Passpoint questions

A client has bursitis in the subacromial bursa. A nurse determines that the client understands teaching when the client makes which statement? apply moist heat to the shoulder for 20 minutes place an ice pack on the shoulder for 20 minutes lift weights practice circular exercises

Moist heat is a nonpharmacologic pain management strategy that may alleviate pain and reduce the dose of analgesic, if required. Heat dilates blood vessels and decreases inflammation. Lifting and circular exercises will aggravate the already inflamed joint. Cold constricts blood vessels.

Following nasal surgery, the client has packing in the nose. The nurse should: instill nasal drops examine nares for ulceration perform frequent mouth care monitor the patient for elevated temperature q4hr

Mouth breathing dries the oral mucous membranes. Frequent mouth care is necessary for comfort and to combat the anorexia associated with the taste of blood and loss of the sense of smell. Checking the nares for ulcerations and monitoring the temperature every 4 hours are not necessary. Nose drops are not instilled with packing in place.

In evaluating a client's response to nutrition therapy which laboratory test would be of highest priority to examine? pottasium lymphocyte count CBC albumin level

Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge their nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? a small amount of yellow drainage at the left pin insertion site crust formation at pin site redness at the insertion site pain at the insertion site

The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A child has chickenpox. The parent asks how to care for the lesions. What should the nurse tell the parent? take an antihistamine and use calamine lotion on the lesions soak in a hot tub for 30 minutes 3 times/day remove crusts take acetaminophen

Use of an antihistamine and calamine lotion are recommended to help decrease the itching. The child can have a bath in cool water, but soaking in a hot tub will dry out the skin. Use of oatmeal baths helps decrease itching. Acetaminophen should be used only if the child has a fever. Antibiotic ointment may be used if lesions are infected. The father should only remove loose crusts that rub and irritate the child.

Why does the nurse plan to use both hands to assess the client's fundus in the immediate postpartum period? promote uterine involution promote uterine inversion hasten the puerperium period. determine fundus size

Using both hands to assess the fundus is useful for the prevention of uterine inversion. With one hand, the nurse should support the position of the lower uterus and cervix, while palpating the fundus with the other hand. Using both hands does not hasten or promote uterine involution, which lasts about 6 weeks from the time of childbirth. Using both hands to assess the fundus will not hasten the puerperium period. Determining the size of the fundus may be important if the client is experiencing excessive lochia because an enlarged fundus may be an indicator of retained blood clots or placenta fragments. The nurse, though, does not need to use both hands to determine this.

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? initiate a consult with a psychologist contact the physician administer medication as ordered

administer medication as ordered The sensation of pain and discomfort in an amputated extremity is known as phantom pain. Phantom pain is a normal occurrence after an amputation. It should be treated with medication. The nurse doesn't need to contact the physician at this time. Consultation with the psychologist isn't indicated, and the nurse shouldn't take this action without consulting the physician.

A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged I.V. pole. The nurse then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow?

evaluating patency of the drainage lumen The nurse should evaluate patency of the drainage tubing before leaving the client's room. If the lumen is obstructed, the solution infuses into the bladder but isn't eliminated through the drainage tubing, a situation that may cause client injury. Balancing the pole is important; however, the nurse would have had to address this issue immediately after hanging the 2 L bag. Using an I.V. pump isn't necessary for continuous bladder irrigation. Unless specifically ordered, obtaining a urine specimen before beginning continuous bladder irrigation isn't necessary.

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? semi fowler left lateral supine right lateral

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 right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene? using cotton swabs unirritating mouth wash toothbrush applying petroleum jelly to the lips

tooth brush The oral mucous membranes are easily damaged and are commonly ulcerated in the client with leukemia. It is better to provide oral hygiene without using a toothbrush, which can easily damage sensitive oral mucosa. Applying petroleum jelly to the lips, swabbing the mouth with moistened cotton swabs, and rinsing the mouth with a nonirritating mouthwash are appropriate oral care measures for a child with leukemia.