MED 2060 Exam #2 Review

A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

check the client for injuries

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information

client concern

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

close the curtains around the client's bed

A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

determining the client's mobility

A nurse is preparing an older adult client for a physical examination the provider s about to perform. Which of the following actions should the nurse take?

explain to the client what is about to happen.

A nurse is preparing to lift a box of supplies in the supply room. Which of the following body mechanics should the nurse plan to use?

keeping the box close to his body as he lifts it.

A nurse is assisting a client during ambulation when the client begins too fall. Which of the following actions should the nurse take?

lower the client to the floor

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

pinch up a fold of skin to check for turner

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's integrity?

provide the client with a diet high in protein.

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for a client. Which of the following actions should the nurse take?

turn the client on his side before starting oral care

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

"When the client moves, he should move the cane forward first."

A nurse is providing hygiene care for a client who is immobilized. Which of the following actions should the nurse take? (select all that apply)

-check the bed linens when removing them for personal items. -keep the bath water's temperature between 43.3C (110F) and 46.1C (115F) -shave the client's hair in the direction of the hair growth.

A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (select all that apply)

-contractures of extremities -crackles is the lungs -pressure ulcers

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left sims' position.

A nurse is reinforcing teaching with a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Bend at the knees when picking up an object.

A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?

Decreased muscle mass

A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

Grasp a fold of skin on the client's forearm or near the sternum

A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?

Nausea (Subjective data information that only client can perceive and reports. The nurse cannot determine that the client feels nauseated.

A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

The client faces the direction of movement when sliding an object across the floor.

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer. Which of the following is most important for the nurse to determine?

The client's current weight-bearing status (the greatest risk to this client is injury from falling during the transfer due to an inability to bear weight; therefore, the priority data for the nurse to collect is to determine how much of the client's weight he can bear. This will help the nurse select the safest method of transfer.)

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?

The client's sociocultural background influences nonverbal communication.

A nurse on a medical unit is reinforcing teaching with a group of assistive personnel about handling clients' bed linens safety. which of the following instructions should the nurse include?

Tie linen bags securely at the top

A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?

To prevent aspiration problems