Skills Lab

Write it down

A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?

Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes.

A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take?

"Dizziness when you change position can occur when fluid volume in the body is decreased."

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

The client's immune system became further weakened

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

Surgical asepsis

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

Dyspnea

A client has smoked most of his life and has labored respirations. He is experiencing:

"Your elbows will be slightly bent when you are using your crutches."

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

Client is in supine position with arms in functional position and pillow support under the knees.

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

Prodromal phase

A client reports fatigue, malaise, and a low-grade fever. What phase of the infectious process does the nurse determine the client is experiencing?

Fowler's

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

Carrier

A client with HIV is the:

Trochanter rolls

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

"I hold the boxes away from my body so I don't drop them on my feet."

A client works in a warehouse and has been having low back pain. Which statement would indicate the need for more education regarding safe lifting?

Offer the family member a mask, explaining its use.

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. What is the appropriate nursing intervention?

Tremor

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:

The nurse's back is facing the sterile field. The nurse touches an unsterile object to the instrument tray. The nurse is talking with the scrub nurse over the sterile field.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply.

Footdrop

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from:

Listen with the stethoscope at the fifth intercostal space left mid-clavicular line.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

Keep hands lower than elbows to allow water to flow toward fingertips.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Wash the area with soap and water

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?

The nurse should gently slide the client down his or her body to the floor.

A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall?

Inflate the blood pressure cuff while palpating the client's brachial artery.

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?

decrease the apical pulse.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will:

There is an auscultatory gap.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

the ability of the arteries to stretch

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

Pulse is felt with difficulty and disappears with slight pressure.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.

A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?

5,850 mL (5,850 × 109/L)

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

Urinary catheter

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

The nurse places the client in a private room with monitored negative air pressure.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

removal of clutter on the floor placing a nightlight in the bathroom and the hallways moving the bedroom to the ground floor

A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

Exit route

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts?

Stop the procedure, remove damaged gloves, perform handwashing, and open new sterile gloves.

A nurse is performing a venipuncture on a client and notices that there is a hole in one of the sterile gloves. What would be the appropriate action to take to maintain a sterile field?

A commercially packaged surgical item is not considered sterile if past expiration date.

A nurse is preparing an operating room theatre for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?

Client reports feeling dizzy when sitting up from a supine position. Client reports feeling palpitations when rising from a supine to a standing position. The client states, "I feel lightheaded when sitting up."

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? Select all that apply.

Older adult

A nurse is taking care of a client with tuberculosis who has developed resistance to the ordered antibiotic. Which type of client is most likely at increased risk for infection?

Indwelling catheter

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?

Over the client's thigh

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

reaches down to the bed to pick up a sterile drape

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

"You may have infection in your birth canal that you are unaware of."

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:

the apical pulse and the radial pulse rates.

A pulse deficit is the difference between:

"To prevent the legs from rotating outward."

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

near the client's hip, with legs shoulder-width apart and one foot near the head of the bed

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

Temperature drops with age

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

Hand hygiene is needed after contact with objects near the client.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Recapping a needle

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:

Auscultate the client's apical pulse.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

An 80 year old woman

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?

Health-associated infection (HAI)

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?

"Move slowly and sit on the edge of the bed before transferring to the chair."

An older client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?

auscultating a pulse that is difficult to palpate.

An ultrasonic Doppler is used for:

Pathogen

Any microorganism capable of disrupting normal physiologic body processes is a:

1700

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

To clean rooms between clients

Disinfectants are used:

True

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

5, 7, 2, 1, 3, 4, 6

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Muscle injury

One of the most common injuries/risks associated with exercise in a healthy person is:

To protect both the staff and clients from becoming infected by one another

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

Absence of all microorganisms

Surgical asepsis is defined as:

"You have lost the padding in your joints and the friction causes pain."

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?

Adjust the height of the work area. Face the direction of the activity he is performing. Use a wide stance and lift with the large leg muscles.

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.

The client is aware of spatial relationships to avoid the table.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

The client will continue to grow rapidly and will refine both gross and fine motor skills.

The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response?

Ask the client to demonstrate self-blood pressure assessment.

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mm Hg. What is the priority nursing intervention?

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

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Encourage the colleague to remove the glove by grasping the cuff

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response?

Temporal artery

The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature?

Applying a blanket

The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?

When hands are visibly soiled

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

"When your sputum culture is negative."

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?

Flexion

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?

"I will invite a friend to exercise with me."

The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful?

Steps into the walker when walking

The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client:

Wash hands before and after client care. Encourage clients to receive vaccinations. Cluster patients with similar conditions. Select appropriate Personal Protective Equipment (PPE) for all isolation patients.

The nurse has collected data related to the recent occurence of several Health Care Associated Infections (HCAIs) in the acute care facility. What nursing interventions should be implemented to decrease Health Care Associated Infections (HCAIs)? Select all that apply.

40 mmHg

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mm Hg. What is this client's pulse pressure?

"I will clean the thermometer in the dishwasher."

The nurse instructs a mother of young children how to properly use a nonmercury glass thermometer. Which statement made by the client indicates a need for further instruction?

Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider.

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action?

predisposition to renal calculi

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

Listen for heart sounds

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Client stands at bedside, becomes pale, diaphoretic.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?

the 24-month-old child who is unable to walk unassisted

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

Diminished, weaker than expected

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity". What amplitutde is the nurse assessing?

Raise the head of the bed to a sitting position.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Contact precautions

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement?

Supporting the client's back

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

"Put your arm in this sleeve"

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

Transfer Belt

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

Noncommunicable disease

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

health care-associated infection (HCAI)

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?

Remove fresh fruit from the room

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

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

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

"A client can perform this activity to prevent a permanent a condition in the feet caused by bed rest."

The nurse is caring for a client who is on bed rest. After revieiwng the image above, which is the most appropriate reason for the nurse to observe this client perform the activity?

Sims'

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

risk for impaired skin integrity

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?

Change to airborne precautions.

The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?

infectious disease communicable disease contagious disease

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? Select all that apply.

Contact

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

Airborne

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?

The client is covered with a couple of thick blankets.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

"The antiviral medication will cure the virus from my body."

The nurse is discussing antiviral medication with a client diagnosed with human immunodeficiency virus (HIV). Which client statement indicates a need for further teaching?

Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?

Immediately remove the rectal thermometer

The nurse is obtaining a rectal temperature from a client when the client states, "I feel as though I am going to faint." What is the priority action by the nurse?

The client has reports of pain of 8 on a scale of 0-10 The client just finished ambulating with physical therapy The client has a temperature of 101.8 degrees Fahrenheit

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia?

Scoliosis

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

Collect another sterile central line dressing kit.

The nurse is performing a sterile change of a client's central line catheter dressing. The client receives a telephone call and stretches the phone cord across the open sterile dressing kit. What is the next best action the nurse should take?

No masses, deformities, or muscle atrophy Full range of motion with each joint No swelling, heat, tenderness, pain, nodules, or crepitation

The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply.

Shortness of breath after walking up five stairs

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

Lying flat

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

Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse is preparing to apply a prescription ointment to the client's would. After reviewing the image, what is the most important step for the nurse to take?

Assess the skin and neurovascular status of the legs and feet before applying Have the client lie down with legs and feet elevated for at least 15 minutes before applying Launder the stockings at least every 3 days

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What actions by the nurse demonstrate to the client the appropriate way to apply the stockings? Select all that apply.

Deep in the posterior sublingual pocket

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Lightly compress the client's radial artery using the first, second, and third fingers.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options.

Thrombus formation

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

Into a private room

The nurse is receiving a confused client with a draining wound onto the medical-surgical unit. Which room assignment will the nurse make?

Discard the sterile field and the supplies and start over.

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

Remove the thermometer and assess the blood pressure and heart rate.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

Opposite the client's center

The nurse is turning a client in bed. Where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed?

Trapeze bar

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

Review the current infection control protocols.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?

staff education on utilizing hand hygiene

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

Adduction

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

MRSA in the wound

The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?

Assess the client's ability to stand or sit.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

Remind the student that a fitted N95 respirator is required.

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

removes gloves and walks out of the room

The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

There is a large pillow under the client's head. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position.

The nurse observes an unlicensed assistive personnel (UAP) placing a client in the Fowler's position. To prevent complications to the client, in which situation should the nurse intervene? Select all that apply.

surgical asepsis

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Pour the liquid into a sterile container within the sterile field.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

A client who has leg strength and can cooperate with the movement

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

The nurse keeps fingernails less than 1/4 in (0.63 cm) long.

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

40% of the circumference of the limb to be used

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

Acts to prevent injury to the client and/or nurse

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

Supine

The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep?

Use the Doppler ultrasound device.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Increased temperature

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

Immediately deposit uncapped needles into puncture-proof plastic container.

To eliminate needlesticks as potential hazards to nurses, the nurse should:

Shift their weight back and forth, from back leg to front leg.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Using proper body mechanics, which motions would the nurse make to move an object?

Decreased heart rate

What is a benefit of regular exercise over time?

Skin

What organ is the primary site of heat loss in the body?

The client's pulse rate is below 60 beats per minute.

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?

Auscultate the apical pulse for 60 seconds

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Do it immediately after the pulse assessment so the client is unaware of it.

When assessing a client's respiratory rate, the nurse should take which action?

1°F (0.5°C) lower than an oral temperature.

When assessing an infant's axillary temperature, it will be:

The middle-aged computer programmer

When assessing the physical activity of clients, the nurse would be most concerned about which client?

Orthostatic Hypotension

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client?

Have the client fold their arms across their chest

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Cleanse and disinfect the sphygmomanometer.

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?

Obtain a new bottle of sterile saline.

When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do?

"The axillary route is the most accurate of all routes."

When taking the client's temperature, the student nurse will require further education when they state:

Short bones contribute to movement

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

a client with low blood volume

Which client would the nurse consider at risk for low blood pressure?

The systolic reading is below 100 and diastolic reading is below 60.

Which client's blood pressure best describes the condition called hypotension?

Exercise

Which condition will lead to an increase in cardiac output?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

Which describes diastolic blood pressure?

Depth

Which is not a characteristic used to describe the pulse?

use of one gown per person per shift

Which is not appropriate regarding the use of gowns as PPE?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

Carotid

Which peripheral pulse site is generally used in emergency situations?

Rectal

Which site results in measuring a client's core body temperature?

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume.

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse?

Pyrexia

Which term indicates a potentially serious client condition?

a cane with four prongs on the end (quad cane)

Which type of mobility aid would be most appropriate for a client who has poor balance?

Bradypnea is a response to IICP.

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?