Safety - HESI

The nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which findings noted by the nurse are indicative of impaired circulation?

-Areas of pallor -Decreased movement -Decreased temperature -Reports of pain or tingling

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply.

-Keeping pregnant women out of the client's room -Placing the client in a private room with a private bath -Wearing a lead shield when providing direct client care

The nurse is assessing an older adult who was just admitted to the emergency department with a possible hip fracture. What typical complaints of types and/or locations of pain might the nurse expect? Select all that apply.

-No pain -Groin pain -Pain referred to the lower back -Pain referred to the back of the knee

The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicates an understanding of the care for this client?

"I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."

The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statement?

"If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply.

-Risk for unsafe conditions because of homelessness -Anxiety when consciousness is regained because of the unfamiliar surroundings -Risk for infection because of his unkempt condition, various scratches, and homelessness

A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment should include which parameters?

-The client's vital signs, -Level of consciousness, -The patency of intravenous lines

The nurse is preparing to administer an intramuscular injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected?

1.5 mL ages 3 to 6 years, the maximum volume of medication that can be safely injected into the ventral gluteal muscle is 1.5 mL.

The nurse is transcribing a health care provider's prescription and notes that the client is to receive a medication at 1:00 p.m. Using the military time clock, the nurse documents which military time in the medication record for administration of the medication?

1300

The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters?

2 cm.

The nurse has administered diazepam 5 mg by the intravenous route to a client. The nurse should plan to maintain the client on bed rest for at least how long?

3 hours The medication is a centrally acting skeletal muscle relaxant and has antianxiety, sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary adverse effects of the medication include apnea, hypotension, bradycardia, and cardiac arrest. For this reason, resuscitative equipment also is kept nearby.

The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times?

A pair of scissors

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L) The normal platelet count is 150,000 to 450,000 mm3 (150-400 × 109/L).

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

Activate the emergency response plan.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm.

The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What should the nurse's first action be?

Activate the fire alarm.

The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place and takes which action next?

Activates the fire alarm

The nurse is instructing a client to perform a two-point gait for crutch walking. The nurse should tell the client to perform which action?

Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.

A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that further teaching is required if the client performs which action?

Advances the walker with reciprocal motion

The nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor?

An apnea monitor should not be adjusted to eliminate false alarms. The monitor should be placed on a firm surface away from the crib and drapes. The caregiver should not sleep in the same bed as a monitored infant. Pets and children should be kept away from the monitor and infant. Emergency rescue numbers should be kept near phones in the home. Leads should be removed when the infant is not attached to the monitor.

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do?

Apply prolonged pressure to the IM site after the injection.

A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit?

Approaching the client from the unaffected side

The nurse is preparing to administer 1 mg of hydromorphone, a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct?

Ask a second nurse to witness disposal of the unused portion.

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next?

Asks the client to swallow while palpating the throat

The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider?

Aspiration is a concern with an NG tube feeding.

A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priority action in the care of this client?

Assign the client to a private room.

The nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need?

Assist the client onto a bedpan. Because preoperative medications cause sedation, the client should not be allowed to leave the bed or stretcher after the medications are administered.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?

Bed rest with elevation of the affected extremity

A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel to clean up the blood spill is incorrect?

Blots up the spill with a face cloth or cloth towel. Should use disposable such as paper towels or terry wipes.

The nurse is caring for a client with a nasogastric tube connected to continuous suction. During assessment the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which intervention would be most appropriate to maintain the integrity of this client's oral mucosa?

Brush the teeth frequently; use mouthwash and water

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?

Call the Poison Control Center.

At a local school, a community health nurse is providing an educational session on childhood poisoning. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse should include taking which action first if an accidental poisoning occurs?

Call the Poison Control Center.

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?

Call the health care provider to request a prescription for a chest radiograph. Gastric aspirates have acidic pH values and should be 3.5 or lower.

The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation?

Carefully pick up the syringe from the floor and dispose of it in a sharps container.

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety?

Check for tube placement and residual amount at least every 4 hours.

The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the health care provider (HCP) has prescribed a dose that is twice the amount that the client has reported taking before admission. What is the most appropriate nursing action?

Contact the HCP directly.

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance.

The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do?

Cover the ice pack with a pillowcase and place it on the eye.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?

Determine whether there are medication duplications.

A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard?

Disinfect the toilet with bleach after voiding for 6 hours after a treatment.

The mother of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition?

Do you live in a house that is more than 25 years old?

The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position?

Elevated on one or two pillows and does not exceed shoulder elevation. This promotes optimal drainage from the limb without impairing the circulation to the arm. If the arm is flat or dependent , this could increase the edema in the arm

A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care?

Encourage the client to use artificial saliva to manage dryness. Because of Epithelial cells are destroyed by radiation involving the head and neck.

The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is appropriate to prevent these disorders from developing?

Encouraging active range-of-motion exercises

A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family?

Encouraging the client to stand unassisted on the leg

A cold, moist compress is prescribed to be applied to the client's right knee. Which should the nurse plan for?

Ensure that the temperature of the compress is 15°C (59°F).

A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse providing care for the client administers an opioid analgesic to relieve the pain, as prescribed. What is the next nursing action for this client?

Ensure the call bell is within the client's reach.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients?

Every 1 hour

An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury?

Explore the client's knowledge of gun safety.

The nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care should include nursing interventions that address which early characteristic of Alzheimer's disease?

Forgetfulness interferes with the daily routine.

A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home?

Have the client verbalize and demonstrate the correct administration procedures.

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client?

Hold the cane on the unaffected (strong) side.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take?

Hold the feeding and reinstill the residual amount.

The nurse has instructed a client with a continuous passive motion device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question?

How to reset the degrees of flexion or extension according to comfort Patient should not adjust the flexion and extension settings.

The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question?

Hydrochlorothiazide orally twice daily. Dosage is missing.

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

I should sleep on my left side.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective?

I will avoid getting the cast wet.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What action should the nurse take next?

Insert the catheter 2.5 cm to 5 cm and inflate the balloon.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room. The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Liberia.

The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction?

It is all right to use an electric razor for shaving only if I leave it plugged in for a short time.

A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure?

Keep traveled paths in the home free of clutter. Cranial nerve II is the optic nerve, which governs vision.

The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse?

Leaves the ulcer open to the air after the enzymatic agent is applied. thin dressing tape should be used.

The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly?

Makes sure that two fingers can be inserted under the restraint

A client has a prescription for an injection to be administered by the intradermal route. The nurse should avoid which action when administering this medication?

Massaging the area after removing the needle

The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention?

Nonstop physical activity and poor nutritional intake

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?

On the nonoperative side with the legs abducted

When administering an intramuscular injection in the ventrogluteal muscle, how should the nurse position the client to best relax the muscle?

On the side with the hip and knee of the uppermost leg flexed

The community health nurse is conducting an education session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time?

One hour before exposure to the sun

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container.

The nurse creates a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan?

Place a lead shield at the bedside.

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention?

Place a mattress sensor pad on the bed.

Treatment for a client with bleeding esophageal varices has been unsuccessful, and the health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action?

Place a pair of scissors at the client's bedside.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway. Client needs to be in a private room with a private bath instead.

The health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe?

Placing the heating pad under the client

The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client?

Prepare a private room at the end of the hallway.

The health care provider (HCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the HCP's prescription and address the needs of the client?

Progressively ambulate the client in the hall three times daily.

The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action should the nurse take?

Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy.

The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?

Properly glazed pottery. Paint chips, soil contaminated with lead, lead solder used in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

What action should the nurse take as a priority after administering an opioid analgesic to a client experiencing pain?

Provide safety measures per agency protocol.

The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse should perform which action?

Pulls the pinna of the ear back and down. If the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up.

The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating?

Quad cane

The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions should the nurse take?

RACE PASS Remove patient, Activate alarm, Close door & window, Extinguish by Pull a pin, Aim at base, Squeeze, and sweep side to side.

The nurse has called a client's primary health care provider (HCP) to clarify a medication prescription. The HCP gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time?

Read the prescription back to the HCP after writing it on the prescription sheet.

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?

Reassess the client

The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by one of the parents should the nurse identify as something that requires the need for reinforcement of the instructions?

Refers to medication as "candy for when you are sick"

The nurse in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first?

Remove the client from the waiting room

A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased, and the client is still shivering. What should the nurse do next?

Remove the hypothermia blanket and notify the client's health care provider.

The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan?

Remove throw rugs and clutter in the home.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

Removing the client from any immediate danger

The nurse provides instructions to the parents of an infant regarding car travel and safety seats. Which is the appropriate information related to the safety of the infant?

Restrain in a car seat in the back seat in a semireclined rear-facing position.

A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe?

Restraints

The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk?

Review hand washing techniques and pericare procedures with the client.

The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure?

Rinsing with a large volume of fluid

The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority?

Risk for injury. late-stage Alzheimer has significant cognitive impairment.

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?

Safely securing the safety device straps to the side rails

The nurse is caring for an 18-month-old child who has been vomiting. Which is the most appropriate position for this child while sleeping?

Side-lying position

The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation?

Speak and move slowly toward the client while assessing the client's needs.

The nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next?

Stop the IV infusion. infiltration of the IV solution has occurred

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene.

The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing?

Tertiary level

The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture?

The IV solution for particles or contamination

The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made?

The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.

When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action?

The restraints were applied tightly.

A home care nurse performs a home safety assessment and discovers that a client is using a space heater in the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn.

The home health nurse performs an assessment on a client who had cardiac surgery 10 days ago. The client states, "I get dizzy in the shower." On the basis of the client's statement, which should the nurse assess first?

The temperature of the water of the client's shower. hot showers can cause vasodilation which decrease in venous return to the heart which lead to dizziness.

The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction?

The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe. should be 25 to 30 degrees

The community health nurse is performing a safety assessment in the home of a mother with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children?

Toys with small loose parts in the playroom

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention?

Unsecured scatter rugs

The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration?

Upright in a chair

The nurse is caring for an older client who had a hip pinned after being fractured. Which should the nurse do to prevent further injury?

Use a night light in the hospital room and the bathroom.

The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action?

Using a gloved finger to open the client's mouth Use a bite stick or a padded tongue blade instead.

The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the coassigned licensed nurse identifies which action as an incorrect intervention?

Using padded restraints to immobilize the limb

An unconscious client has an impaired corneal reflex on one side. The nurse should demonstrate the best understanding of how to protect the client's eye by performing which action?

Using sterile saline drops every few hours to keep the eye moist

A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method?

Ventrogluteal muscle using Z-track technique

A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client?

Walker. The cerebellum is responsible for balance and coordination.

The nurse is completing medication reconciliation with a client just before discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response?

We do this to make sure you will be receiving the correct medications once you are at home.

The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?

When I'm feeling better, I'm returning to the soccer team.

A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period?

Within 20 to 30 minutes of application

The nurse is providing instructions to an unlicensed assistive personnel (UAP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the UAP to place personal articles for morning care?

Within the client's reach on the left side

A community health nurse is preparing to administer a tuberculin skin test. The nurse should select which syringe to administer the medication?

a small hypodermic syringe. 1 ml syringe.

The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client?

head of the bed elevated 30 to 45