Basic Care and Comfort

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

shearing forces; To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?a) assessing the client's environment for sanitationb) coordinating various agency servicesc) teaching the client about the disease and its treatmentd) offering the client emotional support

teaching the client about the disease and its treatmentExplanation:Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease.

A 7-year-old client is admitted to the hospital for a tonsillectomy. After the surgery, the physician orders a clear liquid diet. The nurse is correct in giving the child which items? Select all that apply.a) Ice creamb) Lime gelatinc) Orange juiced) Cream of chicken soupe) Chicken brothf) Apple juic

• Apple juice• Chicken broth• Lime gelatinCorrectExplanation:Clear liquids include clear broth, gelatin, clear juices, water, and ice chips

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."; To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids.

A school-age child loses their appetite secondary to side effects of chemotherapy. What will the nurse teach the parents about nutritional choices for the child?

"Let your child eat any foods that appeal to them right now."

Which of the following interventions would likely be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?a) Lying in a prone position.b) Applying ice compresses.c) Blowing the nose gently.d) Applying warm, moist compresses.

Applying ice compresses.Explanation:The most effective way to decrease discomfort is to decrease local edema. Cold application, such as an ice compress or ice bag, is effective.

The parent of a child with autism tells the nurse that her child is only sleeping 2 to 3 hours per night. When educating the parent about treatment for the child's sleep disturbance, the nurse should include what information?

Behavioral interventions including sleep-hygiene measures are often effective in treating sleep disturbance.

The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What interventions will the nurse include in the client's plan of care? Select all that apply.

Change tubing and bag every 24 hours.Ensure patency of the tube prior to enteral feedings; The PEG tube should be flushed in between every feeding and access. Formula should not hang longer than 4 to 8 hours. Initial feedings should start out slowly, monitor client comfort, and change tubing/bag every 24 hours. Verification of patency prior to each feeding is essential to prevent aspiration.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Deficient fluid volume

A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first?

Inquire about the client's sleeping habits.

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.

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?

Promote arterial and venous circulation.

To prevent back injury, the nurse should instruct the client to:

avoid prolonged sitting and standing.

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.

Parents of a 4-year-old child with acute leukemia ask a nurse to explain the concept of complementary therapy. The nurse should tell the parents that

complementary therapy is an alternative to conventional medical therapies; The nurse should tell the parents that complementary therapy is a form of alternative medicine. This type of therapy can include diet, exercise, herbal remedies, and prayer.

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 depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on how much time the client spends in bed during the day.

Which diet would be most appropriate for the client with ulcerative colitis?a) high-calorie, low-proteinb) low-fat, high-fiberc) high-protein, low-residued) low-sodium, high-carbohydrate

high-protein, low-residueCorrectExplanation:Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease?

low sodium; A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed.