Basic Care and Comfort (Passpoint)

The nurse is performing a medication reconciliation, and the client requests a green coffee bean supplement to lose weight. What is the nurse's best response? 1. "There is limited scientific information on the connection between green coffee beans and weight loss." 2. "The hospital does not offer any of the green coffee bean items, but I can get you some tomorrow from my home." 3. "I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime." 4. "The hospital does not have green coffee bean supplements in the formulary, but you can bring them from home."

"I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime." Rationale: The nurse needs to contact the healthcare provider (HCP) to complete the medication reconciliation process. The supplement should be added to the regimen only after the HCP has assessed potential contraindications and given approval. While it may be appropriate to inform clients that herbal supplements and alternative therapies do not always have scientific evidence to support their use, merely informing the client of this does not address the request. The nurse can determine how to obtain the green coffee bean supplement if the HCP approves of it.

A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The client asks the nurse how massage will help the pain. What is the best response by the nurse? 1. "A massage will relax muscles but does not work on ligaments and tendons." 2. "Massage is widely practice by all hospitalized clients." 3. "Massage is an alternative therapy that uses herbal supplements." 4. "Massage is point stimulation used for orthopedic and neurological conditions."

"Massage is point stimulation used for orthopedic and neurological conditions." Rationale: Massage uses point stimulation of pushing and pulling of the skin, muscles, tendons, and ligaments to relieve orthopedic and neurological conditions. Massage will relax muscles, ligaments, and tendons. Massage is not widely used by hospitalized clients nor does it include the use of herbal supplements.

For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nursing intervention is likely to be most effective? 1. inviting the client to play a board game with the nurse 2. allowing the client to sit in the community room until the client feels sleepy 3. advising the client to take multiple short naps during the day until symptoms improve 4. teaching the client relaxation exercises to use before bedtime

Make the bed with the bedsheet on top of the pressure mattress. Rationale: To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.

Which client would benefit from the application of warm moist heat? a client with appendicitis a client with a recently sprained joint a client with a suspected malignancy a client with low back pain

a client with low back pain Direct application of warm moist heat would benefit a client with low back pain because the heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis because it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained joints to help decrease edema. Applying heat to the area of a suspected malignancy can increase blood flow to the tumor and promote nourishment of the cancer cells.

The nurse recognizes that discharge planning begins upon admission and the initial step in discharge planning is collecting and organizing data about the client. establishing goals with client. teaching the client self-care activities to be conducted in the home setting. providing home healthcare referrals.

collecting and organizing data about the client. The initial step in discharge planning is collecting and organizing data about the client because this provides information on the client's healthcare needs. Establishing goals, client teaching, and providing home healthcare referrals are steps that will follow the collection and organization of data.

When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of restricting fluids. restricting sodium. encouraging fluids. restricting potassium.

encouraging fluids. The nurse should encourage fluid intake to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's lower foot. ankle. lower thigh. knee.

lower foot Rationale: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return.

A client in the emergency department is diagnosed with benzodiazepine overdose and is lethargic and confused. What would the nurse anticipate as an initial treatment for the overdose? insert a urinary catheter administer intravenous normal saline administer intravenous naloxone perform a whole bowel irrigation

perform a whole bowel irrigation A client who has overdosed with benzodiazepines and is symptomatic will need treatment of the overdose with whole bowel irrigation in order to remove as much of the drug as possible. This may be followed with activated charcoal and a saline cathartic. The other measures of a catheter insertion and IV fluid administration are important parts of supportive care and assessment of the client, but do not treat the overdose initially as a whole bowel irrigation would. Intravenous naloxone would not be used with suspected benzodiazepine overdose but instead with narcotic overdose.

A child is admitted to the pediatric unit with a fracture of the hip. The physician orders Russell traction. This type of traction is skin traction applied to a lower extremity, with the extremity suspended above the bed. skeletal traction applied to a lower extremity. skin traction applied to an extended lower extremity. skin traction applied bilaterally to the lower extremities.

skin traction applied to a lower extremity, with the extremity suspended above the bed. Russell traction is skin traction applied to a lower extremity, with the extremity suspended above the bed and a sling placed under the knee. Skeletal traction applied to a lower extremity is called 90-90 traction. Skin traction applied to an extended lower extremity is called Buck's extension traction. Skin traction applied bilaterally to the lower extremities is called Bryant's traction.

When teaching the parent of an infant with Hirschsprung's disease who received a temporary colostomy about the types of foods the infant will be able to eat, which diet would the nurse recommend? high-fiber diet low-fat diet high-residue diet regular diet

regular diet A regular diet would be recommended for the child with a colostomy; no special diet is needed. A high-fiber diet is not necessary. Fat is necessary for brain growth in the first year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated.