Nuring Exam

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 the nurse's grasp and help provide more stability and balance

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action will the nurse take?

closing the client's room door to reduce unnecessary noises

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

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

The nurse has finished installing a small-volume cleansing enema into a client. What instruction will the nurse give the client following the installation?

'Hold the solution in until the need to defecate is strong.'

The nurse is distributing afternoon medications to the clients. When removing a tablet from a multidose bottle, what should the nurse do first?

Pour the tablet into the bottle cap.

The nurse is preparing to give a bed bath to a client. Which supply(ies) will the nurse gather before entering the client's room? Select all that apply.

Protective pads, Towels, Bath blanket, Gown, Linen

The nurse is aware that the prolonged use of bedpans by the client has certain risks. Which intervention will the nurse perform to prevent skin breakdown for a client using a bedpan?

Provide skin and perineal care after bedpan use.

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.'

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why they need to ambulate in the hall three times per day. What is the correct response by the nurse?

'Ambulation helps prevent thromboembolism.'

The nurse is preparing to administer medications to the client. The client sees the nurse double-checking each medication and asks the nurse what is occurring. What is the nurse's best response?

'Checking the medication again to ensure the right medication is given to you.'

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

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

The nurse is administering medications to the client. What does the nurse explain to the client who asks about the checks of medication administration? Select all that apply.

'I check the label when taking medication from the storage area.', 'I check the label of any medication before administering it to you.', 'I check the label before removing the medication from its container.'

The client overhears the nurse reviewing the rights of medication administration and asks, 'Why are you saying, 'right medication, right client, right dose, right route'?' What is the nurse's best response?

'I review these to make sure your medications are accurate and correct.'

The nurse has completed a preoperative teaching session with a client who will receive morphine via a patient-controlled analgesia (PCA) pump after surgery. Which statement by the client indicates the need for further teaching?

'I will remind my family member to push the PCA pump button for me if I doze off during the day.'

The nurse explains to another nurse the meaning of situational awareness. Which client exemplar does the nurse use to illustrate situational awareness?

'If the call bell has been out of the client's reach, I ask if the client needs to void or defecate.'

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 them, 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.'

The nurse administers medication to a client. Which statement by the nurse is required to satisfy the three checks and rights of medication administration?

'Please tell me your name and date of birth.'

The client asks to help express the small-volume enema solution. Which instruction by the nurse will best facilitate instilling the enema solution completely?

'Roll the bag toward the buttocks and then keep it rolled while removing it from the rectum.'

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

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

A client has been prescribed a small-volume enema for constipation following surgery and asks the nurse how such a small amount of fluid can lead to a bowel movement. How will the nurse respond?

'This enema pulls fluid from the intestine to stimulate defecation.'

The nurse is preparing to administer a sublingual medication. Which instruction to the client is correct?

'Try not to swallow while the pill dissolves.'

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.'

The nurse is presenting an educational inservice about comfort and asks the participants to provide examples of effective comfort measures. Which response(s) by participants indicates a correct understanding of the concept? Select all that apply.

'straightening wrinkled bed linens', 'holding a client's hand during an invasive procedure or during times of emotional stress', 'assisting a client with hygiene needs', 'keeping the client's environment free from unpleasant odors', 'administering prescribed analgesic medications'

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 assisting a client to use progressive muscle relaxation techniques. Place in order, from first to last, the action the nurse will implement. Use all options.

1)Explain procedure and rationale to client. 2)Assist client to a comfortable position. 3)Ask client to focus on a specific muscle group. 4)Instruct client to tighten that muscle group and hold it tight for 5 seconds. 5)Instruct client to totally relax a specific muscle group and concentrate of the sensation.

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.

Place in the correct order the process to verify the placement of the nasogastric tube. Use all options

1)Measure exposed length of tube.2)Attach syringe to tube and aspirate 6 ml of gastric secretions.3)Measure pH using appropriate testing strips.4)Flush the tube with 30 to 50 ml of water.5)Remove syringe and attach to feeding delivery set.

The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Place the following steps in the correct order. Use all options.

1)Position the client with the head of bed elevated 30 to 45 degrees.2)Verify correct tube placement.3)Aspirate all gastric contents.4)Verify that residual volume is less than 200 ml.5)Flush the tube with 30 ml of water.6)Administer the feeding.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. At what level does the nurse place the feeding bag on the pole?

12 in (30 cm) above the stomach

The nurse prepares to provide gastrostomy insertion site care. The gastrostomy tube was placed this week. The client reports pain at the site. Which action does the nurse take next?

Administer pain medication.

The nurse is helping a client to climb stairs while using a cane. Which step will the nurse emphasize?

Advance the stronger leg up the stair first, followed by the cane and weaker leg.

The nurse provides the client with a gravity feeding via a gastrostomy tube. Which action is most appropriate for the nurse to ensure is accomplished?

Allow the feeding to infuse slowly from the feeding bag.

The nurse has finished aspirating the gastric contents before administering a prefilled, continuous tube feeding. At this point in the procedure, how much sterile water does the nurse use to flush the tube?

30 ml

The nurse is providing a continuous tube feeding for a client. At what angle will the nurse place the head of the bed during the feeding?

30 to 45 degrees

The nurse is caring for a client who had a gastrostomy tube placed 24 hours ago. While assessing and changing the dressing, the nurse will ensure the gastrostomy tube is rotated at least how many degrees?

360 degrees

A nurse is checking a client's nasogastric tube aspirate before administering the prescribed medication. Which pH reading does the nurse find concerning?

6.0

The nurse is caring for a client who is receiving a continuous tube feeding. Which accurately describes an aspect of this procedure?

A feeding pump is used for a continuous feeding.

Which recommendation(s) will the nurse include in a teaching plan for preventing falls in the home? Select all that apply.

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

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

Begins cleansing from the anus toward the pubic bone.

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

Apply a thin barrier of skin protectant to the perineal area.

A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. On inspection the nurse finds a great deal of slack in the tube. Which action will the nurse take next?

Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

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

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

A nurse delivers a tray of food to an older adult client who shows no interest in the food. Which response(s) will the nurse prioritize? Select all that apply.

Ask why the client does not want to eat anything on the tray., Assess the client for signs of depression.

A nurse enters a client's room to perform a tube feeding. Which nursing action will the nurse perform first?

Aspirate stomach contents and check pH.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What action will the nurse take first?

Assess both eyes for contact lenses.

The nurse is caring for a client who asks to use a bedside commode. Prior to assisting the client, what action(s) will the nurse take? Select all that apply.

Assess client for weakness or unsteady gait., Evaluate the client for any functional limitations., Check for the presence of drains and IV fluid lines.

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 intervention is appropriate?

Assess for the need to urinate.

Prior to allowing a client to eat, which action is most important for the nurse to take?

Assess the client's level of consciousness.

The nurse arrives to begin a 12-hour shift and learns one of the clients was prescribed wrist restraints during the last shift because the client pulled out the IV. Which action(s) will the nurse complete on this client when it is time for the next 2-hour restraint removal period? Select all that apply.

Assess the client's skin integrity under the restraints., Assess the circulation in the hands., Reassess the client's behavior to determine if restraints are still needed.

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 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 will the nurse take?

Change into a new pair of gloves.

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.

The client tells the nurse that the medication in the cup is not the same as the medication they took the day before. The client is insistent that the medication is not the one prescribed. Which action does the nurse prioritize?

Check the drug package with what is written on the medication administration record.

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?

Check the medical record for the client's prescribed diet.

The nurse is performing the third medication check for a medication administered from a multidose bottle. What will the nurse do?

Check the multidose bottle label after identifying the client and before administering the medication.

The nurse is to administer a medication to a client in isolation and the medication is in a multidose container. How will the nurse complete the third check of medication administration?

Check the multidose label before putting the container back in the drawer and label medicine cup with needed information.

The nurse is administering an intermittent tube feeding using a gravity set-up and open feeding bag system. After checking tube placement, which does will the nurse take next?

Check the residual.

The nurse has administered a client's medication. Which action is most appropriate if the client vomits immediately or soon after administration?

Check the vomit/emesis for pills or pill fragments and call the client's health care provider.

The older adult client is moving to another apartment. The nurse encourages 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.

The nurse is in the client's room to administer the client's morning oral medications. Which action does the nurse take first?

Confirm the client's identity.

The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action will the nurse take?

Connect a syringe filled with warm water to the feeding tube and flush the tube using gentle pressure.

The nurse is caring for a client who has a newly written prescription for 'fluoxetine 20 mg by mouth daily for treatment of depression.' The nurse is unfamiliar with this medication. Which action is appropriate?

Consult a professional medication reference before preparing to administer the medication.

A nurse is preparing to administer oral medications to a client. While opening the unit-dose package, the medication inadvertently falls on the floor. Which action by the nurse is appropriate?

Discard the current unit-dose package and obtain a new one.

The nurse is caring for a client who has a prescription for strict intake and output measurements. The client wants to use the bedside commode. What is most important for the nurse to instruct the client?

Do not place toilet tissue in the commode because it may affect accurate our measurement.

The nurse is administering a client's medication and more tablets than needed fall into the bottle cap. What will the nurse do?

Drop extra tablets into bottle from bottle cap.

A client with dysphagia prepares to eat dinner. Which action will the nurse ensure is completed?

Ensure the head of the bed is high-Fowler.

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

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 anticipates the need to check on the client at which frequency?

Every 1 to 2 hours

The nurse is caring for a client receiving patient-controlled analgesia (PCA). How often does the nurse assess the client?

Every 4 hours.

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(s) will the nurse include? Select all that apply.

Falls, Pressure injuries, Contractures, Delirium

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

Fanfold the linens at the bottom of the bed and remove them to the chair.

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 action(s) is appropriate? Select all that apply.

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

The nurse is helping a client perform range-of-motion exercises on the hand and fingers. Which exercise will be performed first?

Flex the hand down and backward and relax.

The nurse is administering an intermittent tube feeding to a client via gravity using an open feeding bag system. What step will the nurse perform when the feeding bag is empty?

Flush the feeding bag with 30 ml water.

The nurse has assisted a client to roll onto their side and then, after placing the bedpan under the buttocks, asks the client to roll back over on the bedpan. What is another method of having the client assist with getting on a bedpan?

Have the client flex their knees. lift their buttocks so the nurse can slide the bedpan under them.

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.

The nurse is assisting a male client who is unable to use their arms with urination. Which action is appropriate for the nurse to complete while assisting this client?

Hold the urinal in place while the client urinates.

The instructor observes a nursing student who is preparing a liquid medication from a multidose bottle. Which action concerns the instructor if it were demonstrated by the student?

Holds the bottle of liquid medication with the label facing the medication cup.

After reviewing the skills for administering different medications, a student nurse demonstrates the need for additional review when which action is taken?

Leaves before verifying that the client has swallowed the medication.

A client has alerted the nurse that they are finished using a bedpan. What action does the nurse perform before removing the bedpan?

Lower the head of the bed slightly.

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

Lying on one side

The nurse is making an occupied bed. What is the appropriate location for the nurse to place the drawsheet under the client?

Midsection

The nurse is instructing a client to perform range-of-motion exercises on the head. Which statement accurately describes a recommended movement?

Move the chin down to rest on the chest.

The nurse adjusts a client's bed to a comfortable working height to turn a client. What is the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning.

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 caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action is appropriate to address this concern?

Notify the health care provider for a prescription to apply an antifungal powder.

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.

The nurse enters the client's room to administer oral medications. Which action does the nurse take first?

Perform hand hygiene.

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take?

Place a gauze dressing under the external bumper.

The nurse is assisting the client with transfer to a bedside commode. After the client stands and pivots, what will the nurse instruct the client to do next?

Place hands on the armrests prior to sitting down.

The nurse has assisted the bedbound client to place the urinal between their legs. The nurse instructs the client to place the penis into the urinal. After covering the client with the bed linens, what is the nurse's next action?

Place the call bell and toilet paper next to the client and instruct the client to call when finished urinating.

When pouring a liquid medication into a graduated liquid medication cup, which nursing action is most appropriate?

Place the cup on a flat surface at eye level.

The nurse is administering routine medications to a postsurgical client and the client asks, 'Could I have something for pain?' The nurse checks the medication administration record (MAR) and notes that the medication is an opioid. What will the nurse do?

Place the opioid into a separate cup.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse requires intervention by the charge nurse?

Places the client in the left lateral recumbent position.

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?

Placing the client in a side-lying position

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action will the nurse take next to decrease the risk of impaired skin integrity?

Pull the shoulder blade forward and out from under the client.

The nurse is disposing of the contents of the client's urinal. Which procedure will the nurse follow when cleaning the urinal?

Put on clean gloves, rinse the urinal with water, and dry with paper towel.

A nurse must change the linens on a bed while it is occupied. Which action(s) will the nurse take? Select all that apply.

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

The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method will the nurse use to increase the flow rate of the formula?

Raise the height of the syringe.

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What action will the nurse take next?

Raise the side rail.

A nurse has administered a pain medication to the client. What should the nurse do next?

Reassess the client.

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 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 projected outcome will the nurse question?

Reported increased strength in the weaker leg.

A new client has been admitted to an acute care unit who is wandering into other client's rooms and nursing work areas. Which action will the nurse utilize to help keep this client safe?

Request a sitter to stay with the client.

The nurse is caring for a client receiving patient-controlled analgesia (PCA). Why does the nurse assess the client's sedation score while the PCA is active?

Respiratory depression can occur with the use of opioid analgesics.

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.

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

Scrotum

The client has had surgery to repair a left hip fracture. The client is asking to use the bedpan. How will the nurse assist the client onto the bedpan? Select all that apply.

Seek assistance from another nurse to support the affected leg., Turn the client onto the unaffected leg to place the bedpan., Ensure the client's buttocks are resting on the shallow rim of bedpan.

The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this scheduled unit-dose packaged antihypertensive medication?

Set the antihypertensive dose aside pending assessment.

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

The nurse is checking on a client who has just completed receiving a tube feeding. Which action does the nurse now instruct the client to take?

Sit up for 1 hour.

The nurse is caring for a client who has dysphagia and is unable to eat independently. Which action is appropriate by the nurse while assisting this client?

Speak to the client but limit the need for the client to respond verbally while chewing and swallowing.

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

Start with cleanest areas and end with most soiled areas.

When assessing a client receiving patient-controlled analgesia (PCA), the nurse assigns the client a sedation score of 4. Which action will the nurse take at this time?

Stop the medication infusion immediately and notify the health care provider.

A nurse is administering a small-volume enema to a client to relieve fecal impaction. After initiating this action, the client reports nausea and lightheadedness. The nurse also notes a decrease in the client's heart rate. Which action does the nurse prioritize?

Stop the procedure and monitor client's heart rate.

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

Suction toothbrush

The nurse splits a medication for client administration. What action(s) will the nurse take to assure safety and proper documentation? Select all that apply.

Take medication to bedside., Take medication package and label to bedside., Take computer to the bedside

The nurse has inserted a nasogastric tube in a client per orders. Which action will the nurse accomplish next?

Test the pH of aspirated content.

The nurse performs a situational assessment for a client with a high risk of injury. Which finding(s) during this assessment requires the nurse to act? Select all that apply.

The client is confused as to why the call bell wo not call home., The client's adult child places shoes and a cane next to the raised bed rail., The client needs the assistance of two staff when getting out of bed.

The nurse is completing a situational assessment. Which findings will the nurse prioiritize? Select all that apply.

The client is wearing the oxygen around the neck., There is spilled water on the floor., The IV is not infusing at the correct rate., The skin is a bluish-color.

The nurse typically delegates a situational assessment to the unlicensed assistive personnel (UAP) for the home care client with heart failure. Which finding indicates the nurse will perform this assessment rather than delegate it?

The client went to the emergency department to be evaluated after a fall.

The nurse has asked the unlicensed assistive personnel (UAP) to help a client with a bedpan. In which situation will the nurse intervene after noting the UAP is taking powder to the client's bedside?

The client's urine is needed for a urinalysis.

A nurse is preparing to assist a client in using a bedpan. Which factor will the nurse use when assisting the client?

The largest part of a regular bedpan will be placed under the client's buttocks.

The nurse is educating the client about the benefits of implementing nonpharmacologic methods of comfort and pain management. What will the nurse include in the teaching plan? Select all that apply.

They can lessen the emotional aspects of pain., They can improve your sense of control., They can help promote restful sleep., They can strengthen your coping abilities.

The nurse is caring for a client receiving patient-controlled analgesia (PCA) on hospice care. Which is the nurse's best response when asked by a family member for the purpose of the PCA pump's lockout interval?

To prevent reactivation of the PCA pump and administration of another dose during the specified period of time.

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

Twice a day

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 will pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds

A nurse is teaching a client on the proper use of a urinal. Which information will the nurse ensure is included in the teaching session?

Unless contraindicated, the client should stand to use a urinal.

A nurse is distributing the 0900 hour medications to the client. What action(s) will the nurse take when removing a tablet from a multidose bottle? Select all that apply.

Use gloves for extra protection., Take the multidose bottle into the client's room., Put an extra tablet back into the bottle from cap.

A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain?

Use of nonpharmacologic methods can diminish the emotional component of pain.

The nurse is helping to clean a female client who has urinated into a bedpan. What action will the nurse prioritize to complete this task?

Use toilet paper to wipe the client from the pubic area to the anal area.

The nurse has just completed programming of a patient-controlled analgesia (PCA) pump using prescribed parameters. Which action will the nurse take next?

Verify the settings with another nurse.

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instruction(s) will the nurse include in the teaching? Select all that apply.

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

What will the nurse teach the client who is ambulating with a cane to do after advancing the cane a short distance?

While supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

The nurse is caring for a female client who has used a bedside commode. The client requires assistance with personal care after voiding. How will the nurse assist the client with personal hygiene?

Wipe using one stroke from the pubic area toward the anal area.

The nurse is teaching a client how to prepare and administer liquid medications. The client has been on other types of medications for several years. What common error is most appropriate for the nurse to caution the client against performint during the teaching?

You should use an accurate measuring device, not use any other type of measuring device.

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client completed?

active

The acute care nurse is preparing to care for an 86-year-old client with severe dementia, just returned to the unit after surgery to repair a fractured hip. Which pain management strategy is appropriate for this client?

authorized agent-controlled analgesia (AACA)

A client has had a nasogastric tube inserted in preparation for tube feedings. When developing the client's plan of care, the nurse anticipates checking the placement of the tube at which time?

before administering a medication through the tube

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 is most appropriate for this client?

cane with four prongs on the end (quad cane)

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 risk(s) in the home? Select all that apply.

clutter, polypharmacy, extension cords

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

cognitive function level

A nurse is caring for a client who has been prescribed a clear liquid diet. Which liquid can be included in the client's diet?

cranberry juice

A client is recovering from abdominal surgery. The nurse notes it is time for the client to be repositioned. Which action will the nurse prioritize when repositioning the client?

determining the client's level of pain

The nurse is preparing a bedpan for a client to use after an abdominal surgery. What is the most important concept that the nurse incorporates when assisting the client with a bedpan?

dignity

The client is receiving a continuous tube feeding using a feeding pump. How often should the nurse plan to check for gastric residual in this client?

every 4 to 6 hours

The nurse is caring for a client who has a continuous tube feeding. How often will the nurse confirm placement of the tube?

every 4 to 6 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

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

The nurse is teaching a client how to perform range-of-motion exercises on the toes. What motions will be accomplished by curling the toes downward, spreading the toes apart, and then bringing them together?

flexion, extension, abduction, and adduction

The nurse is helping a client with musculoskeletal alterations to perform range-of-motion exercises. In what order will the nurse perform the exercises for the client?

from the head and down one side of the body at a time

The nurse moves a client's leg laterally away from the client's body and then crosses it over the other leg. What joint or muscle is the nurse exercising?

hip

The nurse is caring for a postsurgical client. The client asks the nurse why they need to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factor(s)? Select all that apply.

increase joint flexibility, improve respiratory function, aid gastrointestinal motility

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 10 breaths per minute. The client is somnolent, with minimal response to physical stimulation. Which medication will the nurse administer immediately?

intravenous naloxone

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

leaning for prolonged periods by the axilla on the crutches

The nurse is preparing a client to be turned in bed. In what position will the nurse place the bed to begin this procedure?

lying flat

The nurse is preparing a client to receive a small-volume cleansing enema. In what position will the nurse place the client for this procedure?

lying on the left side with the bed flat and the back of the client facing the nurse

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

on the right side

Which route of medication administration is the most commonly prescribed?

oral

A nurse learns that a client will be receiving patient-controlled analgesia (PCA). In which format(s) might the nurse give the PCA to the client? Select all that apply.

oral analgesic agents, intravenous opioid analgesic agents, subcutaneous opioid analgesic agents, epidural opioid analgesic agents, perineural opioid analgesic agents

A nurse is preparing several oral medications for administration. One of the medications requires the nurse to obtain the client's apical pulse before administering it. Which action is most appropriate?

placing the medication requiring the assessment in a separate medication cup

Prior to placing the bedpan under a client's buttocks, what will the nurse apply to the bedpan if a urine specimen is not needed?

powder

When administering medications to a client, what information should the nurse know about the medication? Select all that apply.

purpose, adverse effects, action, safe dose range

A nurse is concerned the end of a client's nasogastric tube is in the wrong location. Which method is most reliable for the nurse to verify the correct placement of the tube?

radiographic confirmation of position

What motion is being provided for the shoulder when the nurse raises a client's arm at the side until the upper arm is in line with the shoulder, bends the elbow at a 90-degree angle, moves the forearm upward and downward, and returns the arm to the side?

rotation

When performing a situational assessment, which assessment will the nurse complete as the last step?

safety survey

The nurse is preparing a female client to use a bedpan. In what position will the nurse place this client?

sitting upright

The nurse places a frail older adult client on the bedpan. After the client has voided and the nurse has removed the bedpan, what assessment is necessary for the nurse to complete?

skin assessment of the buttocks and coccyx

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where does the nurse place an additional pillow?

supporting the client's back

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

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

A nurse is measuring a liquid medication in a graduated liquid medication cup. The nurse determines the correct amount by reading:

the bottom of the meniscus.

The nurse is preparing to assist a client by placing a bedpan. For which client will a fracture bedpan be the most comfortable choice for urinary elimination?

thin, older adult female client who has pneumonia

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

tip of the penis

If the nurse is the only caregiver assisting a client with gait belt ambulation, where will the nurse position themself?

to either side and slightly behind the client with near hand on gait belt

The nurse is assisting a client who is immobilized with a neck injury to use a bedpan for urinary elimination. What is one of the primary nursing goals when assisting a client with urinary elimination?

to promote comfort and normalcy with urinary elimination

The nurse is caring for a client who has used the bedside commode. What will the nurse document for this client? Select all that apply.

tolerance of activity, characteristics of urine and/or stool, alterations in skin integrity

The nurse is assisting a client, who is on bed rest following surgery, with range-of-motion exercises. How many repetitions will the nurse perform with each range-of-motion exercise?

two to five

The nurse has asked the unlicensed assistive personnel (UAP) to assist a 42-year-old male client who is on bed rest following knee surgery to empty the bladder. Which device will the nurse choose with this client?

urinal

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which action by the new nurse requires the charge nurse to intervene?

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

The nurse is teaching proper ambulation technique with crutches to a child with a fractured ankle. Which priority assessment will the nurse perform during this process?

weight-bearing status

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