Test #7 chapters 23,24,25,26 (Prepu's)

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but the care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler

Later today, a client will mobilize for the first time since surgery. The client has a history of orthostatic hypotension and experienced a fall prior to admission. How can the nurse bestnormalize the client's blood pressure to ensure safety during mobilization?

Have the client dangle at the edge of the bed for several minutes prior to standing.

A nurse places a client in the position shown in the accompanying photo. What position is the client assuming?

Trendelenburg

The client incurred a severe fracture of the tibia. An external fixator was applied. Daily pin site care is prescribed. What action will the nurse perform while providing pin site care?

Use a separate swab for each pin site.

The nurse is caring for a client who required hip pinning during surgery to repair a hip fracture. When the nurse is performing pin site care for this client, the nurse will follow which guideline?

Use each sterile applicator once and discard.

A client with an arm cast and sling is having a routine follow-up appointment to check on the progress of the healing fracture. Which assessment finding requires nursing intervention?

fingers of casted arm are cool to touch

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from

foot drop.

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

foot drop.

When moving a client up in bed with the assistance of another caregiver, the nurse should:

have the client fold the arms across the chest.

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims'

The nurse is caring for a client with pneumonia. The nurse notes the client has developed dyspnea. Into which position will the nurse assist this client?

semi-Fowler

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?

trapeze bar

The nurse teaches an unlicensed assistive personnel (UAP) to perform passive range-of-motion exercises for a client using circumduction. How will the nurse teach the UAP to move the joint?

Form a circle.

A client is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the client to ambulate with her crutches?

"Try to avoid putting too much pressure on your armpits with the tops of the crutches."

A nurse is to place a client in the semi-Fowler position. To what degree should the nurse elevate the client's head and torso?

45 degrees

The nurse is providing care to a client who has sustained an injury to the left arm in a motor vehicle accident. When discharging the client, which teaching instructions will the nurse provide?

"Call your health care provider immediately if your pain is unmanageable."

A young client, 3 months after a right below-the-knee amputation (BKA), is brought to the clinic by the caregiver over concerns that the stump is turning red. Which question should the nurse prioritize?

"How long are you wearing the prosthesis during the day?"

The nurse is caring for a client who works in a warehouse and has been having low back pain. Which statement by the client indicates the need for more education regarding safe lifting?

"I hold the boxes away from my body so I do not drop them on my feet."

The nurse is caring for an older adult client who has difficulty walking. The client states, "I hate that I can barely walk. I'm such a burden to my family." What is the appropriate nursing response?

"Let's talk about how mobility can increase your independence."

An adult client has been scheduled for a stress electrocardiogram as part of a larger diagnostic workup. How should the nurse best describe this test to the client?

"The electrical activity of your heart will be measured while you perform exercise."

Before assisting a client from lying in the supine position to standing using an assistive device, the nurse applies elastic stockings on the client. The client asks why these are necessary. Which response from the nurse is accurate?

"The stockings help compress vein walls, preventing blood from pooling in extremities, which can cause fainting."

A client has to perform quadriceps setting exercises. The client asks the nurse how the exercises will help. Which response from the nurse would be most accurate?

"These exercises will help your ability to stand and support your body weight."

A client has suffered musculoskeletal trauma and requires mechanical immobilization. The client asks, "Why is this part of my treatment and is it necessary?" Which response from the nurse would be most appropriate?

"These types of injuries require a period of inactivity to allow new cells to restore integrity to damaged structures."

The nurse applies a continuous passive motion (CPM) machine to a client who is postoperative from a hip replacement. The nurse will include which teaching point(s) to promote client adherence? Select all that apply.

"This machine will help to prevent stiffness in your hip joint." "The machine will help you gently bend your hip joint." "The machine will help to decrease joint swelling."

A client using a cane is learning how to safely get up from sitting. Place the steps in the correct sequence that the nurse would teach the client, from first to last.

1)Grip the arm rests while holding the cane in the stronger hand. 2)Advance the stronger leg. 3)Lean forward. 4) Push with both arms against the arm rests. 5) Stand until balanced and any symptoms of dizziness pass.

The nurse is calculating the maximum heart rate for a 78-year-old client. Which accurately reflects the client's maximum heart rate?

142 beats per minute

The nurse is assessing a 50-year-old client who wants to start a fitness program. The client has a sedentary lifestyle and has not exercised often in the past. The nurse determines the client should achieve which target heart rate when starting the fitness program?

85 beats/min

A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?

Apply lotions and take warm baths or soaks.

The nurse is caring for a client with a fractured femur who is being treated with skeletal traction. Which action(s) will the nurse implement when caring for this client? Select all that apply.

Assess capillary refill. Check for pedal pulses. Encourage deep breathing and coughing. Determine the last date of bowel movement.

The nurse is providing care for a client who is recovering in the hospital from a traumatic brain injury. How can the nurse best prevent the development of disuse syndrome and ankylosis?

Assist the client with passive range of motion of joints that the client is unable to move.

A nurse is caring for a client who has been recommended an ambulatory electrocardiogram for recording the heart rate and rhythm. What instructions should the nurse provide the client with regarding the use of the Holter monitor? Select all that apply.

Avoid using magnets during the test. Avoid using an electric blanket while the device is in place. Avoid taking a shower while the device is in place.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

The nurse is helping a client with musculoskeletal alterations to perform range-of-motion exercises. In what order would the nurse perform the exercises for the client?

Begin with exercises of the head. Move down the body, completing exercises equally on either side of the body.

An older adult client with generalized weakness who lives in a two-story home has a bathroom upstairs and a bedroom downstairs. Which nursing teaching is appropriate?

Consider a bedside commode.

To avoid postural hypotension, which teaching will the nurse provide to the client?

Dangle feet before moving from a reclining position.

A nurse is following a plan of care for passive range-of-motion (ROM) exercises. What specifics will be included on the plan?

Do ROM exercises twice a day, each exercise two to five times.

The nurse is assisting a client from the bed to a chair that is positioned next to the bed. The client requires partial assistance in the transfer. What action will the nurse perform to prevent injury to self?

Keep the knees bent while assisting the client from the bed.

The nurse is caring for a client who sustained a mild neck sprain in a motor vehicle accident. What teaching regarding the use of a cervical collar will the nurse include?

Limit neck and head movements.

The meal tray has been delivered to the client's room. The client needs to be repositioned higher in the bed with the head raised. The client is unable to assist with moving in the bed. What action is best for the nurse to perform to prevent injury to the nurse and/or the client?

Obtain assistance from another nursing staff member.

The nurse is caring for an older adult client who has pain and loss of function associated with arthritis. Which nursing teaching is appropriate?

Physical and occupational therapy may be initially helpful.

A client that is being ambulated in the hallway by the nurse reports dizziness and proceeds to begin falling. Which nursing action is appropriate?

Place nurse's foot to the side, and slide arm under client's axilla.

A nurse is applying a cervical collar to a client with severe neck strain. Which actions should the nurse perform when applying a cervical collar? Select all that apply.

Place the client's head in a neutral position. Ensure that the collar openings are centered at the back of the neck. Position the collar beneath the chin and then slide upward.

The nurse is caring for a client who has a hip spica. Which nursing intervention is appropriate?

Provide fracture pan as needed.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

A client, currently being treated for cardiovascular disease, attends a nurse-led community-based exercise program. What would the nurse recommend to this client?

See the health care provider and have a checkup first."

The nurse is caring for a client with a whiplash injury. When applying a cervical collar, which action(s) will the nurse take to ensure this intervention is completed safely and effectively? Select all that apply.

Start with a collar placed well beneath the chin. Ensure the opening of the collar is to the back. Assess the client's work of breathing after the collar is applied.

A community health nurse is teaching a workshop on exercise during a health fair that is being sponsored by a local community center. A participant has asked the nurse about a reasonable and healthy goal for the heart rate while a person exercises. The nurse has responded by explaining the relationship between maximum heart rate and target heart rate. How should an individual's maximum heart rate be calculated?

Subtract the individual's age from 220.

An older adult client with weakness on one side of the body needs to use a cane for walking. How should the nurse determine the correct height of the cane to be used by the client?

The cane's handle should be parallel with the hip.

A nurse has assisted with the application of a cervical collar. What would indicate that the collar was applied correctly?

The client is breathing and swallowing without effort.

A nurse is caring for a male client who has recently been fitted with a cast following a tibial fracture. Which assessment findings would be suggestive of neurovascular dysfunction?

The client is unable to wiggle his toes on demand.

The nurse is caring for a client who has had a shoulder spica made of plaster of paris applied. Which teaching will the nurse provide to the client?

The client should expect to feel that the cast is hot and heavy.

A client is to begin ambulating with the use of a T-handle cane. The nurse determines that the cane is at the proper height based on which observation?

The handle is parallel with the client's hip.

A college student fell and sprained his right ankle. The student health physician recommends the student use crutches to facilitate healing. What would the nurse teach the student?

The support of the body should be the hands and arms.

A nurse is assisting with the application of a traction splint. What is an example of a traction splint?

Thomas splint

The community health nurse is teaching a neighborhood group about a safe exercise program. Which education will the nurse provide? Select all that apply.

Use supportive shoes when walking. Complex carbohydrates give energy. Use reflective clothing when walking after dark. Calculate the target heart rate for each individual.

A nurse is caring for a client with a cervical collar. What should the nurse include in the client teaching regarding the use of the cervical collar?

Wear the collar even when sleeping.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

A client has chronic obstructive pulmonary disease (COPD) and is unable to perform basic self-care activities or activities of daily living (ADLs). What would be an appropriate nursing diagnosis?

activity intolerance

A client with asthma tries to jog a mile but cannot finish and reports fatigue. An appropriate nursing diagnosis would be:

activity intolerance related to fatigue.

The proper use of the principles of body mechanics:

acts to prevent injury to the client and/or nurse.

A nurse is performing range-of-motion exercises for a client and moves the client's fingers apart and then back together. The nurse is performing which range of motion?

adduction/abduction

When explaining the benefits of isotonic exercises to promote cardiorespiratory conditioning and increase lean muscle mass, which exercise should the nurse tell the client to perform?

aerobic exercise

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

The client is immobile and on bed rest. When the client lays supine in the bed, the client exhibits external rotation of both hips. What action will the nurse perform to maintain the client's hips and legs in proper alignment?

bed trapeze

The nurse is caring for a client who had a cast applied yesterday for a tibia fracture. When the client returns today with swelling in that extremity, for which procedure does the nurse prepare?

bivalving of the cast

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when the graduate states that back injuries:

can occur when uncooperative clients are being repositioned.

What body system benefits the most from aerobic exercises?

cardiovascular

A client has been prescribed exercise at the metabolic energy equivalent (MET) of 8. Which exercise type will the nurse recommend?

cross-country skiing

A client has been prescribed exercise at the metabolic energy equivalent (MET) of 1. Which exercise type will the nurse recommend?

dressing self

A nurse at a long-term care home has organized a program that is aimed at increasing residents' levels of physical activity. The nurse is aware of precautions that must be taken when promoting exercise among older adults. The nurse should teach participants to:

ensure that they drink water in order to stay hydrated.

A nurse teaches a student nurse the importance of ambulating clients to prevent the effects of immobility on body systems. What is one of these effects?

impaired circulation

A nurse is educating an obese, middle-aged client regarding the benefits of exercise. What should the nurse tell the client are the significant benefits of regular physical exercise? Select all that apply.

increased cardiopulmonary function increased lean mass regularity of bowel elimination

A client has begun exercising four times each week. Which of the following is a cardiovascular response to regular exercise?

increased efficiency of the heart

A nurse is assisting a client with the device shown in the accompanying image. What device is the client using?

inflatable splint

The nurse is caring for a client with impaired mobility who needs help to improve muscle tone and strength. What type of exercise will the nurse recommend for this client to begin the exercise regimen?

isometric

A nurse assists the client into the position shown in the accompanying image. Which position is the client assuming?

lateral oblique

A client has carpal tunnel syndrome. Part of the management plan is the use of a device to limit movement. Which device would the nurse expect this client to use?

molded splint

The nurse is teaching a client about moving joints into positions of abduction and adduction. Which client action reflects that teaching has been effective?

moves the legs away from the midline and then toward the midline

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?

near the client's hip, with legs shoulder width apart and one foot near the head of the bed

A nurse is caring for a client with hypertension. The nurse is aware that certain factors, including high blood pressure, affect the client's capacity to exercise. Which factors directly affect the client's capacity to exercise? Select all that apply

obesity advanced age skeletal function

A nurse is ambulating a client who has had a cerebrovascular accident (CVA). The client has paresis on the right side of the upper body. Where would the nurse stand to walk the client?

on the weak side

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

placing a small towel under the neck

A nurse is caring for an older adult client who is very ill. The nurse uses a lifting sheet to transfer the client from the bed to the stretcher. How does transfer by lifting sheet help the client?

prevents shearing of tissue

The client recently had abdominal surgery and has now developed pneumonia. The client requires frequent turning by the nurse. In what position will the nurse avoid placing the client?

prone

A nurse is caring for an 85-year-old client in an extended-care facility. What position will the nurse recommend to help prevent skin breakdown?

prone position

A nurse is caring for a client with dyspnea. How will the nurse control the speed when repositioning the client?

shifting hands from the posterior of the shoulder and hip to the anterior as the client rolls toward the client's abdomen

A male client is being treated on a neurological unit for the effects of a recent stroke. The client's family members are participating actively in his care and frequently position him in a supine position. The nurse should teach the family members about the benefits of alternative positions in order to reduce the client's risk of:

skin breakdown.

A client is supposed to build up to exercise of moderate intensity. What activity would the nurse recommend to meet this criterion?

slow swimming

A nurse is demonstrating the proper use of body mechanics to a group of nursing students. What would be most appropriate for the nurse to do?

stand with legs wide apart

To assess a potential injury to a client's wrist, the nurse asks the client to turn the hand and forearm upward. This movement is referred to as:

supination

The nurse performs passive range of motion for a client by turning each palm upward and then downward. How will the nurse document this motion?

supination and pronation

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?

supporting the client's back

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the client's ability to assist

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

thrombus formation

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is mostappropriate to assist in transferring?

transfer belt

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

trochanter rolls

The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action reflects that teaching has been effective?

turns the arms downward and then upward

The nurse is caring for an older adult client who is recovering from hip surgery. Which assistive device will the nurse use to facilitate client ambulation?

walker

The nurse is planning discharge care for an older adult client who had been on prolonged bed rest. Which assistive device will the nurse plan to use to facilitate client ambulation?

walker