Basic Care and Comfort

A 10-year-old male is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain?

Obtain vital signs with a pain score.

A child is admitted with constipation and a diagnosis of possible appendicitis. The child is in acute pain. Which nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.

Offer an ice pack. Assume a position of comfort. Limit the child's activity.

An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery?

Place the client in semi-Fowler's position with the knees to the chest.

A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order? Select all that apply.

apple juice broth tea

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods?

fats

A client who suffered blunt chest trauma in a motor vehicle accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume?

leaning forward while sitting

When developing a teaching plan for a client who is 8 weeks pregnant, the nurse would suggest what foods to meet the client's need for increased folic acid? Select all that apply.

spinach beans

The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. The nurse should first:

stop the flow of solution.

What position should the nurse use for the client with venous insufficiency to enhance blood supply?

supine with lower extremities elevated

A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give the consent for surgery?

surrogate decision maker

An anxious client is admitted for treatment of an exacerbation of irritable bowel disease. The client asks the nurse if biofeedback will help after reading about biofeedback online. What is the best response by the nurse?

"Biofeedback will help reduce stress."

The nurse is assessing a client who is in her first trimester of pregnancy. The client states that her nausea has been problematic at times, but says that she is able to partially control it using ginger supplements. What is the nurse's best response?

"Have you let your care provider know that you are taking ginger?"

A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation."

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy."

A breastfeeding postpartum client experiencing breast engorgement tells the nurse that she has applied cabbage leaves to decrease her breast discomfort. What is the nurse's best response?

"Let me know if you get relief using the cabbage leaves."

A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness?

"Let's discuss your desire to integrate these practices with the physician and advocate on your behalf."

A client with chronic pain comes to the clinic for an evaluation. During the visit, the client asks the nurse about possibly using acupuncture for pain relief. Which response by the nurse would be most appropriate?

"Restoring the energy balance in your body could help with pain relief."

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?

"Take a warm tub bath or shower before exercising. This may help with your discomfort."

A client recently experienced a stroke with accompanying left-sided paralysis. The family voices concerns about how to best interact with the client. They report the client doesn't seem aware of their presence when they approach the client on the left side. What advice should the nurse give the family?

"The client is unaware of their left side. You should approach them on the right side."

The nurse has taught the partner of a client who experienced traumatic vision loss strategies for effectively interacting with the spouse. Which statement by the partner indicates that the health teaching was successful?

"Today I used the clock suggestion to state where things were located in the room."

The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's best response?

"Your cervix is not fully dilated. Let's keep breathing through the pressure."

The nurse is completing an intake and output record for a client who is receiving continuous bladder irrigation after transurethral resection of the prostate. How many milliliters of urine should the nurse record as output for the shift if the client received 1,800 ml of normal saline irrigating solution and the output in the urine drainage bag is 2,400 ml? Record your answer using a whole number.

600

When providing care for clients with possible arterial disease, the nurse recognized which clients should have a baseline ankle-brachial index (ABI) assessed? Select all that apply.

65-year-old client with decreased pulses 72-year-old client in the nursing home 75-year-old client with diabetes

Two days after surgery to amputate the left lower leg, a client states that they have pain in the missing extremity. There is an existing prescription for PRN pain medication. Which action by the nurse is most appropriate?

Administer medication for the reported discomfort.

A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

A client admitted to the hospital for chemotherapy states that using a peppermint-scented candle at home to helps control nausea. Which interventions would the nurse plan to promote comfort for this client?

Asking the client to try using peppermint oil in place of scented candles

The parent of a child with autism tells the nurse that her child is only sleeping 2 to 3 hours per night. When educating the parent about treatment for the child's sleep disturbance, the nurse should include what information?

Behavioral interventions including sleep-hygiene measures are often effective in treating sleep disturbance.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse?

Check the medical record for a provider's prescription for compression stockings.

The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate?

Eat a soft, bland diet.

A client has a risk for skin breakdown due to incontinence. Which nursing actions for the client will help with decreasing this risk? Select all that apply.

Have scheduled toileting every 2 hours. Cleanse the perineal area daily and after each incontinent episode. Maintain a voiding record to determine any patterns of incontinence.

When the nurse is developing a plan of care to manage a client's pain from cancer, what should the nurse plan to do?

Individualize the pain medication regimen for the client.

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?

Measure the client's legs.

A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, what should the nurse do next?

Obtain a more detailed assessment of the client's pain using a pain scale.

A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best?

Offer the child small feedings several times a day.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium daily.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include

ground beef patties.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure?

The student nurse irrigates the NG tube through the blue air vent port.

Parents of a neonate who is 32 weeks of age ask the nurse, "Why does he have a feeding tube in his nose?" What is the nurse's best response?

The sucking, swallowing, and breathing are not coordinated.

The nurse is teaching the caregiver of an older adult client about urinary incontinence. What statement should the nurse make to the caregiver about urinary incontinence in the older adult?

Urinary incontinence has many causes and can often be improved with intervention.

Which client would benefit from the application of warm moist heat?

a client with low back pain

A client has refused to take a shower since being admitted 4 days earlier and tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

accepting these fears and allowing the client to take a sponge bath

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

high-protein

When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000 mL/day, which fluid should the nurse consider as most appropriate for the client's condition and effective for preventing excessive thirst?

ice chips

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of

organ meats.

Upon repositioning an immobile client, the nurse notes redness with blanching over a bony prominence. What is the most probable cause?

reactive hyperemia is likely transient.

Which food would be appropriate for a 12-month-old child with celiac disease?

rice cereal

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response?

Ask the parent for more information about the infant's sleep patterns.

The health care provider orders documentation of a client's intake and output. Using the following information, calculate this client's intake in milliliters. Record your answer to the nearest tenth. 250 ml decaffeinated coffee 125 ml green gelatin 62.5 ml apple juice 125 ml lemon-lime soda 250 ml beef broth 300 ml of urine output

812.5

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which actions should the nurse take before starting the NG feeding on the child? Select all that apply.

Verify the physician's order. Check placement of the NG tube. Assess for bowel sounds.

A client has impaired skin integrity related to compromised circulation. What should the nurse include in the teaching plan regarding nutritional considerations?

adequate intake of vitamins A and C, protein, and zinc

A client in a hospice program has increasing pain, and the nurse is collaborating with the client to make a pain management plan. Which plan will be most effective for the client?

administering pain medications over a 24-hour period

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine?

albumin level

The client suffered a traumatic amputation of the left arm about 6 months ago and has severe chronic phantom pain for the last 4 months. The client asks the nurse what interventions can be performed to assist him with phantom pain. What is the best response(s) by the nurse? Select all that apply.

heat application wrapping cold application transcutaneous electrical nerve stimulation (TENS)