the client has discoloration, markings, or blisters on the heel, the nurse would discontinue the stockings and notify the healthcare provider because sequential compression devices may be used instead to prevent deep vein thrombosis. Reapplying the stockings may cause further damage to the heel, therefore the healthcare provider should be notified before making a referral to the skin care team.

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply.

Eat a low-purine diet. Limit alcohol intake; Gout is characterized by an abnormal metabolism of uric acid. Individuals either produce too much uric acid or their body is unable to metabolize and excrete it. Purines are metabolized into uric acid. The client who suffers from gout would be placed on a low-purine diet with foods such as peanut butter, cherries, rice, pasta, fruits, and vegetables. Fluids and sodium do not have to be limited. Alcohol intake would be limited as it is thought to trigger an exacerbation.

The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate?

Eat a soft, bland diet.

During a visit to the clinic, a pregnant 25-year-old woman who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?

Eat at least four pieces of fruit daily; Dietary measures such as increasing dietary intake of bulk and roughage (e.g., eating at least four pieces of fruit each day) help to relieve constipation and should be suggested initially. Other nonpharmacologic measures include drinking a glass of hot fluid in the morning, increasing fluid intake, and exercising regularly.It is best not to suggest laxatives or suppositories because a client may become dependent on them. Additionally, the client should avoid taking any medication unless directed to do so by the primary care provider. If the constipation is unrelieved by other nonpharmacologic measures, the primary care provider may prescribe glycerin suppositories.

A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse use to assess the pain?

FACES Pain Rating Scale; The nurse should use the FACES pain rating scale for children age 3 or older. The visual analog and numerical scales are used preferred with adults or older children who count well. The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate for very small children or nonverbal children.

A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively?

Help the client assume a more comfortable position.

A client is prescribed a bisacodyl suppository. When administering the suppository, the nurse will include what actions?

Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter; The nurse should advance a rectal suppository far enough into the rectum to pass the internal anal sphincter. The client should lie on the left side in Sim's position and should be directed to attempt to hold the suppository in the rectum for at least 20 minutes. This way the nurse ensures the suppository comes in contact with mucous membranes for better absorption of the medication rather than having it in the stool.

An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do?

Make the bed with the bedsheet on top of the pressure mattress; To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate?

Offer the client frequent oral hygiene care.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed; A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown.

For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply.

Pneumatic compression devices may be used with graduated compression stockings or alone to apply sequential pressure to the legs to enhance blood flow and venous return. They require a prescriber's order and are usually prescribed for high-risk surgical clients, clients with decreased mobility, and those at risk for deep vein disorders. Clients with extended low anterior resection and coronary artery bypass graft would be surgical clients at high risk for deep vein thrombosis. The client in the intensive care unit on a ventilator with sepsis has decreased mobility and is also at risk for deep vein thrombosis. Same-day procedures such as endoscopy and laparoscopy would not be considered high risk for deep vein disorders and would not require pneumatic compression devices.

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?

Promote arterial and venous circulation.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs?

Provide client with assistance in hygiene, grooming, and dressing.

A client on heparin for a deep vein thrombosis reports an aching pain in the back and finds it difficult to get comfortable when lying in that position. The client refuses to take any medications for pain. What actions would the nurse take to alleviate the back pain?

Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain.

A 12-year-old has a fractured femur and is immobilized in traction as shown in the figure. What should the nurse do?

Provide opportunities for age-appropriate activities.

A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply.

Provide small, frequent meals. Encourage the client to keep a journal. Monitor weight gain.

While caring for a client who's immobile, a nurse documents this information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?

Risk for impaired skin integrity related to immobility

The nurse is assisting a client diagnosed with dementia during meal time. Which nursing would best prevent complications?

Serve one course at a time with the appropriate utensil.

A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding the application of the complementary oil?

Tea tree oil has antibacterial properties; Tea tree oil is an alternative therapy that has antifungal and antibacterial uses. Clients use it to treat burns, insect bites, irritated skin, and acne. The nurse should review the prescriber's instructions with the client and also call the prescriber to report the tea tree oil application on the surgical site.

The client is discussing the client's medication history with the nurse. During the discussion, the client pulls out a list of the prescribed medications, which include fish oil and St. John's Wort. What is the nurse's understanding of why these alternative therapies are used by the client?

The client has a history of depression.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure?

The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure?

The student nurse irrigates the NG tube through the blue air vent port; The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do?

Turn the client every 1 to 2 hours.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation.

A pediatric client has just had a plaster cast placed on his lower left leg. Which action should the nurse take to provide safe cast care?

Use only the palms of the hand when handling the cast; The wet plaster cast should be handled using only the palms of the hands to prevent indentations of the cast surface.

A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request?

Use the Faces Pain Scale to assess the child's degree of pain.

The nurse is instructing a client about skin care while receiving radiation therapy to the chest. What should the nurse instruct the client to do?

Wash the area with tepid water and mild soap.

Which client requires increased sensory stimulation to prevent sensory deprivation?

a 65-year-old client who has employment-induced presbycusis and advanced glaucoma; There is more risk of sensory deprivation when the primary senses are impaired. This client is most at risk for sensory deprivation because of two sensory deficits: hearing and vision.

A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis?

a low-protein diet with a prescribed amount of water; Although dialysis removes water, creatinine, and urea from the blood, the client's diet must still be monitored. A high-protein diet is not recommended for renal clients. Eating too much protein may cause urea to build up more quickly. Water intake must be monitored, so unlimited water is not a correct choice. The client would be on a no-salt-added diet.

Two days after surgery to amputate their left lower leg, a client states that they have pain in the missing extremity. Which action by the nurse is most appropriate?

administer medication, as ordered, for the reported discomfort.

The nurse is teaching a client with a peptic ulcer about the diet that should be followed after discharge. What types of food should the nurse suggest the client include in the diet?

any foods that are tolerated

A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order? Select all that apply.

apple juice broth tea; A clear liquid diet includes foods that are clear (that you can see through) and are liquid at room temperature.

A 7-year-old client is prescribed a clear liquid diet by the healthcare provider after tonsillectomy. What nutrition will the nurse give the child? Select all that apply.

apple juice lime gelatin chicken broth

After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching?

application of powder to the skin under the cast; Powder should not be applied to the skin beneath the cast because powder can cause irritation and skin breakdown.

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

assessing the extremity for neurovascular integrity

To prevent back injury, the nurse should instruct the client to:

avoid prolonged sitting and standing.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for

diaphoresis, vomiting, and diarrhea; The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

Two days after a herniorrhaphy, the client reports that his scrotum is swollen and painful. To promote comfort, the nurse should instruct the client to:

elevate the scrotum and place ice bags on the area intermittently.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest?

football hold

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on how much time the client spends in bed during the day.

When assessing a child for impetigo, the nurse expects which assessment findings?

honey-colored, crusted lesions

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute?

keeping extraneous noise to a minimum; A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?

lean meats and low-fat milk

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume?

leaning forward while sitting; The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position?

left lateral; The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease?

low sodium; A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate?

low-protein, low-sodium, low-potassium; Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's

lower foot; An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return.

Which action is most important for the nurse to perform post procedure in a client with impaired renal function who is scheduled for a multidetector-computed tomography (MDCT) to evaluate peripheral circulation?

monitoring strict intake and output; Clients with impaired renal function scheduled for MDCT should be monitored closely after the procedure for urine output of at least 0.5 mmL/kg/hr because they are at risk for contrast-induced nephropathy. Before the procedure, there may be an indication for IV fluids and sodium bicarbonate to alkalinize urine and protect against free radical damage. Allergies should also be assessed prior to the procedure and treated with steroids and/or histamine blockers if necessary

A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity?

potato chips and chocolate milk shakes; A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues.

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?

prevent the development of ketosis; High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown.

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking gingko biloba to help manage her blood sugars. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication?

prolonged bleeding; Gingko biloba is an herbal supplement commonly taken to improve memory or improve glycemic control. It has known antiplatelet effects and can put surgical clients at risk for bleeding. Gingko's primary medication interaction relates to its potential to enhance the effects of other anticoagulants and lead to prolonged bleeding.

When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate?

prone with hips in abduction; Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler's position, even though the chest and abdomen are elevated.

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

shearing forces; To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

A client has been positioned in the lithotomy position under general anesthesia for a pelvic procedure. In which anatomic area may the client expect to experience postoperative discomfort?

shoulders

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is

skin traction applied to a lower extremity, with the extremity suspended above the bed; Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

The nurse is caring for an older adult who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which type of chair?

straight-back chair with elevated seat

Sudoriferous glands secrete which type of substance?

sweat