PP Unit one basic comfort care
A client with diabetes is explaining to the nurse about doing foot care at home. Which statement indicates the client needs further instruction on how to care for the feet properly?
"I inspect my feet once a week for cuts and redness."
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."
The breastfeeding parent of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what they should do about feeding their infant. Which recommendation would be mostappropriate?
"Continue to breastfeed, but eliminate all milk products from your own diet."
A client has received dietary instructions as part of the treatment plan for diabetes type 1. Which statement by the client would alert the nurse of needing additional instructions?
"I can eat whatever I want as long as I cover the calories with sufficient insulin."
A client is resting in bed. The nurse visits the client to reassess the client's pain. The nurse notices that a visitor is in the room and is touching the client in various places on the client's body. The nurse understands that this type of practice is called:
therapeutic touch.
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 states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?
"What does the pain feel like?"
The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. What is the most appropriate goal for this client?
Gradually increase activity tolerance.
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."
The nurse is preparing to administer a continuous enteral feeding. Which action is mostimportant for the nurse to include in the plan of care?
Elevate the head of the bed.
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.
Encourage the client to eat a well-balanced diet. Perform range-of-motion exercises. Reposition the client every 2 hours.
The nurse is preparing to initiate an enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What intervention will the nurse include in the client's plan of care?
Ensure patency of the tube.
The nurse is assessing an older adult client who reports urinary incontinence. The client states, "I don't really leave the house anymore because I'm always leaking urine. I hate how this has changed my life so much." Which response by the nurse is most appropriate?
"Let's talk more about when this started and complete a full assessment. There may be an underlying cause that we can treat."
The nurse teaches the parent of a child newly diagnosed with insulin-dependent diabetes about the principles of a healthy eating plan. Which statement by the parent indicates effective teaching?
"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."
The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do?
Ensure there are no kinks in the catheter tubing.
The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) about obtaining the best nutrition. Which diet would be best for this client?
high-calorie, high-protein diet Explanation:The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals.
The nurse is caring for a client who is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client:
increases the amount of food intake gradually.
A nurse is assessing a client with bone cancer pain. Which part of a thorough pain assessment is most significant for this client?
intensity
Which nutritional deficiency may delay wound healing?
lack of vitamin C
The nurse is reviewing the intraoperative record of a client. Which information would alert the nurse to the greatest possibility of a potential for skin breakdown?
length of surgery
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?
metabolic alkalosis
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
A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of
organ meats.
A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that their lower back aches when arriving home from work. The nurse should suggest that the client perform which exercise?
pelvic tilts
The nurse is recording the intake and output for a client: D5NS 1,000 ml, urine 450 ml, emesis 125 ml, Jackson-Pratt drain #1 35 ml, Jackson-Pratt drain #2 32 ml, and Jackson-Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number
654
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.
Parents of a neonate who is 32 weeks of age ask the nurse, "Why does he have a feeding tube in his nose?" What is the nurse's best response?
The sucking, swallowing, and breathing are not coordinated.
The nurse is caring for a client with an indwelling urinary catheter. The nurse has noted that there has been no urine output for the past 2 hours. There has been no change in vital signs during that time period. What should the nurse do to determine if there is a problem with the urinary catheter?
Use a bladder scanner to determine if there is urine in the bladder.
A client who underwent surgery had this intake on the day of the procedure: Day shift: 500 mL packed blood cells and 236 mL platelets in additive solution; 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? Record your answer using a whole number.
Add up all of these values to determine the total intake for the course of a day: The total volume is 4736 ml (500 ml + 236 ml + 750 ml + 1000 ml + 250 ml + 1000 ml + 1000 ml). The nurse should document the client's 24-hour intake as 4,736 milliliters.
The nurse is planning interventions for a client who is having an acute gout attack. What is the priority nursing intervention for this client?
Administer prescribed analgesics
A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply.
Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music canterm-23 help.
A client reports abdominal pain. Which action allows the nurse to investigate this complaint?
Assessing the painful area last
The registered nurse (RN) is referred to a client's home when spouses have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority?
Use hot water throughout wash cycle.
A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea?
Offer yogurt several times a day.
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.
One day after an appendectomy, a 9-year-old rates pain at 4 out of 5 on the pain scale but is playing video games and laughing with a friend. What should the nurse document on the child's chart?
The child rates pain at 4 out of 5. Administered pain medication as ordered.
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
"I need to use laxatives regularly to prevent constipation."
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."
A client with cerumen impaction presents to the emergency department. The client asks about supplies to perform ear irrigations at home. What is the nurse's best response?
"It is not a procedure you should do at home."
A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?
"Take a warm tub bath or shower before exercising. This may help with your discomfort."
The nurse is teaching a client who has been experiencing constipation over the past several years how to resume a more normal pattern and frequency of bowel movements. The nurse notes the teaching is successful when the client makes which statement?
"The best time for a bowel movement is approximately 30 minutes after a meal."
After arriving to view a deceased client, the family asks why intravenous lines and tubes are still inserted into the body. Which response should the nurse make to the family?
"The client had an advance directive for an autopsy and all tubes need to remain in place."
The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's bestresponse?
"Your cervix is not fully dilated. Let's keep breathing through the pressure."
The health care provider writes an order that a client may have 12 oz (360 ml) of clear liquids at each meal and may supplement this with an additional 10 oz (300 ml) at each shift (7 to 3, 3 to 11, and 11 to 7). How many milliliters would the nurse document for the day shift (7 to 3) if the client took in all of the ordered volumes? Record your answer using a whole number.
1020 mL
Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using one decimal place.
240
The nurse is assessing a client whose history includes type 2 diabetes and atrial fibrillation, treated with warfarin. The client tells the nurse that the client began taking ginseng supplements several days ago in an effort to boost the immune system. After providing health education, what is the nurse's priority action?
Collaborate with the care team to have the client's prothrombin time and international normalized ratio (INR) assessed.
The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person?
Console the roommate as grieving begins.
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.
A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?
Continue to monitor and record hourly urine output.
The nurse is teaching a client who had a gastrectomy how to reduce the risk for dumping syndrome. What should the nurse teach the client to do?
Decrease the carbohydrate content of meals.
The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse tell them?
Dehydration is expected during the dying process.
The nurse is setting goals with a client with rheumatoid arthritis. Which is a priority goal for the client?
Demonstrate the use of adaptive equipment.
During a visit to the clinic, a pregnant 25-year-old client who began prenatal care at 10 weeks' gestation and is now in the third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?
Eat at least four pieces of fruit daily.
Which instruction should a nurse give to a client who's 26 weeks pregnant and complains of constipation?
Encourage her to increase her intake of roughage and to drink at least six glasses of water per day.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?
Face the client and establish eye contact.
When the nurse is developing a plan of care to manage a client's pain from cancer, what should the nurse plan to do?
Individualize the pain medication regimen for the client.
The nurse is preparing to insert an intravenous catheter into an acutely ill toddler. Place the following steps in the order the nurse would follow. All options must be used.
Inform the parents of the procedure. Wash hands and gather supplies. Prepare the equipment. Inform the toddler of the procedure. Select and prep the appropriate site. Insert the intravenous catheter and secure it appropriately.
An adolescent is being seen in the clinic for abdominal pain with a fever. In what order should the nurse assess the abdomen? All options must be used.
Inspect, Auscultate, Percuss, Palpate
A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?
Keeping the perineal area clean and dry
The nurse is preparing the client with heart failure to go home. Which instruction should the nurse give to the client?
Monitor weight daily.
An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that they have muscle cramps, nausea, and dizziness. Which action should the school nurse do first?
Move the adolescent to a cool environment.
The nurse is planning care for a client with cervical cancer who has an internal radium implant in place, Which action should be included in the nursing care plan?
Offer a low-residue diet.
A 4-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery?
Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.
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.
The family of a deceased client has yet to make funeral arrangements. What should the nurse expect to be done with the body?
Prepare it for storage in the facility's morgue refrigerator.
The nurse is caring for a child with swollen, painful joints. Which nonpharmacologic measure is most important to implement for pain relief?
Provide a bedside commode.
A client receiving chemotherapy for lung cancer reports they have been experiencing diarrhea for the past 3 weeks. The client reports that the severity of the diarrhea is affecting their quality of life in many ways. Which action(s) by the nurse would be appropriate? Select all that apply.
Provide education on foods to eliminate from the diet to help reduce the diarrhea. Assess the client's hydration status, and anticipate potential fluid replacement therapy. Evaluate the client's most recent laboratory test results for electrolyte levels. Ask the client about skin breakdown or rashes around the rectal area.
The family of a client who died unexpectedly arrives to the care area. In which way should the nurse support the family at this time? Select all that apply.
Provide emotional support. Arrange for the family to view the body. Serve as an attentive listener. Expect the family to express grief.
The nurse formulates a plan of care to address negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to implement which intervention(s)? Select all that apply.
Provide support to decrease parental anxiety. Instruct the parents on proper feeding techniques. Observe the parent-child interactions.
A deceased client is a member of a culture where the family is expected to bathe the body after death. What should the nurse do to support the client and family at this time?
Provide the needed supplies to the family.
The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next?
Reposition the client off the reddened skin and reassess in a few hours.
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.
A nurse is caring for a client with the visual field deficit depicted above. What is the mostimportant information for the nurse to teach this client?
Scan the environment on the affected side.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
Stop the feedings and check for residual volume.
The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first?
Stop the flow of solution.
A 911 call was received from a parent indicating their infant is not breathing. Police officers, emergency medical technicians (EMTs), and paramedics arrived at the scene first, resuscitation was unsuccessful. Coroner was called to parents' home to examine infant to determine cause of death. Public health nurses were called to provide support to family. Infant was found in their crib lying on their back; crib had a well-fitting mattress, tight sheets, no blankets or toys, and was up against the back wall of parents' bedroom away from curtains or blinds. Parents deny any gastrointestinal or respiratory infections since birth; they state their infant seemed healthy when they put them to bed last night around 9 p.m. Parents deny smoking around infant or allowing the child to be around anyone who smoked. Birth parent received prenatal care and had no problems during pregnancy until their water broke prematurely at 36 wee
Sudden Infant Death (SIDS) -Offer to call clergy -anticipate an autopsy -status of autopsy -parents emotions
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
A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in a side-lying position?
ankles
The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. How much fluid should the nurse tell the client to drink?
at least 101 fl oz (3030 mL) of fluids daily
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 cheese soft drinks
A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?
broth, gelatin cubes, and tea
The nurse is planning for home care with a client after transurethral resection of the prostate (TURP). What should the nurse tell the client about the dribbling of urine after this surgery? Dribbling of urine:
can persist for several months.
To help promote independence in the area of feeding for a school-age child in skeletal traction, the nurse should help the child choose which meal?
chicken nuggets with sauce, carrot sticks, apple slices, an ice cream sandwich, and milk in a carton
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.
The nurse is developing a long-term care plan with a client who has been diagnosed with multiple sclerosis. To maintain health, which should the nurse teach the client to prevent?
contractures
A multigravida prenatal client with a history of postpartum depression tells the nurse that they are taking measures to make sure that they don't suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?
current medications
A client in labor asks the nurse about Reiki, an alternative therapy that she's heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of
energy from light touch.
A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin
enhances protein synthesis.
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
A client is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom?
fatigue
The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods?
fats
A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply.
prepare the room for sleep and turn off distracting noise avoid caffeine, alcohol, and nicotine before bedtime participate in a bedtime routine
A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client?
providing one-on-one supervision during meals and for 1 hour afterward
Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer?
reassessing the client after administering pain medication
A client progressing through pregnancy develops constipation. What is the primary cause of this problem during pregnancy?
reduced intestinal motility
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to
rest in an air-conditioned room.
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
Which conditions or situations are most likely to result in difficulty sleeping? Select all that apply.
shift work sleep apnea caffeine intake in the evening excessive worry or anxiety
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
A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement?
teaching how to express the breasts
