NCLEX PASSPOINT NUR 221 Basic Care and Comfort

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." Explanation: Having the child take a deep breath and blow it out is a form of distraction and will help the child cope better with the procedure. A child may prefer to keep the eyes open, not shut, during a procedure to see what is happening and anticipate what will happen next. Letting a child scream into a pillow can interfere with breathing, so it is not safe practice. When preparing a child for a procedure, the nurse should avoid using descriptors that mention or suggest pain. For example, the nurse might say, "Sometimes this feels like pushing or sticking, and sometimes it doesn't bother children at all."

The nurse is developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis acute pain related to perineal sutures? Select all that apply.

Administer sitz baths three to four times per day. Encourage the client to do Kegel exercises. Explanation: Sitz baths help decrease inflammation and tension in the perineal area. Kegel exercises improve circulation to the area and help reduce edema. Ice packs should be applied to the perineum for only the first 24 hours; after that time, heat should be used. Topical pain gels should be applied to the suture area to reduce discomfort, as ordered. The perineal pad should be changed frequently to prevent irritation caused by the discharge.

A client had abdominal surgery 2 days ago and has copious drainage. The nurse uses Montgomery straps when changing the dressing. Which is the expected outcome of using these straps?

Avoid skin breakdown. Explanation: While the client has copious drainage and requires frequent dressing changes, the nurse uses Montgomery straps to avoid removing the tape that is holding the dressing in place and thus preventing skin breakdown. The straps are not used to provide pressure on the incision and will not help prevent dehiscence. The straps are secured on the abdomen and would not prevent the client from touching the incision.

A client with a terminal illness dies. What is the nurse's responsibility after the client's death? Select all that apply.

Care for the family. Care for the client's body. Adhere to legal responsibilities. Explanation: When a client dies, the nurse's responsibility includes caring for the client's body, the client's family, and adhering to legal responsibilities. The family decides which spiritual support to notify if desired. There is no reason for other assigned clients to be reassigned to different care providers after the death of a client.

The family of a client who was receiving hospice care contacts the facility every week to talk with the nurse who was the client's primary caregiver. What action should be taken to support the family?

Contact the hospice agency to provide grief support for the family. Explanation: If the client was cared for by hospice, the family should be provided grief support for up to a year following the death of the client. The family may require more support than a visit from the nurse. Everyone grieves in one's own way. Suggesting the family engage with work and leisure activities does not take the family's need to grieve and mourn into consideration. Having the family come to the facility to see the primary nurse caregiver may not be sufficient for the family's needs. The best action is for the hospice agency to provide grief support.

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. Explanation: Experience has demonstrated that clients who feel confidence in the persons who are caring for them do not require as much therapy for pain relief as those who have less confidence. Without the client's confidence, developed in an effective nurse-client relationship, other interventions may be less effective. The client's family can be an important source of support, but it is the nurse who plans strategies for pain relief. The client may require time to adjust to the pain, but the nurse and client can collaborate to try to evaluate a variety of pain relief strategies. Arranging for the client to share a room with another client who has little pain may have negative effects on the client who has pain that is difficult to relieve.

The nurse is measuring a client for thigh high antiembolism stockings. The client's thigh measurements are outside the guidelines for available sizes. What is the next action by the nurse?

Notify the provider. Explanation: If a client's thigh measurements are outside the guidelines for available thigh high antiembolism stockings, the nurse should notify the provider. The client may require custom fitted stockings or some other option for deep vein thrombosis prevention. Improperly fitted stockings are uncomfortable and may cause the client harm, therefore the nurse would not place the next size available or stockings based on the calf measurement. The nurse would not place knee high antiembolism stockings as this would require a provider's order.

A client will be undergoing a lengthy surgery. What precautions should the nurse take to avoid the potential for skin breakdown? Select all that apply.

Pad shoulder braces when in Trendelenburg position. Apply bed straps as needed for proper positioning of limbs. Place grounding pad underneath the client. Explanation: The client undergoing surgery needs protection of the skin to prevent potential skin breakdown. The client needs to have shoulder braces padded in Trendelenburg position to prevent excess pressure, and limbs positioned properly to avoid excess pressure. Placing a grounding pad will help prevent electrical burns. Client draping and temperature monitoring will help decrease the potential for hypothermia, which is another concern intraoperatively with clients, but this does not directly lead to skin breakdown for clients.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg. Explanation: First, perform hand hygiene. Next, secure a gait belt around client's waist. Then, place the cane in the client's right hand, because the right side is the unaffected side. Have the client advance the cane and the left leg about 4 to 8 inches (10 to 20 cm). Finally, have the client advance the right leg the same distance.

A client has a plaster cast applied to the lower extremity that is still wet to touch. In which way should the nurse move the casted limb to elevate it on a pillow?

Place the palms on both sides of the cast. Explanation: When moving a client with a wet plaster cast, only the palms of the hands should be used so that indentations in the cast from the fingers may be prevented. Indentations can result in areas of pressure on the skin. The limb should be supported at both the ankle and the knee because a plaster cast is heavy when wet.

The nurse is caring for a client who is deceased. Which activity should the nurse complete after the client's death? Select all that apply.

Replace soiled dressings. Handle tubes according to facility policy. Place the body in normal anatomic position. Explanation: After a client is pronounced dead, the body should be placed in normal anatomic position. This is done to prevent pooling of blood. Soiled dressings should be replaced. Any tubes should be handled according to the facility's policies and expectations. The body is not necessarily washed because the mortician normally performs this function. In some cultures, the family washes the body. There is no reason to change the dressings on the intravenous lines.

A nurse is caring for a client diagnosed with acute kidney injury with an indwelling urinary catheter. The nurse notes that the total urine output for the previous 24 hours is 35 ml. What action should the nurse perform first?

Scan the client's bladder to determine if residual volumes are present. Explanation: The client with acute kidney injury can potentially progress to anuria (urine output less than 50 ml/24 hr), which can be an indication for beginning hemodialysis. The healthcare provider will also consider the client's kidney function test results when making this decision. However, the nurse should first check the accuracy of the measured output by performing a bladder scan for residual volume that can confirm if the catheter is occluded or if anuria is indeed present. Only once anuria is confirmed should the nurse notify the healthcare provider and then take actions based on the prescribed interventions.

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. Explanation: The wet plaster cast should be handled using only the palms of the hands to prevent indentations of the cast surface. Petaling a cast should be done only when the edges of the cast are rough and are causing irritation to the client's skin. The nurse should not keep the child in the same position until the cast is dry. Doing so would prohibit proper toileting and elimination and would produce undue pressure on the coccyx. The cast typically emits heat as it dries, so notifying a health care provider (HCP) is not necessary in this instance. If needed, a fan can be used to circulate the room air.

A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply.

Weigh the client daily. Measure urine specific gravity. Monitor intake and output. Explanation: The pituitary gland is divided into the anterior and posterior sections with each section secreting specific hormones. Tumors of the posterior pituitary gland can lead to diabetes insipidus because of deficiency of vasopressin, also called antidiuretic hormone (ADH). Decreased ADH reduces the kidneys' ability to concentrate urine, resulting in excessive urination, thirst, and fluid intake. To monitor fluid balance, the nurse would weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse would also encourage fluids to keep intake equal to output and prevent dehydration. The posterior pituitary does not have food or caloric implications; thus, a calorie-restricted diet is not needed.

Which food would be appropriate for a 12-month-old child with celiac disease?

rice cereal Explanation: The child with celiac disease should not eat foods containing wheat, oats, rye, or barley. Pancakes and waffles are made from flour that typically is derived from wheat and therefore should be avoided. Foods containing rice, such as rice cereal, or corn are appropriate. Pancakes and waffles are made from flour that typically is derived from wheat and therefore should be avoided.

Which meal would be appropriate for the child with osteomyelitis to choose?

beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk Explanation: Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients.

The nurse should take action when a healthy 3-month-old infant is:

being fed formula that isn't mixed according to the manufacturer's instructions. Explanation: Incorrectly mixed formula can cause an infant to develop severe electrolyte and nutrition imbalances. This safety hazard necessitates immediate attention. Placing a 3-month-old infant in a rear-facing car seat is appropriate. Although an infant sleeping in a cardboard box on the floor may be a concern, it isn't an immediate safety hazard. An infant being put to sleep with a pacifier isn't a safety concern.

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

enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

What should the nurse recognize as the first sign of peripheral arterial disease (PAD) in inactive older adults?

gangrene Explanation: In older adults who are inactive, limb ischemia or gangrene may be the first sign of PAD because these clients manage their lifestyle by adjusting for limitations imposed by comorbidity; therefore, not walking far enough to develop the pain of claudication. Even though diminished pulses and dry, shiny skin may be present, this is not apparent until trauma occurs and gangrene develops.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include

ground beef patties. Explanation: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to:

offer finger foods and sandwiches. Explanation: Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for large meals. Providing a stimulating mealtime environment is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Letting the client choose some favorite foods is inappropriate because the client has a short attention span and has trouble making choices.

A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority?

pain Explanation: The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness.

The nurse has delegated providing postmortem care of an Asian adult man to an unlicensed assistive personnel (UAP). The family does not wish to have an autopsy but is considering organ donation. Which instructions should the nurse give to the UAP who will provide postmortem care for this client? Select all that apply.

The family may remain with the client for 8 hours after death. Ask the client's family if they have any requests for how to prepare the body. Elevate the head of the bed as soon as possible. Check two identifiers before starting postmortem care. Inquire about the family's preference for shaving the client's beard. Explanation: In the Asian culture, family may wish to remain with the body for 8 hours after a family member's death. Before shaving a client's beard, the nurse should always check with the family or in the chart for the client and family's preference and verify the hospital's policy about shaving the head. The nurse should consult with the family about any preparation requests such as wearing special clothing or jewelry. The nurse should always use two identifiers before providing care. It is important to elevate the head of the bed to prevent pooling of blood and discoloration from pooling blood. In the case of a potential organ donation, indwelling lines should not be removed.