311-Module 1

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse?

"Allow me to show you how to use your walker again." Rationale:The nurse should correct any inappropriate use of assistive devices immediately upon observing improper use.

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why he or she needs to ambulate in halls three times a day. What is the correct response by the nurse?

"Ambulation helps prevent thromboembolism." Rationale:Regular ambulation can decrease the risk of thromboembolism in the postsurgical client. It does not affect risk of surgical wound infection or hypoglycemia. This client should no longer be experiencing any acute effects of anesthesia.

A client with diabetes asks the nurse what should be done for a large callus on the right great toe. What is the best response by the nurse?

"I encourage you to see your podiatrist to get a recommendation for your callus."

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching?

"I will pull the skin taut to reduce the risk for ingrown hairs." Rationale:Pulling the skin taut while shaving increases the risk for ingrown hairs. When shaving the face, the client should use warm water and shave cream to soften the hair, begin shaving using smooth, short strokes in the direction of the hair growth while holding the skin steady to prevent the razor from pulling on the skin and causing discomfort.

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow."

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

"Microbial contamination can occur when cleaning the anal area first."

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond?

"Mouth care during this time helps prevent complications."

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need?

"Place all four feet of the walker on the ground before stepping forward." Rationale:The client should move the walker 6 to 8 in (15 to 20 cm) in a forward direction and set all four feet down and ambulate to the walker. All four walker feet should always be on the ground before the client ambulates. The client should lead with the leg he is most comfortable with. Setting only two walker feet on the ground creates a risk for falling for the client.

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

"Powder in the genital area can create a medium for bacterial growth."

The nurse has instructed the client with a knee injury on how to perform crutch walking with a four-point gait. Which statement clarifies client understanding?

"The four-point gait uses one crutch, then one leg, followed by the other crutch, and then the other leg."

A nurse delegates the application of graduated compressions stockings to a licensed practical nurse. A while later, the client's spouse pulls the nurse aside and says, "I think the other nurse put the stockings on backwards. The opening is facing up." Which response by the nurse would be most appropriate?

"The opening is face up to prevent any interference with the circulation."

The nurse is caring for a client who has had colon surgery. The client asks the nurse "How do pneumatic compression devices decrease risk of thromboemboli?" What is the best response by the nurse?

"They increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart."

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"Use of special bathing products and avoidance of scrubbing help keep your skin intact." Rationale:Nurses should examine bathing practices and consider the effect on the client's skin. In general, they should avoid using soap and hot water and avoid excessive friction and scrubbing, as these can compromise the integrity of the client's skin, especially that of an older client, whose skin tends to be more fragile.

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching?

"When I eat, I will remove my dentures and place them in a napkin." Rationale:Clients should be encouraged to wear dentures to assist with eating. Dentures should not be wrapped in a napkin or paper towels, because they may be mistaken for trash

The nurse is caring for a 2-year-old child for whom elbow restraints have been prescribed. The nurse should remove the restraints and assess the child every how many hour(s)

1 hour

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Place the following instructions in the correct order. Use all options.

1)"Place both crutches under your left arm." 2)"Grasp the stair railing with your right arm." 3)"Place your unaffected leg on the first stair tread." 4)"Transfer your weight to the unaffected leg." 5)"Move up onto the stair tread." 6)"Move your crutches and the affected leg up onto the stair tread."

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.

A nurse is preparing to shampoo a client's hair while the client is in bed. Place the steps below in the order that the nurse would perform them? Use all the steps listed.

1)Place a protective pad under the client's head and shoulders after removing the pillow. 2)Fill the pitcher with water at an appropriate temperature. 3)Place the shampoo board under the client's head .4)Position a drain container underneath the drain of the shampoo board. 5)Put on gloves and give the client a folded washcloth to hold over the forehead. 6)Saturate the client's hair with water from the pitcher.

The nurse must apply a mummy restraint to a small child. Place the steps in the correct order. Use all options.

1)Secure a prescription from the health care provider. 2)Explain the reason for use to the client and family. 3)Open the blanket or sheet and place the child on the blanket. 4)Position the child's right arm alongside the body and pull the right side of the blanket tightly over the child's right shoulder and chest. 5)Secure the blanket under the right side of the child's body. 6)Fold the lower part of the blanket up and pull over the child's body.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply.

1. Increase the parent's social interaction. 2.Ensure the parent engages in regular exercise. 3.Provide frequent reorientation.

3 The nurse has just transferred a client to the chair. The client begins to experience a tonic-clonic seizure. Which actions are appropriate for the nurse to take? Select all that apply.

1. Place a folded blanket under the client's head. 2.Ease the client to the floor. 3.Move furniture and other objects out of the immediate area., 4.Loosen constricting clothing.

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

1. Provide privacy while the client removes dentures from the mouth. 2.Use a toothbrush and paste to gently brush all surfaces., 3.Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate? Select all that apply.

1. Support the client's body against the nurse and gently slide the client onto the floor 2. Firmly grasp the client's gait belt.

The nurse is caring for a postsurgical client. The client asks the nurse why he needs to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factors? Select all that apply.

1. aid gastrointestinal motility 2. Increase joint flexibility 3. improve respiratory function

Which methods can be used to remove a client's soft contact lenses? Select all that apply.

1.Ask the client to remove them, if able. 2.Use the pads of the index finger and thumb to gently pinch and remove the lens.

The nurse is assigned a client for whom an elbow restraint is prescribed. Which general principles of correct placement of the elbow restraint will the nurse follow? Select all that apply.

1.Pad bony prominences. 2.Confirm the restraint does not extend below the wrist or place pressure on the axilla 3. Ensure the restraint is the correct size for the client

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply.

1.Pressure injuries 2.Falls 3.Contractures 4.Delirium

The nurse is providing nail care to a client. Which assessment findings require notification of the client's health care provider? Select all that apply.

1.Red and swollen skin around the great toe 2. Bleeding under the nail bed and from the sides of the toes 3.Nails curled around the tip of the toes 4.Blackened great toe nail

A nurse is providing nail care for an older adult client. Which actions should the nurse take? Select all that apply.

1.Round the tips of the nails in a gentle curve using a file 2.Cut the nail straight across 3.Gently clean under the nails using an orangewood stick 4.File the nail straight across

the nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply.

1.Towels, 2.Protective pads 3.Bath blanket 4.Linen 5.Gown

The nurse is teaching a client with peripheral vascular disease about foot care. What will be included in the teaching plan? Select all that apply.

1.Wear appropriate footwear. 2. See a podiatrist for treatment for bunions. 3. Schedule foot exams with podiatrist at least once per year. Rationale: Clients with peripheral vascular disease are at increased risk for infection, injury and poor healing related to the feet; therefore, diligent foot care is important. It is recommended that a podiatrist treat bunions, corns, and calluses. Clients should always wear appropriate footwear to protect feet from injury.

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100oF (38oC) Rationale:Although water temperature should be adjusted to 100oF (38oC) to less than 120o to 125oF (49oC to 52oC), the lower temperature limit of 100oF (38oC) is suggested for children and adults older than 65 years of age. A temperature of 90oF (32oC) would cause chilling.

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading?

105oF (40.6oC)

The nurse is caring for a client wearing a pneumatic compression device. The nurse has set the device properly when the pressure is in what range?

35 to 55 mm Hg

A client who is recovering from surgery is beginning to ambulate. This client is strong enough to walk without assistance but has poor balance. Which type of mobility aid would be most appropriate for this client?

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

A nurse is providing care to several clients who are extremely weak and need to have their hair shampooed while remaining in bed. When gathering the necessary supplies, the nurse would anticipate needing to adapt the shampoo board for the client with which condition?

Acute spinal cord injury Rationale:If the client has a spinal cord or neck injury, use of the shampoo board may be contraindicated. In this case, a makeshift protection area can be created to wash the client's hair without using the board. The other conditions would not contraindicate the use of the shampoo board.

After monitoring the client during a seizure, the nurse determines the seizure has ended and the client is stable. Which action does the nurse take?

Allow the client to sleep. Rationale:The client will likely sleep after the seizure during the postictal state. Because the client was stable at the conclusion of the seizure (secure airway, normal vital signs), the nurse allows the client to sleep until he or she naturally awakens, at which time the nurse can orient the client to the situation. It is not necessary to awaken the client in 30 minutes and assess the neurological status, nor is it necessary to obtain frequent vital signs during the postseizure period.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next. Rationale:A full bed bath every day may cause excessive dryness in many older adults, and a continent client may not require a bath every day. If dry skin is a problem, water and skin lotion or bath oil may be used on alternate days with a bed bath. Do not use bath oil in tub water, as it can cause tub surfaces to become slippery. Bed baths should not be avoided altogether but simply given every other day.

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

Apply a thin barrier of skin protectant to the perineal area Rationale:The nurse would apply a thin barrier of skin protectant to the perineal area to protect the skin from breakdown associated with contact with stool or moisture.

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures?

Apply gentle pressure with a 4 × 4 gauze to grasp the denture plate. Rationale:Applying gentle pressure with a 4 × 4 gauze prevents slippage and discourages the spread of microorganisms.

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure?

Apply gentle pressure with a piece of gauze to remove the upper dentures.

Which action does the nurse perform to institute seizure precautions for a client after a subdural hematoma?

Apply padding to the bed side rails bilaterally. Rationale:Rail padding decreases the risk for injury

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse?

Apply pressure with a gauze pad for 2 to 3 minutes. Rationale:If a client is cut during shaving and is bleeding, the nurse should apply pressure with a gauze pad or a towel for 2 to 3 minutes, and then check for continued bleeding. After the bleeding has stopped, it is safe to resume shaving. The priority is to stop the bleeding. Applying pressure does this, but it typically does not need 7 to 8 minutes. Rinsing with water will not aid in stopping bleeding, nor will a transparent dressing.

A client's health care provider has prescribed the use of knee-high graduated compression stockings. To ensure that the correct size is obtained for the client, the nurse would measure which area? Select all that apply.

Around the widest part of the calf, From the bottom of the heel to the back of the knee

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client?

Ask for help from a staff member.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

Assess both eyes for contact lenses.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate?

Assess for the need to urinate. Rationale:Client needs should be assessed before considering physical or pharmacologic restraint.

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure. Which intervention should take priority?

Assess the circulation to the client's fingers and hands. Rationale:In this situation, assessing the circulation to the client's fingers and hands should be the priority intervention, because elbow restraints can impair circulation if applied too tightly.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?

Assess the client's need for fluids and toileting every 2 hours. Rationale:Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance.

A client wearing bilateral pneumatic compression devices reports pain and tingling in the left leg. After removing the pneumatic compression device, what is the next intervention by the nurse?

Assess the extremities for peripheral pulses, edema, changes in sensation, and movement.

A client has been out of bed, sitting in the chair for the past hour. The nurse is preparing to apply knee-high length graduated compression stockings as prescribed by the client's health care provider. Which action would be appropriate for the nurse to do? Select all that apply.

Assist the client back to bed. Elevate the client's feet and legs for about 15 minutes.

A client who is wearing soft contact lenses is unable to remove the lenses before bedtime. What action should the nurse take?

Assist the client to remove the lenses using a small pair of rubber grippers.

The health care provider has prescribed application of total-leg pneumatic compression device sleeves to a client's legs. Where would the nurse place the opening in the sleeve?

At the popliteal space behind the knee.

For the client at risk of seizures, which action does the nurse take?

Attach an oxygen regulator at the head of the bed. Rationale:If the client has a seizure, the client is at risk for hypoxia and aspiration. An oxygen and vacuum regulator must be attached at the wall with the correct supplies for delivery of oxygen and suctioning of secretions or vomitus. Also, an oral airway and resuscitation bag, a bag-valve mask device, must be at the wall behind the bed.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath.

The nurse cleans the client after a bowel movement and notes stool on the gloves. The nurse has not finished cleaning the client. What action should the nurse take?

Change into a new pair of gloves.

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client?

Change the bed linens from the top to the bottom.

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take?

Change to a clean wipe after each stroke

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure?

Check the client's chart.

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply.

Choose a walker with wheels on the front legs if you have a faster gait., Wear non skid shoes or slippers., Check the walker for signs of damage, frame deformity, or loose or missing parts before use.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home.

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

Consult with your health care provider about beginning an exercise program.

The nurse considers applying restraints to an agitated client. Which actions does the nurse take?

Dim the lights and speak softly about something the client enjoys."

The nurse is assessing a client with a figure-eight bandage on the right ankle. The client has returned from the bathroom and the bandage is loose and has migrated over the tips of the toes. What action does the nurse perform next?

Discard the bandage and replace with a new bandage following the figure-eight pattern

A nurse is preparing to apply a pneumatic compression device for a client. Which statement accurately describes a contraindication for this device?

Do not place the sleeves of the device above the knee.

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed?

Ease the clean linens under the client, from the top to the bottom of the bed.

When providing oral care to an unconscious client, the nurse takes which action?

Ensure there is a towel and basin positioned for drainage.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency?

Every 1 to 2 hours Rationale:The nurse would plan on increasing the frequency of client observation and surveillance, conducting client/nursing rounds every 1 to 2 hours. These rounds would include assessing for pain, assisting with toileting, providing client comfort, ensuring that personal items are within reach, and meeting client needs. Client care rounds/nursing rounds improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.

How should the nurse open the bottom sheet when making an unoccupied bed?

Fanfold to the center Rationale:The nurse would place the bottom sheet with its center fold in the center of the bed, open the sheet and fanfold to the center of the bed. Opening items on the bed reduces strain on the nurse's arms and diminishes the spread of microorganisms. Centering the sheet provides sufficient coverage for both sides of the mattress.

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens?

Fold the linens in fourths on the bed and then hang them over a clean chair.

How would the nurse remove the top linens when making an occupied bed?

Have the client hold onto the bath blanket and reach under it to remove the linens.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply.

Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible., Place a bath blanket over the client., Put on gloves before removing soiled linens.

A nurse is caring for a 3-year-old who has just been admitted to the hospital due to a severe case of influenza. The child experiences a seizure. The nurse should suspect which as the most likely cause of the seizure?

High fever Rationale:Most seizures in children are caused by disorders that originate outside of the brain, such as high fever, infection, head trauma, toxins, or cardiac arrhythmias.

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted?

Insert the fist between the restraint and the client. Rationale:The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

Where should the nurse roll soiled linens when removing them from an unoccupied bed?

Inside the bottom sheet Rationale:The nurse should snugly roll all the soiled linen inside the bottom sheet and place it directly into the hamper to help prevent the spread of microorganisms

How should the nurse teach the client who is ambulating with a cane?

Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens?

Keep the blanket in place over the client to provide privacy and remove the top sheet.

The nurse is caring for a client, after hip replacement, and receives a prescription to apply a pneumatic compression device. On what part of the body would the nurse place this device?

Legs

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens?

Lying on one side

The nurse making an occupied bed. Under which body part of the client would the nurse place the drawsheet?

Midsection

the nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that wearing contact lenses. What is the priority action by the nurse?

Notify the emergency department health care provider the client is wearing contact lenses.

The nurse is applying a pneumatic compression device to a client's legs. Where would the nurse place the inflation pump?

On the bottom of the bed.

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint?

Pad bony prominences. Rationale:Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. The nurse should remove PPE after applying the restraint.

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?

Perform a circulation check and offer toileting and hydration. Rationale:Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids.

Proper application of a pneumatic compression device includes which step?

Place a sleeve under the client's leg with the tubing toward the heel.

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action?

Provide client comfort Rationale:The main purpose for changing the linens on a client's bed is to provide client comfort.

A nurse is shaving a male client's face. Which should the nurse do?

Pull the skin taut and shave in the direction of hair growth using short strokes. Rationale:The skin on the face is more sensitive and needs to be shaved with the direction of hair growth in short strokes to prevent discomfort. The skin should be pulled taut so that the razor can cut the hair more effectively.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height.

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action?

Raise the side rail.

The nurse is observing the client's caregiver apply a figure-eight bandage to the client's ankle. The caregiver begins wrapping the elastic bandage around the ankle and unrolls the entire bandage before wrapping the ankle in figure-eight fashion. What should the nurse instruct the caregiver?

Re-roll the bandage, wrap twice around the ankle, and then alternate with the bandage rolled ascending and descending with every turn

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply.CMW

Remove clutter from walkways., Use a night light., Avoid climbing on a chair or table to reach items that are too high to reach., Keep electrical and telephone cords against the wall and out of walkways.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action?

Remove gloves, unless indicated for transmission precautions. Rationale:After placing the soiled linens in the laundry hamper, the nurse would remove gloves, unless indicated for transmission precautions, and then place the bottom sheet with its center fold in the middle of the bed. This can be done without gloves, because the linens are clean. If the mattress is soiled, it should be cleaned according to facility policy. Scrubbing the mattress with antimicrobial cleanser is not necessary

The nurse is caring for a middle-aged adult who has been prescribed elbow restraints. The nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. What is the best action by the nurse?

Remove restraints more frequently and perform range of motion (ROM). Rationale:If a client cries or reports discomfort or pain when elbow restraints are removed, the nurse should remove the restraints more frequently and perform active or passive ROM. Eliminating the restraints would alleviate the client's pain only if the reason for which the restraints were prescribed has resolved. The nurse could reassess and consider another type of restraints, but it is better to continue with the type of restraints prescribed by the health care provider. A padded dressing will not alleviate the client's pain, because the restraints are already padded.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

Remove the antiembolism stockings before the bath.

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

Retract the foreskin when washing the prepuce of adolescents and older. Rationale:The nurse would retract the foreskin and wash the area under it when providing perineal care for an uncircumcised male who is an adolescent or older.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. Rationale:In an uncircumcised male client (teenage or older), retract the foreskin (prepuce) while washing the penis but pull it back into place over the glans penis immediately afterwards to prevent constriction of the penis, which may result in edema and tissue injury.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

Scrotum Rationale:When performing perineal care for a male client it is important that the nurse be particularly gentle and avoid pressure when handling the scrotum, because pressure on the scrotum may cause pain for the client.

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client?

Side-lying Rationale:Putting the unresponsive client in a side-lying position while performing oral care facilitates the drainage of any liquid from the client's mouth and prevents aspiration.

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

Start with cleanest areas and end with most soiled areas. Rationale:The nurse should start with cleanest areas and end with most soiled areas, to avoid transferring microorganisms from soiled areas to the clean areas. The other approaches are not valid.

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client?

Suction toothbrush Rationale:A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration.

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift.

What would be most important to document after shaving a client?

That the chin was nicked with the razor Rationale:Shaving a client does not usually require documentation. If the skin is broken while shaving, it is important to document the occurrence and any assessment findings. Otherwise, the time, the type of shaving cream and aftershave are not important to document.

An unlicensed assistive personnel (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

The UAP begins cleansing from the anus toward the pubic bone.

The nurse has delegated contact lens removal to the unlicensed assistive personnel (UAP) for a client in the preoperative area. Which action by the UAP requires intervention by the nurse?

The UAP has placed the client in a side-lying position.

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

The client continually tries to move from head of the bed toward the foot of the bed.

The nurse is teaching proper cane use to a client who has had ankle surgery. The client has been cleared to begin bearing weight on the affected leg. What outcome would be unexpected?

The client reports increased strength in the weaker leg. Rationale:Increased strength in the weaker leg is not considered a projected outcome for proper cane usage. Rather, the cane is used for balance and support to increase safety and independence.

What should the nurse teach the client about climbing stairs with a cane?

The client should advance the stronger leg up the stair first, followed by the cane and weaker leg.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can. Rationale:When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should let the client bathe himself to the extent that he can effectively do so.

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

The client should use an electric razor. Rationale:A client who is prescribed anticoagulant therapy is at risk for bleeding; therefore, it would be important to use an electric razor rather than a blade.

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse?

The health care provider will see the client and assess whether the restraint prescription should be renewed. Rationale:After restraints have been worn for 24 hours, the health care provider who is responsible for the care of the client must see and assess the client before writing a new prescription for the use of restraint or seclusion for the management of violent or self-destructive behavior

A toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint. The procedure is expected to take about 10 minutes. Which approach might the nurse suggest as an alternative to using a mummy restraint?

Therapeutic holding

A nurse is explaining to a client's caregiver the purpose of antiembolism stockings, which the client has received a prescription to wear. Which best explains their purpose?

They promote venous blood return to the heart

The nurse applies a gait belt to a client prior to ambulation. For what reason might the nurse use a gait belt when ambulating certain clients?

To improve grasp and help provide more stability and balance.

The nurse is changing the figure-eight bandage on the client's hand after hand surgery. In addition to the gauze bandage, a small gauze pad is placed in between each finger to prevent what complication?

To pad between fingers so there is no skin to skin contact under the bandage

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth?

Twice a day

The nurse wraps the sleeves of a pneumatic compression device around the legs of a client. How would the nurse determine if the fit is correct?

Two fingers should fit between the leg and the sleeve

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

Uncover only the area being cleaned.

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds Rationale:Skin-fold areas may be sources of odor and skin breakdown if not cleaned and dried properly. Although all the areas listed should be bathed, they do not require the same level of attention as do the skin-folds.

Which describes an accurate step taken by the nurse when applying a pneumatic compression device on a client?

Unfold the sleeves and place them on the bed with the inner lining facing up.

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?

Use a safety monitoring device. Rationale:A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers. Rationale:Moisture barriers and special perineal skin cleansers will help prevent skin breakdown and excoriation. Do not use antibiotic or other antimicrobial cleaners or betadine at the urethral meatus. DO NOT USE POWDERS. CHANCE FOR BACTERIA

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

Use the call bell for any needs and wear nonslip footwear."

A client with a history of diabetes is demonstrating nail care to the nurse. Which action by the client requires teaching by the nurse?

Using a nail clipper to cut the nail straight across

A nurse is directed to apply a pneumatic compression device for a client, after surgery. What postoperative complication would this device help to prevent?

Venous thrombus.

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first?

Warm the cap in the microwave. Rationale:Shampoo caps are commercially prepared, disposable caps that contain a rinseless shampoo product.

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment?

cognitive function level Rationale:Assessment of cognitive function is most important to assure safety for the client with using the walker. A client unable to follow or retain direction would be at risk for injury.

The client is 1 day postsurgery with a figure-eight bandage in place after an open reduction internal fixation (ORIF) of a left wrist fracture. How often should the nurse check the neurovascular status of the left wrist and hand?

every 4 hours

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

every 60 minutes

How often should skin integrity be assessed for a client who is using pneumatic compression devices?

every 8 hours

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply.

extension cords, polypharmacy, clutter

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

extremity restraint Rationale:The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

The nurse is talking to a client who has been using crutches for ambulation. The client reports intermittent numbness of the upper arms. What should the nurse instruct the client to avoid?

leaning for prolonged periods by the axilla on the crutches Rationale:Leaning on the crutches can create pressure on the axillary nerves, creating numbness, tingling, and pain down the arms. The client should not be leaning on the crutches for long periods of time.

After applying a restraint to a client, the nurse is required to stay with the client while it in use. Which type of restraint has the nurse applied?

mummy restraint

The nurse is caring for a hysterical child who requires assessment of a dog bite near the eye. The parent is in emotional state that is not appropriate for helping to immobilize the child. The nurse should implement which restraints to best enable the health care provider to examine the client's injury?

mummy restraint

The client has decreased strength in the left leg. How should the nurse instruct the client to hold a cane for assistance?

on the right side Rationale:The cane should be held in the hand opposite of the weakened leg.

The nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint. The elbow restraint should not impede circulation. Which pulse will the nurse assess to decide if circulation is compromised?

radial Rationale:The nurse should determine if circulation is compromised by assessing the radial pulse and the circulation to the fingers and hand.

The nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint. The infant's parent asks the nurse what will be used to implement the mummy restraint on the infant. What is the best response by the nurse?

sheet or blanket

The nurse should document the time, date, and location of the figure-eight bandage when applied or changed in the nursing record. What other information should the nurse record in the procedure documentation?

size of bandage

The nurse is caring for a client in the postanesthesia care unit (PACU) who has just undergone a third foot surgery. Which gate is best for the nurse to teach this client?

swing-to gait Rationale:The swing-to gait utilizes the client swinging both legs to the crutch position in front of them. This eliminates the client bearing all the weight on the affect foot. The four-point gait utilizes "four" legs; one crutch, then one leg, the other crutch, and then the other leg.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

the alternative measures attempted before applying the restraints

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

tip of the penis Rationale:The nurse would always clean from the least contaminated area to the most contaminated area.

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned?

to either side and slightly behind the client with near hand on gait belt Rationale:When ambulating a client with a gait belt, the nurse should stand to either side and slightly behind the client with near hand on gait belt. The other positions do not allow the nurse to properly use the gait belt to help provide stability and balance.

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate?

tying the restraint behind the chair Rationale:The nurse should run the restraint under the arm rests and tie it behind the chair. Tying the restraint out of the client's reach promotes security. Tying the restraint to the side rail or in the front of the chair would allow the client to untie the restraint. Tying the restraint under the chair would not provide the nurse with swift access to the quick-release knot.

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?MC

waiting outside of the closed bathroom door while the client uses the toilet

The nurse is demonstrating proper ambulation technique with crutches to a child with a fractured ankle. What is priority assessment should the nurse perform?

weight bearing status Rationale:The nurse should assess the client's weight to help determine which crutch gait to demonstrate. The nurse should consider pain, neuromuscular, and neurovascular status when ambulating a client; however, ignoring weight bearing status could cause increased injury to the client as well as impair the client's safety with crutch ambulation.

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms?

wiping down the handles of the walker once the client has returned to bed