Basic Care/Comfort

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? 1. Ask about the client's recent bowel and bladder habits 2. Assess the home for sources of excessive noise 3. Provide information about respite and adult day care 4. Review behavior-management techniques with caregiver

1 Alzheimer disease is a form of dementia that causes a progressive decline in cognitive and physical abilities. Behavioral changes (agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (constipation) or eating (inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs

An adolescent client is brought to the ED after being in a serious motor vehicle crash. The client is undergoing CPR. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs." 2. "His heart has stopped and we are attempting to revive him." 3. "I don't know how he is doing but you need to come." 4. "I will have the HCP talk to you once you arrive."

1 Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want to family to be too distressed to process the situation and arrive safely

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are tor and show signs of wear 2. The client has a 30 degree bend at the elbow when walking 3. The crutches and injured foot are moved simultaneously in a 3 point gait 4. There is a 3 finger-width space noted between the axilla and axillary pads

1 Clients are taught to support body weight on the hands and arms, not the axillae Handgrip location should allow 20-30 degrees of flexion at the elbow The 3 point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously Option 1: Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. Ask the mother's permission to touch the child's hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is no reason for distress 4. Suggest postponing the exam until the mother calms down

1 In Latin American culture, an illness called "mal de ojo" (evil eye) is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The illness or curse is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be BROKEN IF THE ADMIRER TOUCHES THE CHILD while speaking to the child or immediately afterward. Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets

A 55 year old client on a medical surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent that from happening." 3. "Well, we're all going to die sometime." 4. "You should concentrate on getting better rather than thinking about death."

1 The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?" the client is most likely not looking for a direct yes or no answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply 1. Cervical cancer 2. HTN 3. Ischemic stroke 4. Osteoporosis 5. Skin melanoma

1, 2, 3 The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women Option 4: White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply 1. "I can apply vaseline to my nose when my nostrils feel dry from the oxygen." 2. "I can cook on my gas stove as long as I have a fire extinguisher in the kitchen." 3. "I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath." 4. "I should not polish my nails when using my oxygen." 5. "I should not use a wool blanket on my bed."

1, 2, 3 Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames The prescribed concentration of oxygen, usually 24-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mmHg and the saturations from 90-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breathe

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply 1. Arrange for health care workers of the same sex to provide care for the client 2. Coordinate with the dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. Upon death, provide the family with supplies for postmortem care

1, 2, 3, 5 Aspects of care for Muslim clients include: -Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer -Providing foods that are halal (lawful), acceptable for consumption (no pork) -Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly -Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day

The nurse is preparing to change a negative-pressure wound therapy dressing on a client's pressure ulcer. Which actions are appropriate at this time? Select all that apply 1. Administer prescribed pain medication 30 minutes before the procedure 2. Apply skin barrier cream to intact skin surrounding the wound 3. Apply the foam dressing to the wound bed using clean technique 4. Cut the foam dressing to the appropriate size while holding it directly over the wound 5. Ensure that the foam dressing shrinks after the device is turned on

1, 2, 5 Negative pressure wound therapy is the application of negative pressure to a wound to enhance bacteria and exudate removal. Negative pressure promotes healing by stimulating cell growth and vessel perfusion in the wound bed After wound cleansing, a skin protectant is applied around the wound to prevent breakdown and promote an air-tight seal A sterile foam dressing is cut to fit the wound shape and size and is placed in the wound bed. An occlusive dressing large enough to extend 1.2-2 inches beyond the wound edges is applied to create a seal. Then a vacuum-assisted closure unit is connected to create negative pressure. The foam dressing should compress when the device is turned on

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply 1. Palliative care focuses on quality of life and can be provided at any time 2. Palliative care is only possible with a terminal diagnosis of < 6 months 3. Palliative care is provided by a multidisciplinary team 4. Palliative care is another term for hospice care 5. Palliative care provides relief from symptoms associated with chronic illnesses

1, 3, 5 Option 2: Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease Option 4: The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply 1. Dimming the lights at night 2. Increasing the level of continuous IV sedation during nighttime hours 3. Leaving the television on for diversion at night 4. Opening the window blinds/shades in the morning 5. Scheduling interventions and activities during the day when possible 6. Turning off equipment alarms in the client's room at night

1, 4, 5 It is important to maintain the client's normal circadian rhythms in the ICU. Option 2: Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management

The nurse is preparing to irrigate the ears of a 67 year old client with impacted cerumen. Place the following steps for ear irrigation in the correct order Place the client in a sitting position with the head tilted toward the affected ear Place a towel and an emesis basin under the ear Assess the client for fever, ear infection, or tympanic membrane injury Straighten the ear canal by pulling the pinna up and back Gently irrigate the ear canal with a slow, steady flow of solution

1. Assess the client for fever, ear infection, or tympanic membrane injury 2. Place the client in a sitting position with the head tilted toward the affected ear 3. Place a towel and an emesis basin under the ear 4. Straighten the ear canal by pulling the pinna up and back 5. Gently irrigate the ear canal with a slow, steady flow of solution

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit? 1. High-Fowler's position with the affected side's arm resting on the bed 2. Semi-Fowler's position with the affected side's arm on several pillows 3. Supine with the affected side arm's on several pillows 4. Supine with the affected side's arm resting on the bed

2 Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to PROMOTE DRAINAGE and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few post op days. Post op arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks Option 1: Placing the client in a high-Fowler's position immediately after anesthesia might cause a decrease in blood pressure and subsequent dizziness. Resting the affected side's arm on the bed would place the arm in a dependent position, which would lead to swelling due to decrease in lymphatic and venous drainage

As the nurse begins to assist with ambulation of a 9 year old who is one day post appendectomy, the child cries out, "it hurts too much, i can't do it." What is the first action by the nurse? 1. Administer an analgesic 2. Assess the child's level of pain using a numeric rating scale 3. Come back later in the day 4. Tell the child, "get up and walk if you want to go home soon."

2 Postoperative pain control is a priority intervention for a child of any age. However, the nurse needs to first perform an assessment of the child's pain to determine the appropriate pharmacological or non-pharmacological measures to implement.

The family of a terminally ill, dying client verbalizes concerns that the client is becoming dehydrated due to poor fluid intake. When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement? 1. Providing artificial hydration at the end of life will make the client feel more comfortable 2. The decision whether to provide artificial hydration should consider client preferences and goals 3. The HCP will prescribe artificial hydration when the client can no longer swallow 4. Withholding artificial hydration at the end of life speeds up the dying process

2 The decision about providing artificial nutrition to a dying client is complex. Although certain situations involving terminal illness, such as a terminally ill client who wants to attend an important family function, can justify the decision to provide IV fluids, providing artificial hydration in other situations may not be justified and may even be harmful. Ethical principles dictate that client preferences should be respected and that client/family members have the right to make decisions about artificial nutrition and hydration at the end of life

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report the bruises to the client's HCP 4. Talk to the client's child about the injuries

2 The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgemental attitude to facilitate a trusting nurse-client relationship Option 1: Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defense, and does not facilitate a trusting nurse-client relationship

The client has a dislocated shoulder and the nurse is assisting the HCP with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "help me!" What action should the nurse take first? 1. Administer midazolam per protocol 2. Check the client's pulse ox 3. Give more morphine per protocol 4. Open the airway with head tilt-chin lift

2 When there is new, sudden onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation Scale, during which the client is drowsy but responds to a voice command

The RN and LPN are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realized that which client positions require intervention? Select all that apply 1. High Fowler position in preparation for a paracentesis 2. Left side-lying position after percutaneous liver biopsy 3. Semi-Fowler after cardiac catheterization via femoral entry 4. Sims during soap-suds enema administration 5. Supine position after a lumbar puncture

2, 3 A paracentesis requires the client to be upright so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of CSF After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for >3 hours afterward to promote direct internal pressure of the lever against itself, which minimizes bleeding Option 3: After cardiac cath via femoral entry, place clients flat or in low Fowlers position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma

The nurse initiates prescribed IV therapy on an 86 year old hospitalized client. Which life span concepts should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply 1. Avoid infusion devices in confused clients as alarms can be disruptive 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration 4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45 degree angle on insertion because old adults have deeper veins that roll

2, 3, 4 The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile Use a 5-15 degree angle on insertion as veins of the elderly are usually more superficial

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply 1. Ask a family member about the client's preferences for room arrangement 2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3. Say goodbye when leaving the room to help orient the client 4. Speak slowly and slightly louder so the client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray

2, 3, 5 -Announce room entry and exit to orient and avoid startling the client -Describe the location of items (food, hygiene supplies) using a clock-face orientation so the client can find them easily -Instruct the client to use a cane with the dominant hand and to sweet areas in front from side to side for orientation Option 1: Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement

The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply 1. Dim lights to prevent overstimulation 2. Post a hearing impairment sign on the client's door 3. Raise voice to speak more loudly 4. Speak directly facing the client 5. Tell family to take hearing aids home so they will not be lost

2, 4 Option 3: When speaking to a client with hearing loss, speech should be directed toward the least-affected ear and should be at a normal volume. Raising the voice to speak loudly creates a higher pitch that is harder to understand

The educator on a rehabilitation unit is teaching a GN about caring for clients who have had a stoke. Which of the following statements by the GN indicate correct understanding of the teaching? Select all that apply 1. "Approach clients with visual impairment from the affected side when entering the room." 2. "Instruct clients with unilateral weakness to dress by donning clothes on the affected side first." 3. "Provide written instructions for activities of daily living to clients with receptive aphasia." 4. "Teach clients with left-sided neglect to turn their heads to scan the environment." 5. "Teach families of clients with right-sided stroke to expect impulsive behaviors."

2, 4, 5 Clients with unilateral weakness from stroke may have limited mobility and control on the affected side. Clients being taught to dress independently should FIRST CLOTHE THE AFFECTED SIDE, which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance. Clients with right-sided CVA tend to be IMPULSIVE and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions Option 3: Receptive aphasia (Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communcation

The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching? 1. "I will avoid naps later in the day." 2. "I will keep the bedroom temperature cool." 3. "I will read in bed before trying to go to sleep." 4. "I will try to go to bed and wake up at the same time each day."

3 Clients should be taught to avoid non-sleep related activities (reading, television, working) other than sex in the bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed

A home health nurse is visiting a 72 year old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? 1."Don't worry. You'll feel better in a few weeks." 2. "How well are you sleeping at night?" 3. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." 4. "You may be experiencing depression. I'll call the HCP and see if we can get a prescription for an antidepressant."

3 Clients who have undergone surgery (coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred.

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells. What information contained in the admission history of this client will need to be addressed during discharge education? 1. Eats steamed vegetables daily 2. Enjoys eating grilled shrimp weekly 3. Gardens as hobby 4. Takes a bath daily and applies moisturizer

3 This client has a very low absolute neutrophil count (normal: 2200-7700) having <500 cells indicates severe neutropenia and increases the risk of infection. Soil contains many pathogens, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask Option 1: The client with neutropenia is allowed to consume cook veggies. However, raw or unwashed veggies should be avoided

A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image? 1. "Do you feel you are able to engage in sexual activity with your prosthesis?" 2. "Do you wear the prosthesis all the time or only when out of the home?" 3. "How do you cope with feelings of self-consciousness?" 4. "Since receiving your prosthesis, how do you see yourself differently?"

4 A breast prosthesis is an artificial appliance that is fitted to the external chest wall or inserted into a female client's undergarments to simulate previous symmetry after a mastectomy or breast trauma. When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using open-ended questions and therapeutic communication Option 2: How often a prosthesis is used is not an indication of its effect on body image. Not all clients feel the need to wear a prosthesis for a healthy body image

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent? 1. Do your other children have this condition? 2. How long did your infant have diarrhea? 3. How often are you feeding the infant? 4. What do you think caused your infant's illness?

4 All clients have cultural influences that can affect their beliefs and concerns about causes of medical conditions and expectations for treatment. The nurse should have clients express what caused their medical illnesses or problems to gain knowledge of their beliefs and understandings about the conditions Culturally competent care requires the nurse to recognize that the client's interpretation of an illness is more significant than the nurse's knowledge of the illness

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time? 1. Call emergency medical services and place ice packs on the client's axilla and groin 2. Encourage the client to leave the venue to visit a HCP 3. Evaluate whether the client may be intoxicated 4. Move the client to an air-conditioned booth and provide a cool sports drink

4 Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body temperature, intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage (Gatorade), or water. This priority is to lower the body temperature to prevent heat stroke Option 1: If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via NG tube. The client is receiving a hypertonic formula. What is the best nursing action? 1. Dilute the formula with water 2. Discontinue the tube feeding 3. Send a stool sample to the lab for culture and sensitivity 4. Slow the rate of administration of the feeding

4 Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their high osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems

A client has COPD exacerbation. The pulse ox shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2. Non-rebreathing mask 3. Oxymizer 4. Venturi mask

4 The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume. The adaptor or barrel can be set to deliver 24%-50% oxygen concentration. In the presence of tachypnea, shallow breathing with decreased tidal volume, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD Option 1: The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed Option 2: The non-rebreathing reservoir mask can deliver 60-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis