Practice Questions

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? *Select all that apply.* 1. Change in lacrimation on the affected side. 2. Electric shock-like pain in the lips and gums. 3. Flattening of the nasolabial fold. 4. Inability to smile symmetrically. 5. Severe pain along the cheekbone.

1,3,4 Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve in the absence of a stroke or other causative agent. Manifestations include: -Inability to completely close the eye on affected side -Alteration in tear production due to weakness of lower eyelid muscle -Flattening of the nasolabial fold on the side of paralysis (facial drooping) -Inability to smile or frown symmetrically

The nurse is caring for a client with multiple renal calculi. Which nursing interventions should be included in the plan of care? *Select all that apply.* 1. Administer analgesics at regularly scheduled intervals 2. Encourage fluid intake of up to 3L/day 3. Instruct client to stay on bed rest 4. Provide massage to the client's flank 5. Strain all urine for the presence of stones

1,3,5

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse? 1. BUN 15 mg/dL 2. Serum albumin 3.7 g/dL 3. Potassium 4.5 mEq/L 4. Sodium 153 mEq/L

4 Nutritional deficiencies (zinc, protein, vitamin C) and dehydration (hypernatremia, elevated BUN) can impair would healing.

The nurse is caring for a client with C.diff colitis. Which of the following infection control measures by the nurse are appropriate. *Select all that apply.* 1. Applies sterile gloves before performing patient care. 2. Ensures surgical masks are worn by staff in the client's room. 3. Requests that the client be assigned to a single-client room. 4. Uses alcohol-based sanitizers for hand hygiene. 5. Wears a single-use, disposable gown during client care.

3,5 When caring for a client with C.diff, it is critical that the nurse implements *contact isolation precautions* to prevent transmission between clients.