practice quizzes for basic physical care

A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness?

"Let's discuss your desire to integrate these practices with the physician and advocate on your behalf." The client has a right to incorporate some of the traditional Chinese therapies. It is important to be respectful of cultural beliefs and to advocate for the client. Contacting the physician is important because there could be herbal-drug interactions. Each of the other choices does not respect cultural choices or explore the possibility of interactions. Openness with health care members is important because clients may choose to integrate these therapies without notifying the nurse or the physician.

The home health nurse is conducting a safety assessment in an older adult's home. On the bathroom floor, the nurse finds a throw rug that the client refuses to remove. What is the appropriate recommendation by the nurse?

Place nonslip backing on the underside of the rug.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

at the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

Which nursing action best addresses the outcome: The client will be free from falls?

Encourage use of grab bars and railings in the bathroom and halls. To address the client outcome of being free from falls, it is best to place assistive devices of grab bars especially in the bathroom and railings in the halls and on the stairs to promote balance. Focusing on how to transfer a client is a nursing-focused action, not a client-focused action. It is important to place an emergency contact number close by and have an emergency monitoring system; however, they will not prevent falls. Although limiting the use of stairs decreases the potential of falls, any time that stairs are used creates a fall possibility.

When administering a tube feeding to a client through a percutaneous feeding tube, how should the nurse position the client?

Head of bed elevated 30 to 45 degrees The client should be positioned with the head of the bed raised 30 to 45 degrees to help prevent aspiration and promote gastric emptying. Having the head of the bed raised to 90 degrees would also help prevent aspiration, but is uncomfortable and not feasible for many clients being tube fed, particularly those that are critically ill or who receive continuous feedings. Lying a client supine while tube feeding should be avoided, because it increases the risk for aspiration and can lead to many negative outcomes. Side lying on the left side with the top leg bent at the knee would be the proper positioning for an enema or rectal examination, not a tube feeding, because it would also increase the risk of aspiration and should be avoided.

A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action?

Stop the staple removal, cover the incision, and report the findings to the physician. If there are signs of dehiscence while removing staples, it is important to stop the removal of staples and to dress the open wound. It is very important to relay the observations of mid-incision pain and separation of the wound to the physician as soon as possible. Continuing the staple removal is not appropriate. A dehiscence presenting with other signs of pain could indicate the presence of an abscess. It is not enough to apply butterfly tapes. The observations need to be relayed to the physician.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection?

The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection.The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection.A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns.While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS?

identifying who will be responsible for making client care decisions Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations but they are not actually determined by the NCDS.

Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis?

sliding the client to move up in bed Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and the limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply.

the student nurse the nursing instructor the assigned nurse

While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?

Continue to monitor the suture line, and document findings. During the fibroplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to continue to monitor the suture line. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept moist.

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs. After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help him sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed.

The community health nurse is completing a health history of an older adult. Which statement made by the client indicates an increased risk for skin breakdown? Select all that apply.

The wound on my foot is taking a long time to heal." "I have diabetes, which is hard for me to control." "I use a walker because I had a stroke a few years ago." Older adult clients with diabetes that is hard to control, as evidenced by the wound on the foot that takes longer to heal, are at a greater risk for skin breakdown. Using a walker indicates an impairment in mobility and also causes an increased risk for skin breakdown. Having brown crusty spots, or actinic keratosis, is part of normal aging and does not present an increased risk for skin breakdown. Being on anticoagulants due to atrial fibrillation does not have an effect on skin integrity.

A client has left-sided paralysis. The nurse should document this condition as left-sided

hemiplegia. Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

The nurse is interested in serving as an expert nursing witness in the court of law. What actions will support the nurse expert witness role? Select all that apply.

practicing in multiple clinical experiences achieving a solid educational background An expert nurse witness will have strong clinical experiences and a solid nursing educational background. An advanced nursing degree is not required for an expert nurse witness. Researching legal cases and working as a paralegal will provide law insight but is not required for the nurse expert role.

A client has returned from surgery during which the jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed nursing personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the UAP?

Keep the client in a side-lying position with the head slightly elevated. Immediately after surgery, the client should be placed on the side with the head slightly elevated. This position helps facilitate removal of secretions and decreases the likelihood of aspiration should vomiting occur. A RN does not need to be present to reposition the client, unless the client's condition warrants the presence of the nurse. Although it is important to elevate the head, there is no need to keep the client's head elevated on two pillows unless that position is comfortable for the client.

The nurse walks into a client's room to administer the 0900 medications and notices that the client is in an awkward position in bed. What should the nurse do first?

Straighten the client's pillow behind the back. The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his or her name and checking the armband, so that the medication can be administered.