(NURS 100) Assessment 2. WCU

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider?Tinnitus Jaw pain Blurred vision Drowsiness Dysphagia

Jaw pain Blurred vision Dysphagia

A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back/ which of the following is an intervention?

Pinch up a fold of skin to check for turgor

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second ICS

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sounds represents...?

Ventricular gallop

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? A. Change in temperature of the toes. B. Pallor of the toes. C. Edema of the toes. D. Inability to move toes.

B. Pallor of the toes.

A nurse is performing an admission assessment on a client. the nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/minthe pulse deficit is the difference between the apical and radial pulse rates. it reflects the number of ineffective or non perfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84‑68 = 16

A nurse is assessing a client for pitting edema and notes an indentation of 6mm at the point of pressure. Which of the following notations should the nurse document?

3+ (5-7mm) (-2mm :1+, 2-4mm: 2+, +7mm: 4+)

A nurse is instructing an assistive personnel (aP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A."Do not measure the client's temperature rectally." B."Count the client's radial pulse for 30 seconds and multiply it by 2." C."Do not let the client know you are counting her respirations." D."let the client rest for 5 minutes before you measure her blood pressure.

A A. The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. the low platelet count contraindicates the use of the rectal route for this client.

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. the nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A.Presence of associated manifestations B.Location of the pain C.Pain quality D. aggravating and relieving factors

A A. The nurse should attempt to identify manifestations that occur along with the clients pain, such as nausea, fatigue or anxiety.

A nurse should teach which of the following clients requiring crutches about how to use a 3-pt. gait?

A client who has a right femur fracture with no weight bearing on the affected leg.

A nurse is providing teaching to an AP about caring for clients with restraints. Which of the following statements indicates an understanding of the teaching?

I will tie a restraint to the portion of the bed that moves when the head..

A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies. E. immunization status

A, B, C A. Posture is part of the body structure or general appearance portion of the general survey. B. Skin lesions are part of the body structure or general appearance portion of the general survey. C. Speech is part of the behavior portion of the general survey

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A.Place the client in semi‑Fowler's position. B.Have the client rest an arm across the abdomen. C.Observe one full respiratory cycle before counting the rate. D.Count the rate for 30 sec if it is irregular. E.Count and report any sighs the client demonstrates.

A,B,C A. Having the client sit upright facilitates full ventilation and gives the students a clear view of chest and abdominal movements. B. With the client's arm across the abdomen or lower chest, it is easier for the students to see respiratory movements. C. Observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count.

A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (select all that apply.) A. romberg test B. Heel‑to‑toe walk C. snellen test D. spinal accessory function E. rosenbaum test

A,B. A.For the romberg test, the client stands with his eyes closed, arms at his side, and feet together. the nurse verifies balance if the client can stand with minimal swaying for at least 5 seconds. B.For the heel‑to‑toe walk, the client places the heel of one foot in front of the toes of the other foot as he walks in a straight line. the nurse verifies balance if the client can walk in a straight line without losing his balance

Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply.) A. use an open posture. B.Write down what the client says to avoid forgetting details. C. establish and maintain eye contact. D. nod in agreement with the client throughout the conversation. E. respond positively when giving feedback.

A,C,E A/C. Having an open posture m facing the client, and leaning forward are ways the nurse can demonstrate active listening E. responding positively when giving feed back demonstrates active listening

A nurse is caring for an 82‑year‑old client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.) A.Obtain culture specimens before initiating antimicrobials. B.Restrict the client's oral fluid intake. C.Encourage the client to rest and limit activity. D. allow the client to shiver to dispel excess heat. E. assist the client with oral hygiene frequently

A,C,E A. he provider can prescribe cultures to identify any infectious organisms causing the fever. the nurse should obtain culture specimens before antimicrobial therapy to prevent interference with the detection of the infection. C.Rest helps conserve energy and decreases metabolic rate. activity can increase heat production E. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips

A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicated an understanding of the teaching? A. "I can use either heat or ice to help relieve the discomfort." B. "Ibuprofen is the first step in medication therapy for osteoarthritis." C. "I should limit physical activity to prevent further injury." D. "I will elevate my legs by placing two pillows under my knees when I go to bed.

A. "I can use either heat or ice to help relieve the discomfort."

A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include? A. "Sit upright or stand for at least 30 minutes after taking this medication." B. "Take this medication with food." C. "Take this medication with orange juice." D. "Chew or suck on the tablet."

A. "Sit upright or stand for at least 30 minutes after taking this medication."

A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications? A. Acetaminophen B. Celecoxib C. Cyclobenzaprine D. Ibuprofen

A. Acetaminophen

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast? A. Checking capillary refill distal to the cast B. Teaching the client about cast care C. Managing pain D. Performing range of motion

A. Checking capillary refill distal to the cast

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? A. Maintain immobilization and alignment. B. Provide optimal nutrition and hydration C. Promote independence in activities of daily living. D. Provide relief from pain and discomfort.

A. Maintain immobilization and alignment.

A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis? A. Thyroid hormones B. Anticoagulants C. NSAIDs D. Cardiac glycosides

A. Thyroid hormones

A nurse is preparing a client for ambulatio. Which of the following actions should the nurse take to determine the client's level of strength?

As the client to push her feet against the nurse's palms.

A nurse is assessing a client's radial pulse and determines the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before resquesting restraints?

Assist the client Use an electronic position-sensitive device. Provide diversionary activities Involve the family

A nurse is collecting data for a client's comprehensive physical examination. after the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A.olfaction B.auscultation C.Palpation D.Percussion

B B. Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching? A. Buck's extension traction will reduce the fracture. B. Buck's extension traction will relieve muscle spasms. C. Buck's extension traction will maintain alignment of the pins. D. Buck's extension traction will allow supported movement of the extremity.

B. Buck's extension traction will relieve muscle spasms.

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. the client denies any history of hypertension. Which of the following actions should the nurse take first? A.Request a prescription for an antihypertensive medication. B. ask the client if she is having pain. C.Request a prescription for an anti-anxiety medication. D.Return in 30 min to recheck the client's blood pressure

B B. The first action the nurse should take using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. therefore, the nurse's priority is to perform a pain assessment. if the client's blood pressure is still elevated after pain interventions, the nurse should report this finding to the provider.

A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) a.Collect the data in one continuous session. B.Plan to allow plenty of time for position changes. C.Make sure the client has any essential sensory aids in place. D. tell the client to take her time answering questions. E. invite the client to use the bathroom before beginning the examination

B,C,D,E B. Because many older adults have mobility challenges, the nurse should plan to allow extra time for position changes. C. the nurse should make sure clients who use sensory aids have them available for use. the client has to be able to hear the nurse and see well enough to avoid injury. D. Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication. E. This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity.

A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (select all that apply.) A. slower light touch sensation B. some vision and hearing decline C. slower fine finger movement D. some short‑term memory decline E. slower superficial pain sensation

B,C,D. B.losses in vision, hearing, taste, and smell decline for the client who is aging. C. Fine finger movement slows, along with some reflex and motor responses for the client who is aging. D. Minimal decline in short‑term memory is an expected finding for the client who is aging.

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (select all that apply) A. Address the client with the appropriate title and her last name. B. Use a mix of open- and close-ended questions. C. Reduce environmental noise. D. Have the client complete a health history form. E. Perform the general survey before the examination

B,C,E B. Open‑ended questions help the client tell her story in her own way. Closed‑ended questions are useful for clarifying and verifying information the nurse gathers from the client's story C. quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. E. The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process, such as the examination

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply.) A. talk to the interpreter about the family while the family is in the room. B. ask the family one question at a time. C. look at the interpreter when asking the family questions. D. use lay terms if possible. E. do not interrupt the interpreter and the family as they talk

B,D,E B. Asking the family one question at a time will promote effective communication between the family and the nurse/interpreter. D.using lay terms will promote effective communication between the family and the nurse/interpreter. E.not interrupting will promote effective communication between the family and the nurse/interpreter.

A nurse is caring for a school‑age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A.Touch the child's arm. B.Sit at eye level with the child. C.Stand facing the child. D.Stand with a relaxed posture

B. B. The nurse should be at the same eye level as the child to facilitate communication

Which of the following strategies should a nurse use to establish a helping relationship with a client? A. make sure the communication is equally reciprocal between the nurse and the client. B. encourage the client to communicate his thoughts and feelings. C.Give the nurse‑client communication no time limits. D. allow communication to occur spontaneously throughout the nurse‑client relationship

B. B. Therapeutic communication facilitates a helping relationship that maximizes the client's ability to express his thoughts and feelings openly

A nurse is caring for a client who states, "i have to check with my wife and see if she thinks i am ready to go home." The nurse replies, "how do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. pacing B. reflecting C. paraphrasing D. restating

B. B. reflecting defects the focus on the conversation back to the client so that he can further explore his feelings.

A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. the client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? A."i will make sure the menu includes kosher options." B."i will discuss the daily schedule with the client to make sure the client will have time for prayer." C."i will make sure to use direct eye contact when speaking with this client." D."i will make sure daily communion is available for this client."

B. B.Devout Muslims pray five times per day. Without proper awareness and planning, the client can refuse necessary treatments, such as physical therapy, if adequate prayer times are not planned for and incorporated into the client's day

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium?' A. 1 cup carrot strips B. 3 oz canned salmon C. 1 cup chopped chicken breast D. 1 plain baked potato

B. 3 oz canned salmon

A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect? A. Symmetric joints affected B. Pain worsens with activity C. Weight loss D. Ulnar deviation

B. Pain worsens with activity

A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? A. Drinks one alcoholic beverage per day B. Smokes 1 pack of cigarettes per day C. Large body stature D. History of bone fracture during childhood

B. Smokes 1 pack of cigarettes per day

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? A. The client complains of pain. B. The client develops a life-threatening situation. C. The client needs to have an x-ray of the femur performed. D. The client has to be repositioned in the bed.

B. The client develops a life-threatening situation.

A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A.Palmar surface B.Fingertips C.Dorsal surface D.Base of the fingers

C C. The dorsal surface of the hand is the most sensitive to temperature.

A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply.) a.Urinary incontinence B.Diarrhea C.Bradypnea D.Orthostatic hypotension e. nausea

C,D,E C.Opioid analgesia can cause respiratory depression, which causes respiratory rates to drop to dangerously low levels. the nurse should monitor the client's respiratory rate, and administer naloxone if indicated. D. Opioid analgesia can cause orthostatic hypotension. the nurse should monitor the client for dizziness or lightheadedness when changing positions. E. Opioid analgesia can cause nausea and vomiting. the nurse should monitor for and treat these complications as needed.

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A."You will do great! You just have to get used it." B."Why are you worried about going home?" C."Your daily routines will be different when you get home." D."Tell me about your support system you'll have after you leave the hospital." E."Let me tell you about a friend of mine with a colostomy who also enjoys swimming."

C,D,E C.presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made. D. asking open‑ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. E. offering self is an effective communication technique that can convey understanding and share another's experience with the client. however, the nurse should return the focus to the client as soon as she communicates the relevant point

A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply.) A. concave thoracic spine posteriorly B. exaggerated lumbar curvature C. concave lumbar spine posteriorly D. exaggerated thoracic curvature E. Muscles slightly larger on his dominant side

C,E C. The nurse should expect the client to have a concave lumbar spine posteriorly. E. The nurse should expect the client to have muscle size equal on both sides or slightly larger on the dominant side.

A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A."i'll wait to use the device until it's absolutely necessary." B."i'll be careful about pushing the button too much so idon't get an overdose." C."i should tell the nurse if the pain doesn't stop while i am using this device." D."i will ask my adult child to push the dose button when i am sleeping."

C. C. PCA allows the client to self‑administer pain medication on an as‑needed basis. if the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan and possible dosage change.

A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A.Contact the hospital's spiritual services. B. ask him what is making him cry. C. provide quiet times for these moments. d. turn on the television for a distraction

C. C. Providing privacy and time for the reading of religious materials supports the client's spiritual health.

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. ask the client what precipitates the pain. B.Question the client about the location of the pain. C.Offer the client a pain scale to measure his pain. D.Use open‑ended questions to identify the client's pain sensations.

C. C. The nurse should use a pain rating scale to help the client report the intensity of his pain. the nurse should use a numeric, verbal, or visual analog scale appropriate to the client's individual needs.

A nurse is caring for a client who shares the nurse's religious background. Which of the following information should the nurse anticipate A.Members of the same religion share similar feelings about their religion. B. a shared religious background generates mutual regard for one another. C. the same religious beliefs can influence individuals differently. D. the nurse and client should discuss the differences and commonalities in their beliefs

C. C.Members of any particular religion should be assessed for individual feelings and ideas

A nurse is caring for a client who reports pain with internal rotation of her right shoulder. the nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? A.Mopping her floors B.Brushing the back of her hair C.Fastening her bra behind her back D. reaching into a cabinet above her sink

C. C. The client who is fastening a bra from behind requires internal rotation of the shoulder, so this activity will elicit pain.

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? A. Bacteria B. Diuretics C. Aging D. Obesity E. Smoking

C. Aging D. Obesity E. Smoking

A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening? A. Infant B. Toddler/Preschooler C. Pre-adolescent/adolescent D. Older Adult

C. Pre-adolescent/adolescent

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? A. Use a blow dryer on a moderate heat setting to dry the cast after showering. B. Use a cotton swab to relieve itching under the cast. C. Report any worsening or unrelieved pain. D. Avoid moving the affected leg.

C. Report any worsening or unrelieved pain.

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take?

Check for personal items Keep bath water Shave the clients hair

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. Which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

A nurse is assessing a clients cranial nerves as part of neurological examination. Which of the following actions should the nurse take for cranial nerve III?

Checking the pupillary response to light

A nurse is providing nail care for a client. Which actions...?

Clean under the nail w an orange stick

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect?

Contractures Crackles Pressure ulcers

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. a client who has a broken femur and reports hip pain. B. a client who has incisional pain 72 hr following pacemaker insertion. C. a client who has food poisoning and reports abdominal cramping. D. a client who has episodic back pain following a fall 2 years ago

D. D. A client who reports pain that lasts more than 6 months and continues beyond the time of tissue healing is experiencing chronic pain. the nurse should identify this client's pain as chronic, and assist with planning interventions to relieve manifestations associated with the pain

A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. the surgeon tells the client that a blood transfusion is essential. the client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make? A."i believe in this case you should really make an exception and accept the blood transfusion." B."i know your family would approve of your decision to have a blood transfusion." C."Why does your religion mandate that you cannot receive any blood transfusions?" D."let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

D. D. Involving the client's religious and spiritual leaders is a culturally responsive action at this point. alternative forms of blood products can be discussed, and a plan reasonable to all can be reached

A nurse is assessing a client's neurosensory system. to evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? A. a word she whispers 30 cm from his ear B. a number she traces on the palm of his hand C. the vibration of a tuning fork she places on his foot D. a familiar object she places in his hand

D. D.Identifying a familiar object in the hand confirms the client's sense of stereognosis, which is tactile recognition

A nurse is caring for a client who has an un-repaired femur fracture of the mid-shaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Monitor the client's calf for edema. D. Instruct the client to wiggle his toes.

D. Instruct the client to wiggle his toes.

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? A. Administer an opioid analgesic. B. Obtain a prescription to adjust the weight amount. C. Offer a muscle relaxant to the client. D. Realign the client's position.

D. Realign the client's position.

A nurse is planning care for a hospitalized client who is immobile and in continuous mitten restraint. Which of the following interventions should be included in the...?

Document restraints check every 2 hr. Education the client's family about Implement passive ROM exercises

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse take when helping the client ambulate?

Gait belt.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis?

Hold the cane on the right side to provide support for the weaker

A nurse is teaching a client about crutch walking using 3-pt. Gait. which of the following should be... ?

Move both crutches forward while standing on the unaffected leg.

A nurse is completing a client's history and physical exam. Which of the following inso should the nurse consider as subjective data?

Nausea

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention?

Palpate the abdomen prior to performing auscultation

A nurse if assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse in a long term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take.

REMOVE ACTIVE CLOSE THE DOOR EXTINGUISH THE FIRE

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order they should be performed in the case of a fire emergency.

RESCUE PULL CONFINE EXTINGUISH

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following...?

Secure the restraints using a quick-release tie.

A nurse is developing a plan of care for an older adult client who is at risk for falls. Which of the following actions should the nurse plan...?

Teach balance and strength Lock beds and wheelchairs Provide info about home safety Place the bedside table within reach

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?

Teach the client Keep the client's bed Place a fall risk identification

A nurse is assessing a client's ability to ambulate w crutches using a 3-pt. Gait. which of the following actions should the nurse take as a risk to the client's safety?

The client places partial weight on the affected leg

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 to determine?

The client's current weight-bearing status.

A nurse assesses a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraints?

The client's hand is cool and pale.

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following steps should a nurse include for applying restraints?

The restraints should promote the client's safety and prevent injuries

A nurse is providing oral care for a client who is immobile. Which of the following

Turn the client on his side

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client?

Water temp (^120) Throw rugs

A nurse at an extended-care facility is instructing a class of AP about client use of assistive devices during ambulation. Which of the following instructions... about the use of a cane?

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

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

When walking, move your left foot forward first

A nurse is providing home safety info for an older client who uses a cane. Which of the following statements should the nurse include?

You should advance your weak leg forward to the cane, then move your strong leg.

When teaching a patient about fire safety, which activity does the nurse know is the leading cause of fire-related death? a. Cooking b. Playing with matches c. Smoking d. Heating with kerosene heaters

a. Cooking Cooking I the leading cause of residential fires for the last decade, followed by heating, electrical malfunction. And other unintentional causes or carelessness.

Which measures can the nurse teach to prevent poisoning of children? (Select all that apply.) a. Install safety latches on reachable cabinets. b. Keep syrup of ipecac on hand. c. Use childproof caps on medications. d. Use a plunger rather than a chemical drain cleaner. e. Keep cleaning supplies under the kitchen sink.

a. Install safety latches on reachable cabinets. c. Use childproof caps on medications. d. Use a plunger rather than a chemical drain cleaner. Child locks for cabinet and childproof caps for medication bottles are recommended to prevent poisoning. The use of alternatives (e.g. plungers) rather than toxic chemicals. (e.g. Drano) is recommended to prevent ingestion of deadly substances. Syrup of ipecac has been used in the past to treat poisoning after it occurred and is not considered a preventive measure. Keeping cleaning supplies under the kitchen sink is dangerous because the area is within reach o children.

Objective data can be gathered from the patient during which aspects of the physical assessment process? (Select all that apply.)

a. Patient interview b. Health history c. General survey d. Physical examination e. Laboratory testing Objective data consist of observed information or signs that can be collected during all stages of the physical assessment process. Even while the patient is answering questions, providing subjective or symptom information, the nurse observes for physical signs of abnormalities or impairment.

A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to evaluate the patient's aortic valve? a. Second right intercostal space b. Third left intercostal space c. Fifth right intercostal space d. Fifth left intercostal space along the midclavicular line

a. Second right intercostal space The second intercostal space on the right is the auscultation point for the aortic valve. The ventricles and pulmonic valve are located on the left. The point of maximal impulse (PMI) over the mitral valve is located between the left fourth and fifth intercostal spaces.

Which type of lung sounds does the nurse expect to auscultate over most of the lung fields? a. Vesicular b. Resonant c. Dull d. Flat

a. Vesicular Vesicular breathe sound are heard over most of the lung fields. Resonance is heard with percussion, not auscultation. Dullness is heard over the solid organs (liver, heart). Flat sounds are heard over the stomach and intestines.

Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has confusion and incontinence? a. A room near the nurses' station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses' station c. Side rails up and decreased sensory stimuli d. A 24-hour sitter and the patient's favorite TV program

b. A pressure sensor alarm and a room near the nurses' station Patients with confusion may not remember to call for assistance before getting up, especially if they have had an episode of incontinence. A pressure sensor alarm that can be used in a bed or chair should be implemented as a priority intervention along with moving the patient to a room near the nurses station, where the patient be more closely monitored. Although decreasing sensory stimuli may help patient with confusion, it is not a priority intervention. A 24-hour sitter is costly and used only after all other restraint-free alternative are exhausted.

Which actions by the nurse concerning oral care for an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrush

b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours Oral care to unconscious patient is performed with the patient turn to one side so fluid can drain out of the mouth. Suction equipment is used to remove fluid and secretions during oral care on an unconscious patient. Oral care should at least be provided every two hours who are unconscious, and receiving nothing by mouth, intubated or receiving oxygen by a mask. An unconscious patient may aspirate if oral care is done the supine position. A hard-bristle brush may damage the oral mucosa.

Which action by a female patient lets the nurse know the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. d. The patient washes her perineum lightly to prevent tissue damage.

b. The patient washes her perineum from front to back using a clean washcloth. The female perineum is always washed from front to back, washing the area near the urinary meatus and working back to the anus to avoid introducing organisms into the urinary tract. Circular motion is used for male patient, washing around the urinary meatus first then washing down the shaft of the penis.

The nurse has delegated care of a patient's dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates a good understanding of denture care? a. "It is not necessary to use a toothbrush in the patient's mouth since the patient does not have teeth." b. "I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table." c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." d. "I will soak the dentures in the sink and then place them in a denture cup labeled with the patient's name."

c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." Dentures are brushed with a regular toothbrush and toothpaste over a sink that has been padded with a washcloth to prevent breakage if they are accidentally dropped. The patient's mouth should be cleansed with a soft brush or toothette after the dentures are removed and before they are reinserted. Never wrap dentures in a tissue because they may accidentally be discarded. Soaking dentures in a sink where nurses and patients wash their hands is contraindicated because pathogens may be present in the sink.

Which patient appears to be at greatest risk for falls? a. 66 year old post-op, oriented x 3, taking opioid pain meds b. 71 year old with pneumonia, oriented x 2, on oxygen and IV c. 76 year old with acute confusion, knows name, incontinent, has an IV d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications

c. 76 year old with acute confusion, knows name, incontinent, has an IV The 76 year old with acute confusion and incontinence with a continuous IV appears to be at greatest risk for falls. While the other patients also have sources of tethering (e.g., oxygen and IV tubing) and opioid pain medications, the acute confusion and incontinence along with the IV tethering produce the most significant risk.

Which activity would be most appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for fall risk and complications of restraint use b. Evaluating the patient's ability to perform activities of daily living (ADLs) c. Assisting with or performing the patient's ADLs d. Teaching the patient use of assistive devices

c. Assisting with or performing the patient's ADLs UAP such as patient care technicians and nursing assistants, provide hands-on care for patients who may require complete care or total assistance with their activities of daily living (ADL's). However, RN's are responsible for supervising and guiding the UAP so direct care is provided in a safe manner. RNs are responsible for performing patient assessments, and the OT evaluates the patients ability to perform ADL's. A physical therapist evaluates mobility and initially teaches the patient to use an assistive device. If use assistive device needs reinforcement, the RN does the teaching.

3.) Which nursing action is necessary for patient safety during a bed bath? a. All four side rails are always kept in the raised position during the bath. b. The bed is always in the low and locked position while bathing the patient. c. The top side rail is raised opposite the side where the nurse is standing. d. The bed is always kept in a flat position with a pillow under the patient's head.

c. The top side rail is raised opposite the side where the nurse is standing. The bed is raised to a comfortable working position and the side rail is lowered on the side where the nurse is standing. It is important to leave the bed in the low and locked position with the top side rails up when the bath is finished and the nurse is leaving the room. The position of the bed and the patient during the bath is dependent on the patient's condition and comfort level. LO: 27.6 DIF: Applying MSC: NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control

An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient's toenails are long and thick. What is the next step the nurse should take? a. Soak the patient's feet, and trim her toenails using clippers. b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP). c. Assess the patient's self-care abilities. d. Ask the primary care provider (PCP) for a referral to a podiatrist.

d. Ask the primary care provider (PCP) for a referral to a podiatrist. Referral to Podiatrist is appropriate when the diabetic patient is unable to care for her feet. Soaking is contraindicated for patients with diabetes due to the risk for skin breakdown. Clippers are not appropriate if nails are thick. Delegating of nail care to the UAP is inappropriate for patients with peripheral neuropathy. The nurse already knows the patient's self-care status abilities in regard to her feet.

Which sequence best identifies the order in which the nurse should complete an abdominal assessment? a. Inspection, palpation, percussion, auscultation b. Auscultation, inspection, palpation, percussion c. Auscultation, palpation, percussion, inspection d. Inspection, auscultation, percussion, palpation

d. Inspection, auscultation, percussion, palpation Assessment of the abdominal cavity requires inspection then auscultation, percussion then palpation to avoid stimulating the bowel and eliciting inaccurate assessment results.

The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential cause would be considered of most concern, requiring further evaluation as soon as possible? a. Loss of skin elasticity b. Levator muscle weakness c. Congenital ocular abnormality d. Oculomotor cranial nerve III paralysis

d. Oculomotor cranial nerve III paralysis Oculomotor paralysis may indicate the presence of a larger neurologic problem that requires further investigation as soon as possible. Loss of skin elasticity and muscle weakness may be due to aging, and congenital ptosis does not require immediate attention in an adult.