NCLEX - Basic Physical Care
Which task can the licensed practical nurse (LPN) appropriately delegate to the nursing assistant?
4. Encouraging a client to drink fluids
When leaving the room of a client in isolation, the nurse should remove which protective equipment first?
4. Gloves
The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra?
1. 2" (5 cm)
The licensed practical nurse is admitting a client to the medical-surgical floor. She asks the client if he has an advance directive. The client responds by saying, "I don't know what you mean." How should the nurse respond?
1. "An advance directive is a document that states your wishes about health care."
The nurse can document that her client's bowel sounds are absent after listening for how long in each quadrant?
1. 5 minutes
A nurse evaluates learning in a client who's scheduled for discharge. Which client behavior best demonstrates effective discharge teaching?
1. Exhibiting a positive change in behavior
A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique?
1. Figure-eight
The nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. To prevent contamination of the specimen, the nurse should:
1. aspirate urine from the tubing port, using a sterile syringe and needle.
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care?
2. Placing the client in isolation and using airborne precautions
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?
1. Assessing and controlling pain
A client is admitted with diarrhea and dehydration. A stool culture shows Clostridium difficile. The nurse should institute which isolation precaution for this client?
1. Contact
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 findings indicate which nursing diagnosis?
1. Impaired urinary elimination
A client with a fecal impaction typically exhibits which clinical manifestation?
1. Liquid or semiliquid stools
The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair?
1. Parallel to the bed on the right side
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
1. Primary prevention
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the plan of care?
1. Putting on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA) respirator when entering the client's room
A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention would help meet this goal?
1. Repositioning the client every 2 hours
Several residents in a long-term care facility ask the nurse if they can share their aromatherapy with other clients in the dining area. Why shouldn't the nurse permit them to practice aromatherapy in the group environment?
1. Some residents may have an adverse sensitivity to the oils and fragrances.
The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days after discharge. Which client action indicates an accurate understanding of the technique?
1. The client takes slow, deep breaths to elevate the spirometer ball.
When moving a client in bed, the nurse can ensure proper body mechanics by:
1. standing with the feet apart.
A client with severe pain is prescribed hydromorphone (Dilaudid) 10 mg by mouth every 4 hours as needed for pain. The client rates his pain as eight on a one-to-ten scale, so the nurse prepares to administer a dose. The oral liquid contained in the unit's opioid stock contains 5 mg/5 ml. How many milliliters of solution should the nurse give to the client?
10
The nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for laboratory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1/2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinated coffee, tuna fish sandwich, 1/2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz of 1% milk, 16 oz of water Output: 1,300 ml of urine How many milliliters should the nurse document as the client's intake?
1380
The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching?
2. "Hold the cane on the opposite side from the injury."
While preparing a client for a diagnostic study of the colon, the nurse teaches him how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?
2. "I will administer the enema while lying on my left side with my right knee flexed."
Which intervention should the nurse use when administering oxygen by face mask to a client?
2. Assist the client to the semi-Fowler position if possible.
When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?
2. Avoid wearing canvas shoes.
The physician orders chest physiotherapy for a client with respiratory congestion. When should the nurse plan to perform chest physiotherapy?
2. Before meals
A client is prescribed acetaminophen (Tylenol) by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order?
2. Cirrhosis
The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client?
2. Face rating scale
The nurse is caring for a client who was admitted with a stroke. The client has left-sided paralysis. How should the nurse document this finding?
2. Hemiplegia
The nurse is caring for a client with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?
2. Monitor the appearance, size, and number of stools.
When checking a client's incision 1 day after surgery, the nurse expects to see which finding as a sign of a local inflammatory response?
2. Redness and warmth
A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status?
2. Weighing the client at the same time each day
The physician orders a clear-liquid diet for a client. The nurse understands that this client's diet may include:
2. apple juice, chicken broth, and gelatin.
A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include:
2. ground beef patties.
Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately?
3. Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute
The nurse is caring for a dying client who's receiving comfort measures. Which intervention by the nurse is most effective in promoting comfort?
3. Combing the client's hair
A client complains of dyspnea. To help alleviate this problem, the nurse should place the client in which position?
3. Fowler's
While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?
3. Moist sterile saline gauze
A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should:
3. abide by the wishes of the sister who is the durable power of attorney agent.
The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by:
3. checking and taping all connections.
A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should:
3. encourage increased fluid intake.
The nurse is caring for a client with a fractured hip. The client becomes combative, confused, and tries to get out of bed. His vital signs and pulse oximetry results are unchanged. The nurse should:
3. notify the nursing supervisor to see if a staff member can sit with the client.
The nurse is collecting admission data from a newly admitted client. Which question should the nurse include when asking the client about orthopnea?
4. "How many pillows do you use?"
For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the data collection?
4. "Is the pain worse when your toes are pointed toward your knee?"
A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse is collecting data and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time?
4. Checking vital signs and looking for nonverbal indications of pain
Which group of clients is at increased risk for developing a wound infection?
4. Clients who are undernourished
The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse plan to emphasize?
4. Lean meats and low-fat milk
The nurse is caring for a client who has a history of falling at home. Which intervention by the nurse reduces the risk of falling while the client is hospitalized?
4. Placing the call bell close to the client and reminding him to call for assistance with ambulation
Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
4. Side-lying
During data collection, the nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?
4. Tachypnea
The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require:
4. a chest X-ray.
During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
4. bleach.
The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:
4. enhances collagen formation.
Which nursing action is essential when providing continuous enteral feeding?
1. Elevating the head of the bed at least 30 degrees
When preparing a client for bronchoscopy, the nurse should instruct the client to avoid:
4. eating
The nurse is caring for an unconscious client who suffered a stroke 4 days ago. When providing oral hygiene for this client, the nurse must take which essential action?
4. Placing the client in a side-lying position
The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
1. Baked beans, hamburger, and milk
To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?
1. By swabbing the labia minora from front to back
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?
2. Teaching the client how to deep-breathe and cough
Which of the following is an example of a primary preventive measure?
4. Avoiding overexposure to the sun
The physician has ordered a wet-to-dry dressing containing normal saline solution for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to accomplish which action?
2. Debriding the wound
Which procedure or practice requires surgical asepsis?
3. Postoperative dressing changes
A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply:
1. Contact 3. Standard
The nurse notes that a client coughs frequently while eating. Which health team member should be notified of this finding?
2. Speech therapist
The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.), 60 ml (9 a.m.). Based on these amounts, what should the nurse do?
1. Continue to monitor and record hourly urine output.
The licensed practical nurse removes a client's nasogastric (NG) tube according to the physician's order. The nurse should watch for which complication after removing an NG tube?
1. Abdominal distention
Which data collection finding by the nurse contraindicates the application of an aquathermic heating pad?
1. Active bleeding
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply:
1. Administration time of the last dose 2. Client's pain level on a scale of 1 to 10 3. Type of medication the client has been taking 4. Client's reaction to the previous dose 6. Effectiveness of prior dose of medication
The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding of the counseling?
1. "My son can't eat wheat, rye, oats, or barley."
The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:
1. foot.
The nurse is caring for a geriatric client with a history of falls. While evaluating the client's risk of fall, the nurse should collect:
1. gait and balance information.
To check the effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:
1. oxygen saturation.
When changing a sterile surgical dressing, the nurse must first:
1. wash her hands.
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?
2. The client cleans around the incision site, using gauze squares moistened with normal saline.
Nursing care for a client includes removing elastic stockings at least once per day. What is the rationale for this intervention?
2. To observe the lower extremities
When following standard precautions, the nurse's primary responsibility is to:
2. consider all body substances potentially infectious.
A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure that the client is placed:
4. on contact isolation.
A client who underwent surgery had the following intake on the day of surgery: Day shift: 500 ml packed blood cells; 236 ml platelets; 750 ml normal saline solution; 1 L dextrose 5% in normal saline solution Evening shift: 250 ml normal saline solution; 1 L dextrose 5% in normal saline solution Night shift: 1 L dextrose 5% in normal saline solution. How many milliliters of solution should the nurse document as the client's 24-hour intake?
4736
Standard precautions dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?
1. Frequent hand washing reduces transmission of pathogens from one client to another.
A licensed practical nurse (LPN) hears the facility code that indicates an infant has been abducted from the nursery. Which action should the LPN take?
3. Report to an exit and be alert for anyone carrying packages.
Which client requires further data collection by the licensed practical nurse (LPN)?
4. The client who's restless
The nurse is performing her morning assessment when the client says, "I had trouble sleeping last night." Which action should the nurse take first?
2. Gathering more information about the sleep problem
When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action can the nurse institute independently?
2. Gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary
In a client who had major surgery 5 days ago, which data collection finding would be the best indication of a wound infection?
3. Purulent wound drainage
A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?
3. Referring the client to a home health nurse for follow-up visits
The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include?
1. Encourage a high-calorie, high-protein diet.
A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in his abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply:
1. Notifying the client's primary physician 2. Covering the wound with saline-soaked sterile gauze
A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the client's ankle for 30 minutes, which statement by the client suggests that ice application has been effective?
2. "My ankle looks less swollen now."
A client suddenly loses consciousness. What should the nurse do first?
2. Assess for responsiveness.
The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would:
2. remove the warm compress after 20 minutes for at least 15 minutes.
The physician prescribes acetaminophen (Tylenol) 650 mg by mouth every 4 hours for a client with a temperature of 102° F (38.8° C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 ml. How many milliliters of solution should the nurse administer?
20.3
The physician asks the nurse to join him to discuss palliative care options with a terminally ill client and his family. Which statement by the nurse indicates an understanding of palliative care?
4. "I'll assist with the client with his total needs."
A client who is minimally responsive requires suctioning to clear his airway secretions. Which finding best indicates that suctioning has been effective?
4. Clear breath sounds
The nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?
4. Dysuria
While evaluating the incision of a client who had surgery 2 weeks ago, the nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?
3. Do nothing because this is granulation tissue.
A client has a surgical wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?
3. In a circle, from the center outward
To follow standard precautions, the nurse should carry out which of the following measures?
3. Wearing gloves when administering I.M. medication
The nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:
3. in the morning, as soon as the client awakens.
The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
3. washing hands.
Which action would be contraindicated for a client who develops a temperature of 102° F (38.9° C).
4. Providing a low-calorie diet
When collecting data on a client with cellulitis of the right leg, which of the following would the nurse expect to find?
4. Red, swollen skin with inflammation spreading to surrounding tissues
The nurse is preparing to boost a client up in bed. She 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?
4. Shearing forces
A client admitted with dehydration has urinary incontinence and excoriation in the perineal area. Which action would be a priority?
1. Keeping the perineal area clean and dry
The nurse is informed by the secretary that her client will soon be returning from the postanesthesia care unit. What should the nurse do when preparing a surgical bed?
1. Leave the bed in the high position when finished
A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often?
2. Once per year
A client must undergo right thoracotomy for lung cancer. Which member of the health care team is responsible for obtaining informed consent from this client?
2. Physician
A 70-year-old client who's alert and oriented refuses to take his regularly scheduled medications. Which action should the licensed practical nurse (LPN) take?
3. Inform the physician; chart the medications as not given in the medication administration record, and document the reasons the client refused to take them.
The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection?
3. Red, warm, tender incision
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?
1. Clearing the client's airway
A 20-year-old male seeks care at a local emergency care center after spraining his ankle while playing football with his friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician? Select all that apply:
1. Initially apply cold. 2. Instruct the client to elevate the ankle for 48 to 72 hours. 3. Provide crutch gait training. 5. If needed, apply an elastic bandage from the toes to midcalf.
The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed?
1. Irrigate continuously until the solution becomes clear or all of the solution has been used.
The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?
2. Pouring solution directly onto a sterile field cloth
A client who's scheduled for open heart surgery in 2 days has been having circulation problems in his feet and legs, so the physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?
3. To reduce or prevent edema in the legs and feet
A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?
3. Use a bed cradle to keep linens off the joints.
A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should:
3. palpate the bladder above the symphysis pubis.
A client is placed in isolation. Client isolation techniques attempt to break the chain of infection by interfering with the:
3. transmission mode.
For healing by second intention, a client's wound has been packed with medicated dressings. When evaluating the wound, which finding indicates that healing is taking place?
4. Granulation tissue is forming at the wound edges.
To help minimize calcium loss from the bones of a hospitalized client, the nurse should:
2. encourage the client to walk in the hallway.
The nurse is teaching a group of nursing assistants in a long-term care facility about standard precautions. Which statement best describes standard precautions?
4. Wearing gloves, a face shield, and a gown when contact with body fluids is possible
A client with burns on his groin has developed blisters. As the client is bathing, a few blisters open. The best action for the nurse to take would be to:
4. clean the area with normal saline solution and cover it with a gauze dressing
The nurse is caring for a client with stomatitis. To make eating less painful, which foods should the nurse suggest?
2. Soft, bland foods
The licensed practical nurse (LPN) is caring for a group of clients on a medical-surgical floor. Which client should she attend to first?
1. A client whose lower leg is red and swollen
Which of the following clients would qualify for hospice care?
1. A client with late-stage acquired immunodeficiency syndrome (AIDS)
A teenage boy suffers a broken leg as a result of a car accident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse provides the client with instructions regarding cast care. Which instructions are appropriate? Select all that apply:
1. Support the wet cast with pillows until it dries. 6. Avoid putting straws or hangers inside the cast.
A client is unable to take a deep breath effectively and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client compliance with ambulation and deep breathing, the nurse should:
1. administer pain medication before having the client deep-breathe, cough, or get out of bed.
Many clients are brought to the emergency department after sustaining injuries in a building explosion. According to disaster management principles, which client should be triaged first?
2. A 62-year-old with tachypnea
A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply:
2. Assisting the client into Sims' position 3. Washing hands and putting on gloves 6. Encouraging the client to retain the solution for 5 to 15 minutes
Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance?
2. Breath sounds clear on auscultation
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
2. Decreasing the rate of feedings and the concentration of the formula
The nurse is caring for a client who practices reflexology. When collecting client data, the nurse notes that the client's ankles are edematous. Which intervention by the nurse supports the client's beliefs in reflexology and helps reduce edema?
2. Elevating the client's legs
When the nurse enters a client's room, she finds him slumped over in his chair. What actions should the nurse take? Rank in chronological order. Use all the options.
2. Establish unresponsiveness. 1. Activate resuscitation team. 4. Place the client on a firm surface. 6. Open the client's airway. 3. Check breathing; give two breaths if absent. 5. Check pulse; if absent begin compressions.
The physician enters an order into the computer for a client who underwent abdominal surgery 24 hours ago. The order states: "Get client out of bed to chair twice daily." Which action should the nurse take when she transfers the client to the chair?
2. Help the client sit up and dangle his legs over the side of the bed
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received appropriate skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
2. Inadequate protein intake
The nurse is caring for a client who sustained a chemical burn in his right eye. She is preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
2. Place absorbent pads in the area of the client's shoulder. 3. Wash hands and put on gloves. 5. Direct the solution onto the exposed conjunctival sac from the inner to outer canthus.
A female client who had pelvic surgery 2 weeks ago is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important?
2. Recent pelvic surgery
During discharge teaching, a client with a fractured toe asks the emergency department nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?
2. Relieves swelling by reducing blood flow to the injury site
A client who's scheduled for surgery asks the nurse to keep $50 for him until he returns from surgery. How should the nurse respond?
3. "I'll notify the business office to make arrangements for your money to be placed in the hospital safe."
Which assessment finding would be most supportive of the nursing diagnosis, Impaired skin integrity?
3. Area of skin with persistent redness
When preparing a client with a draining vertical incision for ambulation, where should the nurse apply reinforced dressings?
3. At the base of the wound
The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
3. By supplying a magic slate or similar device
A client has a soft wrist-safety device in place. Which data collection finding should the nurse consider abnormal?
3. Cool, pale fingers
The licensed practical nurse (LPN) instructs the nursing assistant to feed a client who has developed dysphagia after being admitted with a stroke. How should the nursing assistant position the client based on the LPN's instruction?
4. In bed with the head of the bed elevated to at least 45 degrees
An obese, malnourished client has undergone abdominal surgery. While ambulating on the 4th postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which of the following is the best initial action for the nurse to take?
4. Lift up the dressing to check the wound.
The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?
4. Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.
What is an appropriate nursing intervention for a client with a soft wrist restraint?
4. Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm
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?
4. Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client
Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance?
4. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.