Basic Care and Comfort

Which client requires increased sensory stimulation to prevent sensory deprivation?

a 65-year-old client who has employment-induced presbycusis and advanced glaucoma

The nurse is administering bolus gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). What should the nurse do to prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube?

Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel.

A nurse is caring for a client with Alzheimer disease who was admitted to the hospital from a nursing home. The hospital staff is having difficulty managing the client's urinary incontinence because the client wanders around the unit all day. What is the most appropriate action by the nurse to assist with elimination?

Incorporate a toileting schedule into the pattern of the client's wandering.

A deceased client had dentures and an artificial eye. What should the nurse do with these items?

Tag them for the mortician.

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.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

Which meal would be most appropriate for an adolescent with glomerulonephritis with severe hypertension?

baked chicken, rice, beans, orange juice

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

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.

Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next:

discuss the situation and possible courses of action with the dietitian and the client.

A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?

encouraging intake of at least 2 L of fluid daily

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse?

Discontinue the graduated compression stockings and notify the healthcare provider. When a client has prescribed graduated compression stockings, the nurse would remove the stockings and inspect the skin at least every 8 hours. If the client has discoloration, markings, or blisters on the heel, the nurse would discontinue the stockings and notify the healthcare provider because sequential compression devices may be used instead to prevent deep vein thrombosis. Applying antibiotic ointment or sterile dressings would require a healthcare provider's order, therefore the healthcare provider should be notified before proceeding with the reapplication of the stockings. Reapplying the stockings may cause further damage to the heel, therefore the healthcare provider should be notified before making a referral to the skin care team.

A nurse is planning to implement nonpharmacological pain management strategies as part of a multimodal approach for managing the client's pain. For which strategy does the nurse seek a prescription from the health care provider?

application of an ice bag

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which actions should the nurse take before starting the NG feeding on the child? Select all that apply.

Verify the physician's order. Check placement of the NG tube. Assess for bowel sounds. Verifying the order, checking the placement of the NG tube, and assessing bowel sounds are necessary before initiating an NG feeding. Formula should not be heated in the microwave and no more than a 4-hour supply should be hung to prevent the growth of microorganisms.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate?

Offer the client frequent oral hygiene care.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:

maintain adequate nutrition through oral or parenteral feedings.

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

The client sustained a tibia fracture and a cast was applied. The client is reporting increasing pain when flexing toes. Which symptoms does the nurse assess as associated with compartment syndrome? Select all that apply.

pain pulselessness paresthesia

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."

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. Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

The nurse recognizes that discharge planning begins upon admission and the initial step in discharge planning is

collecting and organizing data about the client.

A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the spouse speaking for the client and finishing the client's sentences?

"Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse."

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which statement indicates the client's understanding of the nurse's instructions?

"I'll increase my intake of unrefined grains."

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." Clients who need ear irrigations should not perform these at home. The procedure is one that should be performed by a healthcare professional only due to the risk of damage to the ear if performed incorrectly. Supplies are not routinely furnished by the hospital, and could be obtained from a medical supply company; however, this is not relevant because the client should not irrigate the ear.

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

The nurse is caring for a client with bipolar disorder who was recently admitted to an inpatient unit and is experiencing a manic episode. What is a priority nursing intervention for this client?

Closely monitor the client's eating and sleeping habits.

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.

A prenatal client wants to begin a yoga-based exercise class to keep her healthy during pregnancy. What information should the nurse include in the plan of care? Select all that apply

Drink plenty of water before, during, and after a workout. Take precaution to prevent overheating. Avoid jerky, high-impact motions. Modify any positions that put strain on the abdomen.

For a client with anorexia nervosa, which goal takes the highest priority?

The client will establish adequate daily nutritional intake.

The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which type of food to minimize the rise in blood glucose level after meals?

dietary fiber

Two days after a herniorrhaphy, the client reports that his scrotum is swollen and painful. To promote comfort, the nurse should instruct the client to:

elevate the scrotum and place ice bags on the area intermittently.

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 7-year-old client is prescribed a clear liquid diet by the healthcare provider after tonsillectomy. What nutrition will the nurse give the child? Select all that apply.

lime gelatin apple juice chicken broth

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

vesicle

The nurse places inflatable compression sleeves on the legs of a client undergoing a cesarean birth under regional anesthetic. When does the nurse tell the client that the sleeves will be removed?

when the client resumes ambulating

A client recently experienced a stroke with accompanying left-sided paralysis. The family voices concerns about how to best interact with the client. They report the client doesn't seem aware of their presence when they approach the client on the left side. What advice should the nurse give the family?

"The client is unaware of their left side. You should approach them on the right side."

A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown? Select all that apply.

Always wear socks, and preferably, shoes to protect the feet. Use lotion on feet to keep skin from becoming dry and cracked. Check the feet daily to look for any injuries to the feet.

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 can help.

An adolescent has skeletal traction for a fractured femur. Which is the most appropriate nursing intervention for this client?

Assess pin sites every shift and as needed.

Which nursing intervention is essential while caring for an infant with cleft lip or palate?

Involve the parents in feeding as soon as possible.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Prioritize the steps of proper cane usage. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Hold the cane on the right side and advance the left leg. Advance the cane 6 to 10 inches (15 to 25 cm) with each step.

A client with a history of posttraumatic stress is panting and breathing heavily while shouting out some strange words. The nurse reviews the nursing assessment and understands that the client is practicing a form of relaxation called power breathing. The best action for the nurse to take is to:

allow privacy, but check on the client frequently.

For which client is the nursing assessment of pain most likely to result in undertreatment?

an older adult who grimaces and states no pain after a gastrostomy tube placement

A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. What is the nurse's best response?

"Let us try this until you can have acupuncture."

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?

"No, it can initiate premature uterine contractions."

The nurse is educating a client who works with chemicals on immediate emergency care in the event of eye exposure. Which statement reflects correct teaching by the nurse?

"You should flush your eyes for about 15 minutes with tap water to remove the chemical." The client who works with chemicals should be taught emergency care of the eyes in the event of chemical exposure. If one or both eyes are exposed, the client should irrigate the eyes for approximately 15 minutes with tap water to try to remove the chemical (sterile water is not required for flushing). Waiting until the client gets to the emergency department would delay care that could prevent more extensive injury to the eyes. There is no need to irrigate both eyes if only one is exposed; the client should be careful to not let the water run into the unaffected eye in case of chemical exposure in this way.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse?

Check the medical record for a provider's prescription for compression stockings.

A client with venous thrombus reports having pain in the legs. What should the nurse do first?

Elevate the foot of the bed.

A child is prescribed amoxicillin for otitis media. What should the nurse recommend the mother do when the child develops diarrhea?

Offer yogurt several times a day.

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 is instructing the client with a new colostomy about protecting the skin around the colostomy. Which skin barrier should the nurse tell the client is best to apply around the colostomy?

adhesive skin barrier

When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?

high purine

An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate?

providing small, frequent meals

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

stress incontinence.

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that 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 client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn for pain. The client rates the pain as a 7 on the numeric scale of 0/10. The nurse should administer how many oxycodone/acetaminophen?

2

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highestpriority?

Elevate the head of the bed during and after the PEG tube feedings.

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage?

milk

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 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.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest?

football hold

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client?

high-calorie, high-protein

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs?

Provide client with assistance in hygiene, grooming, and dressing.

The nurse is caring for a child in Bryant's traction (see figure). What action should the nurse take?

Provide frequent skin care.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?

Restrict sodium.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently. These infants usually swallow a lot of air from sucking on their hands and fingers because of their intense hunger. Burping frequently will reduce gastric distention, and increase the likelihood that the infant will retain the feeding. Feedings should be given slowly with the infant lying in a semi-upright position. Parental participation should be encouraged to the extent possible, but this will not increase the likelihood that the feeding will be retained. Record the type, amount, and character of the vomit, as well as its relation to the feeding. The amount of feeding volume lost is usually refed to the infant.