Passpoint: Basic Physical Care

A licensed practical nurse (LPN) is assisting with the admission of a client to the medical-surgical unit. While gathering data about the client, the LPN asks the client if an advance directive has been prepared. The client responds, "I don't know what you mean." Which response by the nurse would be most appropriate? "An advance directive explains how you want your finances used should you become disabled." "An advance directive is a document that states your wishes about health care." "An advance directive tells us your wishes should you die during hospitalization." "An advance directive states your wishes concerning what to do with your personal items."

"An advance directive is a document that states your wishes about health care." An advance directive is a written document that states a client's health care wishes regarding withdrawing treatment, resuscitation measures, life support, and end-of-life care. Wishes related to dying, finances, and personal items pertain to a last will and testament, not an advance directive.

The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching? "Hold the cane on the same side as the injury." "Hold the cane on the opposite side from the injury." "Don't use the cane when climbing stairs." "Use the cane when walking further than 50 feet."

"Hold the cane on the opposite side from the injury." The nurse should instruct the client to hold the cane in the hand opposite the affected extremity; the only exception is when the client is physically unable to hold the cane in that hand. A cane helps maintain balance; so the client should be encouraged to use the cane when navigating stairs. The cane should be used when walking any distance to prevent injury from falls.

The nurse is collecting admission data from a newly admitted client. Which question should the nurse include when asking the client about orthopnea? "Does the symptom move to another area?" "How many pillows do you use?" "Do you cough up blood?" "Is the sensation sharp, stabbing, or aching?"

"How many pillows do you use?" The nurse should ask the client with orthopnea (shortness of breath while lying down) how many pillows he uses. The question regarding coughing should be used when questioning the client about hemoptysis. The other options involve asking a client about pain.

A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply. "Client privacy is part of the hospital code of conduct." "You will need to ask your manager." "You should know better than to ask that question." "I am not able to provide that information." "The client is in room 313."

"I am not able to provide that information." "Client privacy is part of the hospital code of conduct." The statement "You should know better than to ask that question" implicitly reprimands the employee who asked and is not respectful. "You will need to ask your manager" avoids the issue and is not a forthright response. Disclosing the client's room number affirms that the client is there, violating the client's privacy.

The nurse is teaching a client who will be discharged with a prescription for warfarin. Which statement by the client indicates understanding? "If I miss a dose, I should double the next dose." "I should avoid aspirin while taking warfarin." "This drug will dissolve any clots I may still have." "I should increase my intake of yogurt and broccoli."

"I should avoid aspirin while taking warfarin." Because aspirin decreases platelet agglutination and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects — and bleeding. Warfarin therapy doesn't necessitate dietary changes. Although warfarin interrupts the normal clotting cycle, it doesn't dissolve clots that already have formed. The client should take warfarin exactly as prescribed to maintain the desired level of anticoagulation. Doubling a dose could lead to bleeding.

A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates that the client understands? "I should avoid meat and milk." "I should schedule a visit once per week for I.V. antihypertensive medications." "I should skip my medication dose if dizziness occurs." "I should only have approximately 2400 mg of sodium per day."

"I should only have approximately 2400 mg of sodium per day." The nurse must teach the hypertensive client how to modify the diet to restrict sodium and saturated fats. In addition, the nurse should explain the actions, dosages, and adverse effects of prescribed antihypertensives. A client receiving antihypertensives also may take a diuretic as part of the drug regimen, should eat a potassium-rich diet including meats and milk, and may require dietary potassium supplements and high-potassium foods to avoid electrolyte disturbances. Instead of skipping medication if dizziness occurs, the client should notify the physician of this symptom. The client receiving antihypertensives at home takes them by mouth, not I.V.

While preparing a client for a diagnostic study of the colon, the nurse teaches him how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? "I will administer the enema while lying on my right side with my left knee flexed." "I will administer the enema while lying on my back with both knees flexed." "I will administer the enema while lying on my left side with my right knee flexed." "I will administer the enema while sitting on the toilet."

"I will administer the enema while lying on my left side with my right knee flexed." Lying on the left side allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. The other options don't accomplish this goal and therefore are less effective in evacuating the lower bowel.

The nurse is reinforcing education regarding the use of an incentive spirometer after abdominal surgery in order to prevent complications postoperatively. Which statement made by the client demonstrates an adequate understanding of the use of the spirometer? "If I use this I won't have to get out of the bed so early after surgery." "It will help me visualize deep breathing to prevent my lungs from collapse." "If I use this, I won't have to take deep breaths to prevent my lungs from collapse." "It won't hurt as bad as deep breathing exercises."

"It will help me visualize deep breathing to prevent my lungs from collapse." Incentive spirometry helps the client see inspiratory effort using floating balls, lights, or bellows. Early ambulation is still indicated for this client after abdominal surgery. Incentive spirometry is no more effective than deep breathing without equipment. Deep breathing and incentive spirometry cause equal discomfort during inspiration.

The health care provider writes an order that a client may have 12 oz (360 mL) of clear liquids at each meal and may supplement this with an additional 10 oz (300mL) at each shift (7-3, 3-11, and 11-7). How many milliliters should the nurse document for the day shift (7-3) if the client took in all of the ordered volumes? Record your answer using a whole number. 1000 mL 1350 mL 1020 mL 660 mL

1020 The nurse must add all the volumes together, knowing that 1 oz equals 30 mL. There are two meals in the day shift (7-3). 12 oz X 30 mL = 360 mL. 360 mL X 2 meals = 720 mL. 10 oz (supplement) X 30 mL = 300 mL. 720 mL + 300 mL = 1,020 mL.

A nurse is preparing to administer a preoperative intramuscular (IM) injection a 9-year-old child. Which size needle should the nurse select? 22G, 1-inch 20G, 1½-inch 20G, 1-inch 22G, 1½-inch

22G, 1-inch The nurse should first evaluate the child's muscle mass and amount of subcutaneous fat and then select the correct size needle. Without more information, the nurse should select the 22G, 1-inch needle, which is appropriate for an average-sized school-age child. The 20G, 1-inch needle would be unnecessarily large. The 22G, 1½-needle would be too long. The 20G, 1½-inch needle would be both too long and unnecessarily large.

The nurse is caring for a client with a fever of 103°F (39°C) due to a respiratory infection. The client states, "I am freezing and I have a terrible headache!" What is the appropriate nursing action? Administer acetaminophen as prescribed. Apply extra blankets to warm the client. No intervention should be provided since the fever will kill the bacteria. Assist the client into a cool bath.

Administer acetaminophen as prescribed. Acetaminophen will help to reduce the fever and relieve the pain of the headache. Placing the client into a cool bath will increase shivering which increases the metabolic rate and causes increase in fever. Applying extra blankets will increase the body temperature. The respiratory infection may be viral. The client has the right to pain relief from the headache.

Which situation demonstrates correct principles of confidentiality? Two nurses alone in an elevator are discussing a client's status. A nurse talks about clients without disclosing their names on Facebook. An emergency department nurse reports suspected child abuse. During change-of-shift report, a nurse talks about a client's personal problems that the client disclosed to the nurse that day.

An emergency department nurse reports suspected child abuse. Any health care provider must report suspected child abuse. Sharing this information doesn't violate the client's right to confidentiality. A discussion of confidential information in a public place may be overheard and is a breach of confidentiality regardless if no one else is present in the elevator. Any client information, whether written or electronic, regardless if a name is not used, is considered confidential; sharing information about the nurse's assignment would be considered a breach of confidentiality. Nurses must discuss client's problems during change-of-shift report, but these discussions should be limited to information needed to provide safe care.

The nurse is performing a surgical dressing change and drops a sterile gauze on the bedside table outside the sterile dressing tray's field. What would be the appropriate action by the nurse? Use sterile gloves to put the gauze back on the dressing tray. Place the noncontaminated side of the gauze next to the wound. Ask an unlicensed assistive personnel to obtain another sterile gauze from the supply room. Leave the room to obtain another sterile gauze dressing.

Ask an unlicensed assistive personnel to obtain another sterile gauze from the supply room. Asking the unlicensed assistive personnel to obtain a new sterile gauze from the supply room demonstrates that the nurse is aware of the contamination of the gauze and that it should not be used. The nurse would not leave the room as this would also cause a break in sterile technique. Using sterile gloves to place the gauze back on the tray contaminates both the sterile gloves and the sterile dressing tray. Using the dressing with the noncontaminated side next to the wound puts the client at risk for infection.

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? Baked beans, hamburger, and milk Chicken cutlet, spinach, and soda Bouillon, spinach, and soda Spaghetti with cream sauce, broccoli, and tea

Baked beans, hamburger, and milk Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

While making rounds on the pediatric floor, a nurse finds an infant in the crib unresponsive and without respirations. Which action should the nurse take first? Notify the parents. Call for assistance. Declare the efforts futile. Begin rescue breathing.

Call for assistance. If a nurse is alone when he or she discovers a child who is unresponsive and not breathing, the nurse should call for assistance immediately. The nurse should then assess the child for a pulse; if no pulse is found, the nurse should begin CPR by performing 30 chest compressions followed by two ventilations. If a pulse is detected, the nurse should perform rescue breathing only. It is not in the scope of the nurse's practice to declare the efforts futile. Care of the child should occur prior to calling the parents.

Which nursing action is appropriate when performing wound care for a client who has a diabetic foot ulcer? Clean the wound using a circular motion, moving from outer edges to the center. Change the sterile field after sterile water is spilled on it. Put on sterile gloves and then opening a container of sterile saline. Place a sterile dressing 1 inch (2.5 cm) from the edge of the sterile field.

Change the sterile field after sterile water is spilled on it. A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. Changing the sterile field after sterile water is spilled on it demonstrates surgical asepsis. The outsides of containers, such as sterile saline bottles, are not sterile. Containers should be opened before putting on sterile gloves, and the solution should be poured over the sterile dressings in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area (for example, from the center outward). The outer inch of a sterile field is not considered sterile.

The nurse is reviewing the proper technique for obtaining a urine specimen from an indwelling urinary catheter. When collecting the urine, what is the most appropriate technique to use? Clean the tubing's drainage port with alcohol and then insert a sterile needle with syringe to collect the specimen. Remove the indwelling catheter and insert a sterile straight catheter to collect urine. Collect urine from the drainage collection bag. Disconnect the catheter from the drainage tubing to collect urine.

Clean the tubing's drainage port with alcohol and then insert a sterile needle with syringe to collect the specimen. The nurse should wear clean gloves, clean the drainage port with alcohol, and then obtain the specimen with a sterile needle to ensure that the specimen and the closed urinary drainage system will not be contaminated. A urine specimen must collect new urine, and the urine in the bag could be several hours old and growing bacteria. The urinary drainage system must be kept closed to prevent microorganisms from entering. A straight catheter is used to relieve urine retention, obtain sterile urine specimens, measure the amount of postvoid residual urine, and empty the bladder for certain procedures. It is not necessary to remove an indwelling catheter to obtain a sterile urine specimen unless the health care provider requests that the whole system be changed.

After stepping on a rusty nail in the backyard, a client comes to the emergency department for a tetanus immunization. Which bacterium is responsible for tetany? Pasteurella multocida Streptobacillus moniliformis Clostridium tetani Bartonella henselae

Clostridium tetani C. tetani inhabits the intestinal tracts of humans and animals, enters the bloodstream, and travels to the central nervous system. It has the capability to survive in soil for years. P. multocida, B. henselae, and S. moniliformis are pathogens that live in the soil and are associated with other environmental injuries, such as cat bites.

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation? Ask the nurse on the day shift to report the situation to the nurse manager. Cover by assessing the first nurse's patients hourly. Nothing; the first nurse's patients did not call for assistance. Discuss the situation with the first nurse, including the safety implications of sleeping on the job.

Discuss the situation with the first nurse, including the safety implications of sleeping on the job. The second nurse is responsible for immediately discussing this behavior and its safety implications with the first nurse. The other options do not demonstrate behavior representative of advocating for safe and competent care.

The nurse is caring for a client who practices reflexology. When collecting client data, the nurse notes that the client's ankles are edematous. Which intervention by the nurse supports the client's beliefs in reflexology and helps reduce edema? Abducting the client's legs Adducting the client's legs Elevating the client's legs Lowering the client's legs

Elevating the client's legs Reflexology is based on the theory that fluid in interstitial spaces blocks oxygen supply to tissues. Therefore, elevating the client's legs helps decrease fluid in the ankles, thereby increasing oxygen supply to the tissues. Lowering, abducting, or adducting the client's legs won't lessen edema or promote reflexology.

After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's child returns to the hospital 6 hours later to find that the client remains on a stretcher in the emergency department hallway. The child begins to shout "I will not allow my insurance to pay for your failure to provide care." What is the best action for the nurse to take in this situation? Contact the receiving unit to expedite the transfer process. Contact hospital security to arrange for the removal of the disruptive family member. Contact the nursing supervisor to insist that this client is transferred immediately Ensure the comfort and security of the client and meet privately with the family member.

Ensure the comfort and security of the client and meet privately with the family member. It is imperative to insure that the client who remains in an interim status awaiting admission to a hospital ward bed is safe and comfortable, as well as being reassured that this person is being cared for. The nurse should then meet privately with the family member to address concerns, provide reassurance, answer questions, and provide referrals (to administration or advocacy as may be indicated). It is inappropriate to have the family confronted by security or threatened to be removed. The nurse may contact security as warranted if the family member becomes threatening. Arranging for the client to be moved out of the hallway is a reasonable compromise if this option is, or becomes, available. Contacting the nursing supervisor is appropriate, but it is unreasonable to insist that the client be transferred immediately.

The nurse is performing her morning assessment when the client says, "I had trouble sleeping last night." Which action should the nurse take first? Recommending warm milk or a warm shower at bedtime Gathering more information about the sleep problem Finding out whether the client is taking medication that may impede sleep Determining whether the client is worried about something

Gathering more information about the sleep problem The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use.

A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care? Good Samaritan laws are designed to protect the caregiver in emergency situations. Malpractice is failure to perform professional duties that result in client injury. Scope of practice involves general guidelines that define nursing. Negligence is intentional failure to act responsibly or deliberate omission of a professional act.

Good Samaritan laws are designed to protect the caregiver in emergency situations. Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure? nasogastric tube irrigation instilling eye drops colostomy irrigation IV catheter insertion

IV catheter insertion Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an IV catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

A hospitalized client has been receiving intravenous (IV) antibiotics for the treatment of pneumonia over 3 days. The nurse observes the client having several foul smelling, loose stools during the day and suspects the client may have developed clostridioides difficile. What is the priority action by the nurse? Insert a rectal tube so that the client will not soil the bed linens. Notify the charge nurse that the medication should be changed. Initiate the use of contact precautions to prevent the spread of the bacteria. Administer an antidiarrheal medication to stop the diarrhea.

Initiate the use of contact precautions to prevent the spread of the bacteria. Clostridioides difficile (C. difficile) is the most common cause of antibiotic associated diarrhea. Contact precautions should be initiated immediately to prevent the spread of bacteria to other clients as well as health care workers. Using soap and water is preferable for hand washing than an alcohol-based hand sanitizer. The contact precautions can be initiated independently and does not require a health care provider order. Notifying the charge nurse that the client condition has changed is appropriate but not the priority action. Inserting a rectal tube may damage the mucosa of the rectum and is not a priority. Administering an antidiarrheal may be done as well as the initiation of a probiotic but is not a priority action at this time.

The nurse is performing tracheal suction for a client as indicated due to a "gurgling" sound with respirations. Which nursing action is correct for performing this procedure? Apply suction during insertion of the catheter. Repeat suctioning intervals every 15 minutes until clear. Re-sterilize the suction catheter in alcohol after use. Limit suctioning to 10 to 15 seconds' duration.

Limit suctioning to 10 to 15 seconds' duration. The length of time a client should be able to tolerate the suction procedure is 10 to 15 seconds. Any longer may cause hypoxia. Suctioning during insertion can cause trauma to the mucosa and removes oxygen from the respiratory tract. Suction catheters are disposed of after each use and are cleaned in normal saline solution after each pass. Suctioning, with supplemental oxygen between suctions, is performed in a minimum of 1-minute intervals in order to allow the client to rest.

A client is determined to be at risk for the development of hypertension and is encouraged by the health care provider to begin using the Dietary Approaches to Stop Hypertension (DASH) eating plan. When reinforcing the teaching about the plan, which information should the nurse be sure to include? Select all that apply. Nuts such as walnuts, pine nuts, and almonds can help reduce cholesterol. Eat fruits, vegetables, and whole grains. Include foods high in saturated fats such as fatty meats and whole milk. Use dairy foods such as yogurt and cheese labeled "fat-free" or "low-fat." Since alcohol does not contain fat, there are no restrictions on alcohol consumption.

Nuts such as walnuts, pine nuts, and almonds can help reduce cholesterol., Eat fruits, vegetables, and whole grains., Use dairy foods such as yogurt and cheese labeled "fat-free" or "low-fat."

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy? Instruct the client on use of the call bell. Provide a bed that is low to the floor. Have a family member stay with the client. Raise all side rails while the client is in bed.

Provide a bed that is low to the floor. Providing a bed that is low to the floor complies with the least restraint policy and prevents falls from the bed. Raising all side rails on the bed would be considered excessive restraint and could contribute to greater risk of injury if the client tried to climb out of bed. The other options do not fully ensure the safety of the client.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? Offer the client sips of clear liquids. Remove restraints and assess skin and circulation. Assist the client to the bathroom. Assess cognitive status.

Remove restraints and assess skin and circulation. Placing a client in any type of restraint is a controversial issue. Strict guidelines exist. The client in restraints must have the skin integrity and circulation assessed every 1-2 hours. It is also appropriate to massage the area and provide range of motion exercises. On a regular basis, the client would be offered to use a bedpan or ambulate to the bathroom and the nurse would assess the cognitive status. A client with a nasogastric tube would not be offered fluids.

A nurse is providing home care to a client who has failing vision. The nurse is concerned about the client's safety. Which action should the nurse take to help reduce the client's risk of a fall? Contact the disability association to install a flashing light to indicate when the phone or doorbell rings. Arrange pieces of furniture close together so the client can use them for guidance and support. Encourage the client to wear a medical identification bracelet that describes the client's visual deficit. Request that the family have handrails installed on the stairs, in hallways, and in bathrooms.

Request that the family have handrails installed on the stairs, in hallways, and in bathrooms. For a client with failing vision, handrails can help the client to navigate the environment and provide physical support to enhance stability. Close arrangement of furniture creates dangerous obstacles that could precipitate falls on sharp, hard objects. A medical identification bracelet provides the client with no protection in the event of a fall. Blinking lights that indicate a ringing doorbell or telephone are useful for clients who are hearing impaired.

Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation? Confront the mother by asking her what she's doing and why. Leave the room immediately, without the neonate, and notify the nursing supervisor. Return the neonate to the nursery and inform coworkers so they can monitor the mother's behavior. Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance.

Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance. The neonate's safety and protection is the first priority. The nurse should immediately return the neonate to the nursery and inform the physician of the neonate's abuse. By being the neonate's advocate, the nurse allows the physician to examine the neonate for injuries resulting from the incident. Social services should be notified. The neonate shouldn't remain in the room with the mother unsupervised. The nurse should follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the mother and neonate's revised care plan, it requires immediate intervention, not simple notification of coworkers. Confronting the mother doesn't provide for the neonate's safety.

A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is working with a nursing student. The student does not attempt to suction or assist with care of the client. Which action by the nurse is appropriate? Report this issue to the nurse-manager . Seek advice from the student's instructor. Address a coworker with the concerns. Talk to the student to determine the issue.

Talk to the student to determine the issue. The nurse should approach the student first to determine feelings and experience in caring for a client with AIDS. The nurse-manager and coworkers are not familiar with the student's abilities, but the instructor may be approached if the nurse cannot communicate with the student.

During a teaching session, the nurse demonstrates how to change a tracheostomy dressing. Then, the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client cleans around the incision site, using gauze squares moistened with tap water. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client cleans around the incision site, using gauze squares moistened with normal saline. The client applies cotton-filled gauze squares as the sterile dressing after cleaning.

The client cleans around the incision site, using gauze squares moistened with normal saline. To change a tracheostomy dressing effectively, the client should clean around the incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. The client shouldn't use tap water because it may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of material that won't tangle or stick together instead of cotton-filled gauze squares.

During a teaching session, the nurse demonstrates how to change a tracheostomy dressing. Then, the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client cleans around the incision site, using gauze squares moistened with tap water. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client cleans around the incision site, using gauze squares moistened with normal saline. The client applies cotton-filled gauze squares as the sterile dressing after cleaning.

The client cleans around the incision site, using gauze squares moistened with normal saline. Explanation: To change a tracheostomy dressing effectively, the client should clean around the incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. The client shouldn't use tap water because it may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of material that won't tangle or stick together instead of cotton-filled gauze squares.

A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality? The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit. At the client's request, the CCU nurse updates the client's spouse on their condition. The CCU nurse notifies the on-call provider about a change in the client's condition. The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress.

The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress. The ED nurse is no longer directly involved with the client's care, and has no legal right to information about the client's present condition. Anyone directly involved in their care (such as the telemetry nurse and the on-call provider) has the right to information about the client's condition. Because this client asked the nurse to update their spouse, doing so doesn't breach confidentiality.

What is the nurse's initial action when preparing to insert a nasogastric (NG) tube? Open all necessary kits and tubing. Apply sterile gloves. Wash hands. Apply a mask and gown.

Wash hands. The first intervention before a procedure is hand washing. Clean gloves are used because the mouth and nasopharynx aren't considered sterile. A mask and gown aren't required. Opening all the equipment is the next step before inserting the NG tube.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Sterile packages are opened with the first edge away from the technician. The outer inch of the sterile towel hangs over the side of the table. Wetness in the sterile cloth on top of the nonsterile table has been noted. Sterile objects are held above the waist of the technician.

Wetness in the sterile cloth on top of the nonsterile table has been noted. Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.

The home health nurse is reviewing clients for hospice care. Which client would qualify for hospice care? a client with late-stage acquired immunodeficiency syndrome (AIDS) a client with left-sided paralysis resulting from a stroke a client who had a myocardial infarction 2 weeks previously a client who's undergoing treatment for heroin addiction

a client with late-stage acquired immunodeficiency syndrome (AIDS) Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who recently had a myocardial infarction because these health problems aren't necessarily terminal.

A nurse prepares to perform postural drainage on a client. How should the nurse determine the best position to facilitate clearing the lungs? auscultation of lung sounds inspection of chest expansion palpation for tactile fremitus percussion of the chest wall

auscultation of lung sounds The nurse should auscultate the client's lung sounds before doing postural drainage to determine the areas that need draining. Inspection, percussion, and palpation are all evaluation parameters that give good information about the respiratory system, but they are not necessary to determine lung areas requiring postural drainage.

A client with terminal breast cancer is being cared for by a long-time friend who is a physician. The client has identified her sister as the agent in her healthcare power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should ask the dismissed physician if the client ever stated that she wanted a different physician. abide by the wishes of the sister who holds the durable power of attorney. inform the sister that she doesn't have the authority to assign a different physician. politely ignore the sister's statement and continue to call the dismissed physician for orders.

abide by the wishes of the sister who holds the durable power of attorney. A healthcare power of attorney transfers an individual's rights regarding healthcare decisions to the designated agent. It's within the sister's power to change the physician caring for the terminally ill client. The dismissed physician has no power to interfere with the wishes of the healthcare power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.

A nurse is caring for a client with osteoarthritis. What collaborative treatment strategy should the nurse anticipate participating in for this client? assisting the client with maintaining bed rest for painful exacerbations administering nonsteroidal anti-inflammatory drugs for pain control assisting with vigorous physical therapy for the joints administering narcotics for pain control

administering nonsteroidal anti-inflammatory drugs for pain control Nonsteroidal anti-inflammatory drugs (NSAIDs) are routinely prescribed clients with osteoarthritis because of their anti-inflammatory and analgesic effects. NSAIDs reduce inflammation that causes pain. Narcotics are not used for pain control in osteoarthritis. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

An adult male client with Parkinson's disease is frequently incontinent of urine. Which intervention by the nurse is appropriate? use adult briefs apply a condom catheter insert an indwelling urinary catheter provide skin care every 4 hours

apply a condom catheter A condom catheter uses a condom-type device to drain urine away from the client. Applying a brief on the client may keep urine away from the body but may also be demeaning if the client is alert or the family objects. Because the client with Parkinson's disease is prone to urinary tract infections, an indwelling urinary catheter should be avoided because it may promote this. Skin care must be provided to prevent skin maceration and breakdown and should begin as soon as the client is incontinent.

Which intervention should the nurse implement to promote adequate nutritional intake for a client with Alzheimer's disease? fill out the menu for the client give the client privacy during meals assist the client with feeding help the client fill out the menu

assist the client with feeding Because a client with Alzheimer disease can forget how to eat, the nurse should stay and assist the client with eating to ensure adequate food intake. Allowing privacy during meals, filling out the menu, and helping the client to complete the menu don't ensure that the client will eat.

A pregnant client who comes to the prenatal clinic is diagnosed with a chlamydia infection. When providing care to the client, the nurse anticipates that the primary care provider would most likely prescribe which medication? doxycycline acyclovir azithromycin miconazole

azithromycin Chlamydia infection in pregnant clients is treated with azithromycin or amoxicillin. Doxycycline, which is used to treat syphilis, is not indicated for chlamydia infection in a pregnant client. Acyclovir, used to treat the herpes virus, and miconazole, used to treat yeast infections, are not indicated for chlamydia.

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? utilitarianism care-based ethics principle-based ethics deontology

care-based ethics Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology, utilitarianism, and principle-based ethics each prioritize goals and principles that exist beyond the particularities of the nurse-client relationship.

While hospitalized, a child develops a clostridioides difficile infection. The nurse can anticipate adding which type of precautions for this client? airborne precautions droplet precautions standard precautions contact precautions

contact precautions Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridioides difficile infection is an example of an infection that is spread in this manner. Droplet precautions are used for serious illnesses transmitted by large particle droplets. Standard precautions are used for all clients. Airborne precautions are used for suspected illnesses transmitted by airborne nuclei.

A client with pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of narcotic analgesic? emphasize the rationale for taking the medication now as ordered try to persuade the client to take the medication as ordered by the health care provider ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue document the client's choice and re-assess pain in 1 hour

document the client's choice and re-assess pain in 1 hour A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.

A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique? circular recurrent spiral reverse figure-eight

figure-eight The nurse should use a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee, to support the joint and limit joint movement. The circular bandaging technique is used to anchor a bandage; the recurrent technique is used to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique is used to accommodate the increasing circumference of a body part such as when in a cast.

A client arrives in the emergency department stating that the car battery exploded and acid splashed in both eyes. Which is the correct initial nursing action? apply an antibiotic ointment to both eyes flush both eyes with sterile saline apply a bandage to the eyes neutralize the acid with an alkali solution

flush both eyes with sterile saline A chemical burn to the eyes should be flushed with copious amounts of water to neutralize the chemical. Instilling an alkali solution will cause further burns to the eyes. An antibiotic ointment may be applied after the eyes are flushed with water as well as a bandage applied.

A nurse is transferring a client from a bed to a chair. Which action should the nurse take during client transfer? face the chair away from the head of bed help the client dangle the legs stand directly behind the client position the head of the bed flat

help the client dangle the legs After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help the client sit on the edge of the bed and dangle the legs. The nurse should then face the client and place the chair next to, and facing, the head of the bed.

The nurse is managing care for a group of clients on a busy medical-surgical unit. What is the best way for the nurse to prevent errors? identifying incorrect dosages or potential interactions of ordered medications notifying the Occupational Safety and Health Administration (OSHA) of workplace violations not questioning a healthcare provider order because the healthcare provider is ultimately responsible for the client outcome informing the client of the Patient's Bill of Rights

identifying incorrect dosages or potential interactions of ordered medications The nurse must be knowledgeable about drug dosages and possible interactions when administering medications and must follow appropriate policies to correct dosage errors or prevent potential interactions. The nurse is responsible for questioning unclear or ambiguous healthcare provider orders and should never carry out an order if uncomfortable. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards, but notifying OSHA of medication errors doesn't resolve the problem. The client should be aware of the rights of a client, but that awareness doesn't play a key role in error prevention.

A nurse is assisting with the plan of care for a client with a diagnosis of myasthenia gravis. Which time would be most appropriate for procedures and care to be completed? before meals to stimulate the client's appetite before bedtime to promote rest all at one time to provide a longer rest period in the morning, with frequent rest periods

in the morning, with frequent rest periods Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort and improves with rest. Procedures should be performed in the morning because the client is most rested at that time. In addition, the client should have frequent rest periods in between procedures. Procedures should be avoided before meals, or the client with myasthenia gravis may become too exhausted to eat. Procedures should also be avoided at bedtime.

A nurse is providing care to a client after surgery. The nurse must practice surgical asepsis when performing which procedure? insertion of an indwelling urinary catheter colostomy care and irrigation irrigation of a nasogastric (NG) tube mouth care

insertion of an indwelling urinary catheter Caregivers must use surgical asepsis when performing any procedure in which skin integrity is broken or a sterile body cavity is entered. Therefore, inserting an indwelling catheter into the client's bladder (a body cavity) requires surgical asepsis. The mouth is not sterile; therefore, mouth care requires standard precautions to prevent the spread of infection. The GI tract also is not sterile; therefore, irrigating an NG tube or a colostomy requires standard precautions.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional values? social justice integrity human dignity altruism

integrity The nurse is demonstrating integrity which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations.

A nurse is caring for a client with an acute head injury and is ready to begin rehabilitation. When transferring the client from the bed to a chair, what should the nurse do to ensure client safety? place socks on the client's feet position the chair 2 feet from the bed raise the side rails on both sides of the bed lock the brakes on the bed

lock the brakes on the bed Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. Positioning the chair alongside the bed, rather than 2 feet away, helps the client to pivot into the chair. The nurse should place shoes or slippers with nonskid soles on the client's feet to help prevent slipping during the transfer.

Which nursing intervention is appropriate for a client with an arm restraint? tying the restraint to the side rail applying the restraint loosely to prevent pressure on the skin positioning the restrained arm in full extension monitoring circulatory status every 2 hours

monitoring circulatory status every 2 hours A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A nurse-manager is reviewing incidents that occurred recently. For which event will the manager need to make a report to the board of nursing? A client develops a urinary tract infection after several days with an indwelling catheter. A home health nurse notifies a primary care provider of a decline in client health. A client falls from bed when the nurse did not raise the side rails after providing care. A nurse documents administering narcotics to a client while personally using the medication.

nurse documents administering narcotics to a client while personally using the medication. Nurse practice/health profession acts regulate nursing licensure and practice. Each state, province, or territory has its own legislation. Violations of criminal law, such as possession of controlled substances, assault, battery, negligence, and rape, must be reported to the board of nursing as well as the police. Most cases of malpractice fall within the realm of civil law.

A client in the long-term care facility sustains a fall when trying to get out of the bed. What is the priority action by the nurse? find out from the unlicensed assistive personnel (UAP) what happened obtain subjective and objective data to determine injury assist the client back into the bed complete an incident form

obtain subjective and objective data to determine injury The priority action by the nurse is to ensure the safety of the client and determine if injury occurred. The client should not be moved until an assessment of injury is done. Questions about what happened can be obtained after ensuring the client is not injured or in pain.

A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should: palpate the bladder at the umbilicus. feel that the bladder is smooth. be unable to palpate the bladder. palpate the bladder above the symphysis pubis.

palpate the bladder above the symphysis pubis. Eight hours is a long time not to have voided. Typically, the kidneys produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder should be full of urine and palpable above the symphysis pubis. If the bladder isn't full after 8 hours, the client's kidneys may be malfunctioning or the client may be dehydrated.

A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which nursing action would best serve the hospital in this disaster situation? volunteer to help where assistance is most needed implement tasks that are beyond the scope of practice offer advice about how to run the facility smoothly perform duties as outlined in the disaster plan

perform duties as outlined in the disaster plan Before a disaster occurs, the nurse should know how the hospital's disaster plan works and what he or she will be required to do. During a disaster, the charge nurse will assign staff to areas where they are needed; therefore, a nurse could be required to perform tasks outside of the usual duties. This practice is permitted if the nurse has the knowledge, skill, and comfort level to perform the assigned tasks. However, the nurse should never perform medical procedures outside of the scope of practice as outlined in the state's Nurse Practice Act.

During an admission history a copy of the living will was provided by the client. The nurse's responsibility at this time is to: place the document on the client's chart and communicate the information to the health care team. record in the comment section of the admission history form key components of the client's living will. ensure that all the components of the living will are addressed within the document. thank the client for the information, read it thoroughly, and ask the client to place it in the top bedside drawer.

place the document on the client's chart and communicate the information to the health care team. Living wills include instructions on when and how to implement their provisions, witness and testator requirements, immunity from liability for anyone following the directives, documentation requirements, and under what circumstances the living will takes effect. The document should be placed on the client's chart and the information shared with the health care team. Nurses do not need to ensure that all components are addressed, nor should the client keep the living will at the bedside.

A nurse is caring for a client with a chest tube. If the chest drainage system is inadvertently disconnected, what is the nurse's priority action? secure the chest tube with tape immediately clamp the chest tube place the end of the chest tube in a container of sterile saline solution apply an occlusive dressing, and notify the health care provider

place the end of the chest tube in a container of sterile saline solution If a chest drainage system becomes disconnected, the nurse should place the end of the chest tube in a container of sterile saline solution or water to prevent air from entering the tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out, not if the system is disconnected. The nurse should not clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has become disconnected.

A nurse is caring for a confused, older adult client. Which action should the nurse prioritize for this client's care? encouraging participation in activities of daily living (ADLs) monitoring for deteriorating of neurologic status. promoting safety by protecting from injury identifying the underlying cause of confusion

promoting safety by protecting from injury The nurse's first responsibility is always to protect the client from injury. Determining the cause of the confusion and protecting the older adult client's neurologic status from deterioration are the primary care provider's responsibilities. Encouraging the client to participate in ADLs is a nursing intervention, but it is not the most important consideration

The licensed practical nurse (LPN) is part of a team caring for a group of clients in a community. Which task carried out by the LPN best describes team nursing? providing care for church members at a community worship center providing total care to a group of clients in the unit providing total care to clients with other health personnel administering medication to all of the clients in the unit

providing total care to clients with other health personnel Being part of a group of nurses providing total care is team nursing. Administering medication to all of the clients in the unit is functional nursing. Providing total care to a group of clients is considered primary nursing. Providing care to church members is called parish nursing.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy? raising one bed rail to offer stabilization when standing raising all side rails while the client is in bed providing a bed that is low to the floor placing the client in a bed with a bed alarm

raising all side rails while the client is in bed Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if the client climbs out of bed. All the other options would comply with a least restraint policy.

A registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are working together in the emergency department to care for a client who is hemorrhaging. Which actions would be delegated to the LPN/VN? assessment of wound, reposition of client off of the wound site, documentation of vital signs during infusion of blood products, reassessment vital signs, dressing wound, initiation of blood products reposition of client off of the wound site, documentation of vital signs during infusion of blood products, assessment of wound assessment of wound, initiation of blood products reposition of client off of the wound site reposition of client off of the wound site, documentation of vital signs during infusion of blood products, reassessment vital signs, dressing wound

reposition of client off of the wound site, documentation of vital signs during infusion of blood products, reassessment vital signs, dressing wound The RN has the primary responsibility of the client in the acute situation. The RN is able to delegate tasks within the scope of practice of the LPN/VN. Assessment of an acutely ill client falls to the RN. In this situation, that includes the assessment of the wound and initiation of blood products and assessment for a transfusion reaction. Once the client is stable, the nurse may choose to delegate reassessment (not initial) vital signs and documentation (also obtaining) of vital signs during the blood transfusion. Once the RN has assessed the wound, the dressing procedure can be delegated and the client may be repositioned.

A nurse is assigned to care for an older adult client who is confused and repeatedly attempts to climb out of bed. While the nurse is out of the room, the client climbs out of bed and falls, but does not sustain injuries from the fall. This situation would most likely present as which type of occurrence? ethical dilemma informed-consent problem risk-management incident quality-improvement issue

risk-management incident This situation reflects a risk-management incident; the immediate responsibility is to fill out an incident report and follow agency policy, notifying the nurse manager and other appropriate personnel such as the risk manager. Quality improvement and ethics are not the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent is not relevant in this incident.

A nurse working in the emergency department (ED) is caring for several clients. The nurse determines that obtaining informed consent for treatment would be unnecessary for which client? the client who is diagnosed with a mental illness the client who refuses to give informed consent the client who is bleeding profusely from a car crash the client who asks the nurse to give substituted consent

the client who is bleeding profusely from a car crash The law does not require informed consent in an emergency situation such as the client who is bleeding profusely, when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. The client may also refuse treatment. Even though a client who has been declared mentally incompetent cannot give informed consent, mental illness does not by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.

A nurse wants to use a waist restraint for a client who wanders at night. Which intervention should be considered before applying the restraint? the client's reason for getting out of bed the nurse's convenience the lack of unlicensed assistive personnel (UAP) on the night shift a sleeping medication ordered as needed at bedtime

the client's reason for getting out of bed The nurse should question the client's reason for getting out of bed because the client may be looking for a bathroom. Lack of adequate staffing and convenience are not reasons for applying restraints. Sleeping medications are chemical restraints that should be used only if the client can't go to sleep and stay asleep.

A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error? improper correction unauthorized entry late entry omission

unauthorized entry This action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency. Omission is a documentation error in which information is missing from the medical record. In this scenario, the day-shift nurse omitted documenting the administration of pain medication. A late entry refers to an entry made later than it should have been. The nurse should identify a necessary late entry as a "late entry" and document the reference date and time. An improper correction is an entry corrected in an improper manner, such as by erasing, using correction fluid, or obliterating the error with a marking pen. The nurse should always follow the facility's documentation guidelines.

A client is scheduled to have sputum studies done for three consecutive days. When is the best time of day for the nurse to collect the sputum specimens? anytime during the day before bedtime when the client awakens early in the evening

when the client awakens Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen as soon as the client awakens and before the client eats or drinks. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture.