Basic Care/Comfort

Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply 1. Soaking the dentures in hot water 2. Donning gloves and using a gauze pad to grasp and remove dentures 3. Moistening the dentures prior to inserting them 4. Wrapping the dentures in tissue while the client sleeps 5. Placing a washcloth in the bathroom sink prior to cleaning.

1. & 4. Correct: Hot water may damage dentures so intervention is needed. Dentures should be stored in a denture cup. 2. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 3. Incorrect: Moistening the dentures will ease insertion. 5. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped.

A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that procedure. What is the most important action for the nurse to take prior to changing this catheter? 1. Check size of existing catheter and balloon. 2. Ask client when the catheter was last changed. 3. Clamp and empty the present catheter bag. 4. Gather clean gloves and basin of hot soapy water.

1. CORRECT. It is important to maintain the same catheter size as the one currently in use since the surgical opening does not increase in size like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is too big, urine will not drain properly, leaving residual and the potential for infection. 2. INCORRECT. Though obtaining information directly from the client is often a good choice, the individual may not be able to recall a precise date or time. When a catheter change is scheduled at specific time intervals, the nurse needs to verify the correct time line. Generally, the primary healthcare provider can provide a current order to facilitate the changing of the catheter. 3. INCORRECT. Although the nurse may empty a catheter bag, if the client uses one, there is no need to clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not include clamping since the catheter does not require long tubing like a regular catheter. Also, urine bags are generally emptied at scheduled times each shift. 4. INCORRECT. Replacing a suprapubic catheter requires the use of sterile gloves both while cleaning and inserting the new catheter. Also, care of the insertion site is completed with sterile normal saline before and after the reinsertion.

While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? 1. Provide for scheduled toileting intervals. 2. Apply a restraining vest on the client at night. 3. Cover the IV site with a gauze dressing. 4. Remind client to ring call bell for the nurse.

1. CORRECT. The client is confused and likely will not remember any verbal instructions. Therefore, the safest priority action would be to check on the client at regular intervals and assist the client with any bathroom needs at those times. 2. INCORRECT. A restraining vest would not guarantee client safety. This client was able to crawl out of bed over a raised side rail; therefore, this client could struggle against the vest with the potential to get entangled and become seriously injured. 3. INCORRECT. Placing gauze over the IV site does not address client safety. The issue is we do not want the client to fall. 4. INCORRECT. This action would not ensure safety because the client is confused. So, it is very unlikely the client would remember to ring for the nurse before getting out of bed.

A client consumes a lacto-ovo vegetarian diet at home. During hospitalization, the primary healthcare provider prescribes an increased calorie diet. Which foods are appropriate for the nurse to serve as between meal snacks to boost caloric intake? 1. Cheese sandwich and milk 2. Boiled eggs but no dairy products 3. Fish sticks and cocktail sausages 4. Fresh vegetables but no milk or eggs

1. Correct: A lacto-ovo vegetarian diet is a vegetarian diet that does not include meat, but does contain eggs and dairy. The client can eat milk and dairy products along with grain products on this diet.2. Incorrect: Dairy products and eggs are allowed on this diet. Milk, cheese and yogurt can be consumed on a lacto-ovo vegetarian diet. 3. Incorrect: The client does not consume meats. Meats should not be provided as a snack. 4. Incorrect: The client can consume milk and eggs as well as fresh fruits and vegetables. Milk and eggs can be consumed on a lacto-ovo vegetarian diet.

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm.

1. Correct: Always assess the physiologic problem first to rule out a urinary tract infection (UTI). Once a physiologic cause is removed as the cause other assessment should be performed. If a UTI is present, treatment should start immediately. 2. Incorrect: Assessing the normal urination habits is not first. Assessing the urinalysis is priority. 3. Incorrect: Regression is the likely cause but the physiologic problems should be assessed first. 4. Incorrect: The child's fluid intake may be too high after 6 pm, but ruling out a urinary tract infection is the first assessment and requires immediate treatment if there is an infection.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies.

The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? 1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." 2. "Coughing and deep breathing are needed to prevent blood clots." 3. "Coughing and deep breathing will aide with healing by increasing available oxygen." 4. "Coughing and deep breathing will help resolve any blood clots that have formed. "

1. Correct: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis. After surgery, due to the pain, clients are prone to shallowly breath which can lead to atelectasis and thick secretions and increased risk of pneumonia. 2. Incorrect: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis after surgery. Coughing and deep breathing will not prevent blood clots. 3. Incorrect: Coughing and deep breathing will increase available oxygen. The main reason client's should cough and deep breath however, is for lung expansion and pneumonia prevention. 4. Incorrect: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis after surgery. Coughing and deep breathing will not resolve blood clots.

The nurse is transferring the client from the bed to the wheelchair. Which nursing intervention would the nurse implement after assisting the client to a sitting position on the side of the bed. 1. Assess the client for lightheadedness. 2. Move the wheelchair closer to the bed. 3. Lower the bed to the lowest position. 4. Position the foot of the stronger leg closer to the bed.

1. Correct: Prior to moving the client from the side of the bed to the wheelchair, assess the client for orthostatic hypotension or postural hypotension. The client may experience a sudden decrease in blood pressure after changing the position form lying down to sitting up. 2. Incorrect: The wheelchair should be positioned in the correct position prior to positioning the client on the side of the bed. Client safety has priority. The nurse should not leave the client to move the wheelchair to the bedside. 3. Incorrect: The bed should have been lowered to the position prior to moving the client to the side of the bed. The client's feet should rest on the floor. This will assist the client in supporting themselves. 4. Incorrect: Positioning the foot of the stronger leg closer to the bed is a transfer step after assessing the client for orthostatic hypotension. Whether the stronger or weaker leg is positioned closer to the bed will not affect the client's blood pressure status.

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will.

1. Correct: Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain. This is consistent with Puerto Rican culture and their response to pain. 2. Incorrect: Quietly enduring pain is consistent with the Japanese culture. This is consistent with the Asian culture and brings honor. 3. Incorrect: Stoic responses are consistent with Asian culture. The client is likely to be quiet about the pain thinking that complaints of pain will bring dishonor to the family. 4. Incorrect: Filipino clients tend to view pain as God's will. They may refuse medication to relieve the pain.

The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? 1. Promotes the return of venous blood to the heart and assists in preventing blood clots. 2. Stabilizes any clots to prevent embolization. 3. To increase the blood pressure in the venous system in the legs to promote perfusion. 4. Promotes lymphatic drainage to prevent swelling and arterial congestion.

1. Correct: The anti-embolic stockings promote return of venous blood to the heart and assist in preventing the stasis of blood that can lead to blood clots. 2. Incorrect: The purpose of the anti-embolism stockings is to promote venous return and prevent blood stasis which can result in blood clot formation. Anti-embolitic stockings will not stabilize existing blood clots. 3. Incorrect: Anti-embolism stockings are used to increase venous return. They are not used to increase blood pressure or perfusion to the legs. 4. Incorrect: Compression garments, not anti-embolitic stockings, are used by persons with lymphedema to reduce edema by promoting the flow of lymph fluid out of the affected limb. Anti-embolitic stockings are to help with venous return and preventing stasis of blood and blood clots.

A nurse is providing dietary instructions for a client diagnosed with liver disease. Which food should the nurse instruct the client to increase in their diet? 1. Pasta 2. Olive oil 3. Spinach 4. Cantaloupe

1. Correct: The client is encouraged to eat an increased amount of carbohydrates in their diet. Carbohydrates should be the major source of calories in their diet. The increased carbohydrates help to reduce the protein break down in the liver. 2. Incorrect: Olive oil has no carbohydrate content. Increasing the amount of olive oil will not affect the need for increase carbohydrates in the diet of clients diagnosed with liver disease. 3. Incorrect: A cup of spinach has about 1 gram of carbohydrates. Spinach is not a vegetable that is high in carbohydrates. 4. Incorrect: One half cup of diced cantaloupe which is a serving size contains 6.5 grams of carbohydrates. This food would not have enough carbohydrates to help reduce the protein break down in the liver.

The charge nurse is assigning an unlicensed assistive personnel (UAP) to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. Client with thrombocytopenia. 2. Client with a fractured femur. 3. Client with an inguinal hernia. 4. Client with irritable bowel syndrome.

1. Correct: Thrombocytopenia is the deficiency of platelets in the blood. Due to the reduced platelet count, the clotting time of the client's blood will be reduced. Inserting a rectal thermometer increases the client's risk of rectal trauma. If there is rectal bleeding from the insertion of the rectal thermometer, the client may experience increased bleeding due to their decreased platelet count. 2. Incorrect: A client with a fractured femur can have their temperature assessed by a rectal temperature. There are no contraindications for a rectal temperature. 3. Incorrect: To evaluate a client's temperature by inserting a rectal thermometer is acceptable procedure for a client with an inguinal hernia. 4. Incorrect: There are no contraindications for clients with irritable bowel syndrome to have their temperature assessed by a rectal thermometer.

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is notappropriate in this situation? Select all that apply 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1. Remove indwelling catheter 3. Remove hospital ID band 5. Wash body head to toe

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? Select all that apply 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1.& 2. Correct: Both legs are extended in a vertical position in order to maintain hip flexion at 90 degrees. This helps to keep the femur in the hip socket. Because the legs are extended upward the circulation and nerves can be affected. The feet should be assessed for color, pulses, warmth, and sensation every 2-4 hours. 3. Incorrect: The child should be repositioned slightly every 1-2 hours to avoid skin breakdown. 4. Incorrect: The child cannot be placed prone while in Bryant's traction. 5. Incorrect: Traction should not be relieved, which is what would happen if straps are removed. 6. Incorrect: A jacket restraint is used to keep the child from turning over in the bed.

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. 5. Incorrect: A back massage is appropriate after a bath and does not require nursing intervention. A back massage is a way of providing relaxation for the client.

The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals.

1., & 6. Correct: Pay attention to hunger and fullness cues before, during, and after meals. Use them to recognize when to eat and when you have had enough. Portion out foods before eating. A smaller plate will make the amount of food look larger. 2. Incorrect: Make half the plate fruits and vegetables. 3. Incorrect: Cut calories by drinking water or unsweetened beverages rather than drinks with sugar, such as soft drinks and sweet tea. 4. Incorrect: Diets should be high in fiber coming from fruits, vegetables, and whole grains. 5. Incorrect: Individuals should consume less than 10% of calories from saturated fatty acids (approximately 20 grams of saturated fat per day in a 2000 calorie diet).

The nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complementary and/or alternative therapies? Select all that apply 1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki 5. Zumba

1., 2, 3, & 4. Correct: All are considered complementary and/or alternative therapies. Acupuncture involves stimulating specific points on the body. This is most often done by inserting thin needles through the skin, to cause a change in the physical functions of the body. Research has shown that acupuncture reduces nausea and vomiting after surgery and chemotherapy. It can also relieve pain. The practice of yoga makes the body strong and flexible, and improves the functioning of the respiratory, circulatory, digestive, and hormonal systems. Yoga brings about emotional stability and clarity of mind. Tai chi is an ancient Chinese discipline involving a continuous series of controlled usually slow movements designed to improve physical and mental well-being. Reiki is a healing technique based on the principle that the therapist can channel energy into the client by means of touch, to activate the natural healing processes of the body and restore physical and emotional well-being. 5. Incorrect: Zumba is a type of dance exercise and is not considered a form of alternative therapy.

The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? Select all that apply 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.

1., 2. & 3. Correct: Working on job-related tasks before bedtime may increase anxiety and contribute to difficulty sleeping. Suspenseful night-time drama TV shows may be too stimulating prior to going to bed. Caffeine following dinner may interfere with sleep.4. Incorrect: Quiet reading is likely to ease the transition from wakefulness to sleep and may be an important intervention to promote sleep.5. Incorrect: Exercising early in the evening may be an effective intervention. If exercise is performed prior to going to bed, it may interfere with falling asleep.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1., 2. & 4. Correct: Two percent milk can reduce the amount of fat consumed daily, not only in milk that the client drinks, but also in foods that contain milk as an ingredient. Air-popped corn contains no fat unless butter is added after popping. The client still is able to have a crunchy snack without the fat. Plant proteins such as kidney, black, or lima beans are good sources of protein without the fat from a meat source.3. Incorrect: Red meats are high in fat. Chicken, fish, and seafood are better meat choices.5. Incorrect: Olive oil is low in saturated fat but still a source of fat. While olive oil may be a healthier choice, all fats have essentially the same number of calories per serving. The goal is to reduce the amount of fat in the diet.

What potential contributing factors for stress urinary incontinence should a nurse assess for in an elderly female client? Select all that apply 1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births 4. Spinal cord injury 5. Dementia

1., 2., & 3. Correct: During pregnancy and childbirth, the sphincter and pelvic muscles stretch out and are weakened. Increased age, decreased estrogen, and a history of multiple vaginal births/pregnancies are contributing factors for stress incontinence. 4. Incorrect: Spinal cord injury results in urge incontinence because of damage to the nerves of the bladder. Urge incontinence means there is a sudden, involuntary contraction of the muscle wall. 5. Incorrect: With functional incontinence the person knows there is a need to urinate but cannot make it to the restroom. The dementia client cannot make the conscious decision or carry out the task of ambulating to the restroom.

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1., 2., & 3. Correct: The BRAT diet is recommended for clients with persistent diarrhea. This diet consists of bananas, rice, applesauce, and toast. Rice and potatoes help to reduce diarrhea. Bananas will help replace potassium. Once the diarrhea subsides, the client can add easily digestible foods like eggs. 4. Incorrect: Avoid coffee and tea because caffeine containing beverages may have a laxative effect. Caffeine is a stimulant and will increase the peristalsis even more. 5. Incorrect: Dairy products may make the diarrhea worse. Avoid these until the diarrhea subsides.

A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse implement for the client's night sweats and fever. Select all that apply 1. Keep water by the bedside 2. Place a plastic cover over the pillow 3. Administer an antipyretic every 4 hours 4. Keep a change of linen in the room 5. Position the client in a semi-fowlers position

1., 2., & 4. Correct: The nurse should encourage the client to consume liquids to replace insensible water loss and sweating. The plastic cover will protect the pillow from contact with perspiration. A time management technique for caring for a client with frequent fever episodes is to keep a change of linen in the room. 3. Incorrect: Antipyretics should be administered to reduce a client's fever. Antipyretics are usually prescribed as needed, not every 4 hours. 5. Incorrect: Placing a client in different positions will not affect the client's fever. Positioning the client in a semi-fowlers position may be more appropriate for the client, but will not affect the client's temperature.

What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.

1., 2., & 4. Correct: These are examples of iron rich foods. Foods high in iron will help with correcting iron deficiency anemia. Glossitis, anorexia, and paresthesias can result from iron deficiency anemia. Foods high in vitamin C such as citrus fruits, dark green leafy vegetables and strawberries help with absorption. 3. Incorrect: Iron is needed for red blood cell development and oxygen transport to the cells. Iron is not needed for white blood cell development. White blood cell development. White blood cells are produced in the bone marrow. 5. Incorrect: Clients should dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing. Iron will stain the teeth.

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs. 3. Incorrect: This is the proper technique for checking placement of the NG tube. The pH should be less than 5 if in the stomach. 4. Incorrect: Yes, the tubing should be marked with a piece of tape and secured to the nose with tape or a commercial device if available.

The nurse is teaching the family of a homebound client about ways to increase the client's safety while bathing independently. Which strategies should the nurse include? Select all that apply 1. Install grab bars in the tub or shower. 2. Install hand bars on sides of tub. 3. Use tub/shower seat for bathing. 4. Provide a long handled bath scrubbie for bathing. 5. Schedule bathing routines three times per week.

1., 2., 3. & 4. Correct: Grab bars will assist the client in getting into or out of the tub or shower, thus reducing the chance for falls. Hand bars are very helpful as one enters or exits the tub. The increased stability offered by these devices reduces risk of falls. Using a shower seat will allow the client to remain independent in terms of entering or exiting the tub or shower. The use of handled scrubbies or sponges allows the client to reach lower extremities or back with greater ease.5. Incorrect: The bathing routine may need to be more often than three times per week depending on the client. The bathing schedule does not relate to a client's independence.

A client has been admitted to the telemetry unit with a diagnosis of a cerebral vascular accident. What should the nurse assess to determine the client's risk for aspiration? Select all that apply 1. Ability to swallow 2. Gag reflex 3. Level of consciousness 4. Cough reflex 5. Ability to follow commands

1., 2., 3., & 4. Correct: Assessing the ability of a client to swallow is something the nurse can and should do. A small amount of water should be given to the client as the nurse observes for coughing or gurgling. If the nurse suspects a client is having difficulty safely swallowing, further assessment by a speech and language therapist is recommended. To test for a gag reflex use a tongue depressor. Ask the client to open the mouth and look at their throat with a penlight. If the uvula and pharynx rise as the client says "aaahh" then the gag reflex is intact. If it does not rise, touch the back of the throat at the soft palate and watch for the rise in the pharynx in a gag response, If intact,the client should not be at risk for aspiration with eating. A client with a decrease level of consciousness is always at risk for dysphagia and aspiration. A cough reflex is assessed by administering a small sip of water and observing for a cough. if the client coughs, feeding should be withheld until further testing can be performed. 5. Incorrect: Assessing ability to follow commands does not identify a problem with swallowing. It does not provide a great deal of information about cognitive function. The other tests provide more information specific to aspiration.

What signs and symptoms would a nurse assess for in a client who is receiving hospice care and is close to death? Select all that apply 1. Cool extremities 2. Mottling 3. Cheyne-Stokes respirations 4. Loss of appetite 5. Increased blood pressure

1., 2., 3., & 4. Correct: In the hours before death, blood will be shunted to the vital organs and not the periphery. This will make the extremities cool to the touch and mottled in appearance. Both cool extremities and mottling are due to reduced blood flow. Cheyne-Stokes respirations is a respiratory pattern that consists of loud deep inhalations followed by a pause of apnea. Loss of appetite will occur as energy needs decline. The use of moistened clothes around the mouth and lip balm may help with keeping lips moist and comfortable. 6. Incorrect: Blood pressure will not increase as death nears. The pumping action of the heart declines when death is occurring which leads to a decrease in cardiac output and blood pressure.

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? Select all that apply 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

1., 2., 3., & 4. Correct: The client's immobility may lead to apathy and isolation. The nurse should explore diversional activities which can reduce the frustration and depression of being immobile. Immobility will result in muscle weakness and decreased venous return. The client is encouraged to perform active range of motion exercises. Also passive range of motion exercises should be performed if the client cannot perform the active exercises themselves. Due to the client's decreased movement of the ankles, the client's feet should be positioned in the dorsiflexion position to prevent plantar flexion contractures. A bed board should be positioned to the foot of the bed. Active and passive range of motion exercises to the ankle and foot will promote proper joint movement. An immobile client's skin is affected by extrinsic, intrinsic, and shear forces. A decrease in the client's perfusion and peripheral circulation are intrinsic factors. The immobile client is experiencing the extrinsic factor of increased skin temperature at the skin pressure points. Moving the immobile client may result in a shearing force on the skin. 5. Incorrect: The effects of immobility on the urinary system may include urinary retention, renal calculi, and urinary tract infections. Also the immobile client may experience constipation if the fluid intake decreases. The fluid intake for a healthy adult is recommended at 2200 - 2700 mL per 24 hours.

A school nurse is planning to teach kindergarten students about oral health. Which points should the nurse include? Select all that apply 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

1., 2., 4., & 5. Correct: Avoid sweet foods and drinks between meals. Take them in moderation at meals. Eat coarse, fibrous foods, cleansing foods, such as fresh fruits and raw vegetables. If unable to brush after a meal, vigorously rinse mouth with water. Teeth should be flossed daily. 3. Incorrect: Brush the teeth thoroughly with toothpaste that has fluoride.

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? Select all that apply 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1., 2., 4., & 5. Correct: These would be signs and symptoms of dehydration in an infant. Amber or dark urine is an indication of dehydration. Urine should be a clear, pale yellow. Fussiness and irritability are seen in infants when they do not feel well. As dehydration worsens, lethargy and unresponsiveness can develop. Tachypnea or rapid respiration along with tachycardia and low blood pressure are present with severe dehydration. With severe dehydration, there will be decreased urine ouput. The body is trying to conserve volume. 3. Incorrect: The fontanels will be sunken rather than bulging. Bulging fontanels indicate brain swelling or fluid build up in the brain. Sunken fontanels are related to dehydration.

A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet. Select all that apply 1. Grilled eggplant 2. Purple grape juice 3. Bacon 4. Cashews 5. Skim milk 6. Salmon

1., 2., 4., 5., & 6. Correct: It is reasonable to counsel clients to follow a Mediterranean-type diet over a low-fat diet. The Mediterranean type diet emphasizes vegetables, fruits, and whole grains and includes low fat dairy products, poultry, fish, legumes, and nuts. It limits intake of sweets and red meats. 3. Incorrect: Substitute fish and poultry for red meat. When eaten, make sure it's lean and keep portions small (about the size of a deck of cards). Also avoid sausage, bacon and other high-fat meats.

A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.

1., 3. & 4. Correct: If you are constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts 2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods. 5. Incorrect: Broccoli and cabbage are common gas-producing foods that can cause abdominal distention and flatulence.

The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? Select all that apply 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? 5. Can the family take turns in managing the mother's sleep problems?

1., 3. & 4. Correct: There may be a physical reason for the difficulty sleeping, perhaps pain or presence of an infection. Diuretics should be scheduled early in the day so as not to interfere with sleep. Perhaps there has been a change in medication schedule. Changes in the sleep environment, such as an additional TV in the home or other noise, may impact sleep.2. Incorrect: This may be necessary; however, the nurse is working toward helping the mother of the family to sleep better.5. Incorrect: The family may need to do this over time; however, the focus is to help the mother of the family to sleep better.

When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? Select all that apply 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.

1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. Pillows under the knees help with pressure on the lower back. However, if pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot.

Which of the following should the nurse teach regarding nutrition for a client with celiac disease? Select all that apply 1. Gluten is a protein found in wheat and oats. 2. A gluten intolerant person can eat foods that are made with barley or rye. 3. Fruits can be eaten on a gluten free diet. 4. Gluten causes inflammation of the large intestines of people with celiac disease. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

1., 3., & 5. Correct: A gluten-free diet is used in the treatment of celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. All products containing these grains are to be avoided. Rice and corn may be used. Fruits, vegetables, nuts, diary products and meats not prepared with gluten containing ingredients can be eaten. Accidentally ingesting food with gluten may result in abdominal pain and diarrhea. 2. Incorrect: The main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and Tapioca. The gluten intolerant clients can not eat barley and rye. Gastrointestinal pain and diarrhea may occur. 4. Incorrect: Gluten causes inflammation in the small intestines of people with celiac disease. Eating a gluten-free diet helps people control their signs and symptoms and prevent complications.

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? Select all that apply 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the air flow on the continuous positive airway pressure (CPAP) machine.

1., 3., & 5. Correct: Consuming chocolate in the evening may cause insomnia. Chocolate contains caffeine and xanthines which are stimulates. The chemicals will suppress melatonin and increase the time to fall asleep. Progressive relaxation techniques are recommended to reduce insomnia. This exercise is a systematic relaxation and tensing of the muscle groups of the body. Insomnia is reduced by increasing muscle relaxation and decreasing the stress level of the client. Nonstrenuous exercises such as a leisure walk performed within 3 hours of bedtime promotes the reduction of the client's stress level. 2. Incorrect: Consuming alcohol prior to bedtime is not recommended. Alcohol consumption increases the start of sleep but reduces rapid eye movement (REM) sleep. The side effect of the alcohol may also cause the client to awaken during night and have difficulty returning to sleep. 4. Incorrect: Diphenhydramine is not recommended for insomnia. The action of the diphenhydramine may cause the client to feel drowsy but provides only temporary increase in quantity of sleep. The hypnotic effect of diphenhydramine will cause client to experience decrease energy levels the next morning. 6. Incorrect: A CPAP is prescribed for a client with obstructive sleep apnea not insomnia. The CPAP machine delivers a constant air pressure to the lungs. The constant air flow will keep the airway open during sleep.

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? Select all that apply 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding. 2. Incorrect: Fontanels should be soft, firm and flat. A depressed or sunken fontanel may indicate dehydration. Dehydration is one of the major causes of sunken fontanels.

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? Select all that apply 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1., 3., 4., & 6. Correct: This client will have progressive weakness and paralysis. Contractures and pressure ulcers need to be prevented through ROM exercises and frequent turning. Muscle spasms and pain can be relieved by therapeutic massage, imagery, diversion, and pain medication. 2. Incorrect: The client will need to be repositioned every 2 hours to prevent pressure sores and pneumonia and atelectasis. Elevate the head of the bed to help with lung expansion. Prone will interfere with lung expansion ability. 5. Incorrect: Encourage small, but frequent meals that are both well-balanced and nourishing.

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

1., 3., 4., 5., & 6. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions prevent infection, keep eyes moist, and protect the eye from injury. 2. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct.

A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that teaching was successful? Select all that apply 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."

1., 3., 5., & 6. Correct: Foods that contain 150 mg or more of purine are considered high purine foods and should be eliminated from the diet. Weight loss has been shown to improve insulin resistance, and therefore reduce uric acid levels in the blood. Vegetables that have high purine content include cauliflower, spinach, peas, asparagus, and mushrooms. These should be limited to no more than 2 times per week. Ensuring a sufficient fluid intake helps to reduce the risk of crystals forming in joints. Keeping hydrated and avoiding dehydration can lessen this risk and help to prevent gout attacks. 2. Incorrect: Alcohol - These cause increased dehydration and interfere with uric acid elimination. The metabolism of alcohol in your body is thought to increase uric acid production, and alcohol contributes to dehydration. Beer is associated with an increased risk of gout and recurring attacks, as are distilled liquors to some extent. The effect of wine is not as well understood. 4. Incorrect: Potatoes, rice, barley, noodles, and pastas are low in purine and can contribute to the 4 or more servings of starches needed per day.

A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? Select all that apply 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.

2 and 5. CORRECT: The nurse must provide the client with alternatives methods to aid sleep that do not present a safety hazard. Potpourri is fragrant dried flowers or plant stems which emit a smell based on the assortment. Sprinkling a small amount inside the nightstand drawer would allow the scent to gently permeate the area next to the client's bed without presenting a safety hazard and the aroma would be consistent over long periods of time. Also, a tiny drop of an essential oil dabbed on the corner of the pillow case or sheet would also provide the client with desired needed sleep enhancement without impacting health or safety issues. 1. INCORRECT: Hospitals have specific regulations about outside electronics, requiring most to be checked by maintenance staff prior to use in the facility. An electric potpourri burner melts scented wax in a small open ceramic dish, providing odor as it dissipates. An open container of hot wax plus the need to keep the burner plugged in all night are extreme safety hazards to client and staff. 3. INCORRECT: This inefficient and costly method to aid client sleep is impractical on several levels. The fragrance of flowers rapidly fades, based on ambient temperature and room size. Additionally, the inconsistency of smell would not provide the same restful level of sleep during the night. 4. INCORRECT: Spraying non-hospital approved air freshener could prove problematic for other clients, since that odor would not be confined to just the client's room. Secondly, the quick dissipation of the spray would not provide an entire night of restful sleep.

The nurse is caring for a client following gastric bypass surgery. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select all that apply 1. Increase liquids with food. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating.

2, 3, & 4. Correct: The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms. 1. Incorrect: Increasing liquids while eating will speed food processing and increase the side effects. Clients are instructed to eliminate all fluids during meals. In some cases, clients may also need to eliminate fluids for one hour before and immediately after meals in order to control symptoms and slow the progress of food through the digestive tract. 5. Incorrect: Sitting up after a meal is counterproductive, since this will increase the speed of food through the digestive tract. Therefore, clients are encouraged to lie down on the left side following meals to slow the progress of food through the GI tract.

After reinforcing dietary teaching to a client diagnosed with Crohn's Disease, the nurse recognizes client understanding when the client selects which low-residue foods? Select all that apply 1. Broccoli 2. Oatmeal 3. Green peas 4. Spaghetti 5. Cantaloupe 6. Raisins

2, 4,& 5 Correct: A low residue diet is recommended for clients with inflammatory bowel diseases such as Crohn's Disease, diverticulitis or Ulcerative Colitis. This special diet is designed to decrease fiber in order to limit bowel peristalsis while still including nutritional elements for clients. Cooked oatmeal or pasta are both good choices as well as fruits with no skin and little pulp. Insoluble fiber—the kind in raw veggies, fruits, and nuts—draws water into the colon and can worsen diarrhea for those with IBD. But oatmeal has soluble fiber, which absorbs water and passes more slowly through your digestive tract. Cantaloupe is an excellent choice, since it is a great source of nutrients but has little pulp. 1. Incorrect: Broccoli is a very fibrous vegetable that causes excessive peristalsis, even when cooked. This will create excessive gas and increase discomfort for clients. 3. Incorrect: Green or yellow peas are rough, fibrous vegetables that will cause gas and cramping for most clients with inflammatory bowel diseases, even if cooked. This vegetable is discouraged along with beans, lentils, seeds, and nuts. 6. Incorrect: Raisins are high in fiber, as are other dried fruits such as prunes. Even cooked raisins tend to increase peristalsis which will lead to cramping and excessive bowel movements daily. Clients also need to avoid most fresh fruits with skin, pulp, or seeds.

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

2. CORRECT. An immobile client is subjected to sheering forces and tissue breakdown because of prolonged contact between the skin and linens. Pressure sores can develop quickly when a client remains in one position over long periods of time, particularly on protruding areas of the body such as hips, elbows, sacrum or heels. Repositioning the client every two hours decreases the potential for skin breakdown and allows for inspection of all vulnerable body areas. 1. INCORRECT. While moving a paralyzed client might stimulate the overall circulation, and even allow for passive range of motion, repositioning a client does not specifically increase blood flow to one side of the body. 3. INCORRECT. Though moving a client can stimulate the circulation, repositioning every two hours is not sufficient to prevent blood stasis in lower extremities, particularly when this client cannot move the right side independently. 4. INCORRECT. Sensory deprivation is not a major concern for the client initially and repositioning is not meant to address sensory needs. The purpose of repositioning is prevention of skin breakdown.

The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so independently. What statement by the nurse is appropriate? 1. "Many spouses have been able to learn this procedure." 2. "Which part of this procedure has you most concerned?" 3. "Don't you have any family to help you with this procedure?" 4. "Are you worried about caring for your spouse?"

2. CORRECT. The nurse's question is open-ended since it allows the spouse to elaborate on any specific areas of concern or doubt. This approach encourages the spouse to express feelings with any care after discharge, and not just the log rolling technique. 1. INCORRECT. This statement by the nurse directs attention away from the spouse's expressed concerns, ignoring feelings stated by the spouse. It implies anyone could perform the needed log rolling and is dismissive of the spouse. 3. INCORRECT. Although the nurse may have meant to suggest others could help the spouse, the phrasing of the question insinuates the spouse should seek others to help, whereas the nurse should focus on educating and encouraging the spouse to perform the task independently. 4. INCORRECT. While the spouse's verbalized concerns may be subconsciously connected to overall care of a post-surgical client, the nurse's comment is an assumption and is confrontational.

What would be most important for the nurse to teach parents in order to promote sleep and rest in the preschool child? 1. Allow the child to choose own bedtime based on degree of fatigue. 2. Develop a consistent routine before going to bed. 3. Assess how much sleep the child requires. 4. Set a consistent wake-up schedule.

2. Correct: A consistent routine helps to prepare the child for sleep. Reading or telling stories before bedtime may help the child to relax and fall asleep more easily. Routines are very important for this age group. Doing specific things before bedtime can signal to the child that it is time to get ready for bed and to go to sleep. 1. Incorrect: Although important, this is not the priority. Establishing a routine is most important. A cool environment will promote rest. A child's sleep cycle is sensitive to light and temperature. Melatonin levels help to regulate the drop in internal temperature needed to sleep. 3. Incorrect: Assessing the amount of sleep needed can help with promoting sleep and rest but routine is priority in the preschool age group. 4. Incorrect: Setting a wake-up time prevents a child from over sleeping on weekends and holidays. Those extra hours can disturb the sleep cycle. For a preschooler routine is the priority answer to promote sleep and rest at night.

The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate electrolyte intake through foods and/or dietary supplements. Which foods should the nurse suggest to the client? 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries

2. Correct: Avocados, apricots, milk, fruit juices, bananas and cantaloupe are good sources of potassium. Loop diuretics deplete the electrolyte potassium. 1. Incorrect: Cereals and breads are good sources of B vitamins. Since the client is losing potassium they need foods that are high in potassium. Cereals and breads are not high in potassium. 3. Incorrect: Table salt and spinach are good sources of sodium, but the hypertensive client usually should limit intake of sodium. The client is taking a potassium depleting diuretic and needs potassium rich foods. Spinach is high in potassium but the table salt makes this option incorrect. 4. Incorrect: Blueberries and strawberries both are relatively low in potassium. Clients on loop diuretics are losing potassium and need to consume foods high in potassium.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Correct: Continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots.The nurse would need to increase the irrigation rate until the urine becomes light pink. 1. Incorrect: If the urine is not diluted, the client could form clots in the urine that could obstruct the urine flow. Charting the drainage color and amount would not address the issue. 3. Incorrect: Dark red color to the urine would warrant an increase in irrigation. There is no need to call the primary healthcare provider. If the color of urine doesn't clear or the vital sign show signs of shock (increased heart rate and decreased blood pressure) then notifying the primary healthcare provider would be needed. 4. Incorrect: This is the intervention that would be carried out if the client is hemorrhaging from the prostate. The balloon on the catheter would be used to apply pressure to the prostate and decrease bleeding. If there was more evidence of hemorrhage such as a decrease in blood pressure or increase in heart rate this type traction would be initiated. There is not enough evidence of hemorrhage at this point to initiate traction, therefore, more assessments should be performed.

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by turning on the TV. 3. Contact the primary healthcare provider for a pain medication prescription. 4. Request that the parents leave the room.

2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, or look at pictures. Heat and cold therapies should also be considered. 1. Incorrect: The client at this age does not have the cognitive abilities to discuss pain other than to say that he/she has pain and to tell where it is. They can rate their pain at age 5-8 but describing or qualifying pain occurs at age 10 and older. 3. Incorrect: Distraction and other techniques should be used before pain medication. If there is something you can do to fix the problem, do that first. 4. Incorrect: Separation from the parents could cause more anxiety for the child. Parents should be allowed to stay with the client unless they are hindering safe care.

A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."

2. Correct: For intermittent catheterization in the home, the client should follow clean technique. Wash rubber catheters thoroughly with soap and water after use, then dry and store in a clean place. 1. Incorrect: There is no drainage bag for intermittent catheterization. If there was an indwelling catheter, it would be secured to the woman's upper thigh. 3. Incorrect: With intermittent catheterization, there is no drainage bag. This would be an incorrect comment if made by the client. 4. Incorrect: Intermittent catheterization should be done first thing in the morning and just before going to bed at night. In most cases, self catheterization should be done every 4 to 6 hours. The client may need to self catheterize more frequently if oral intake of fluids has increased.

Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chick peas and asparagus, apple, tea

2. Correct: Gout is pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choose as it is low in purine and fat. Purines are broken down into uric acid. A diet rich in purines can raise uric acid levels. Meat and seafood increase the risk of gout. Dairy products may lower risk for gout. 1. Incorrect: The client should not eat tuna, which is high in purine. 3. Incorrect: Gravy is a high purine food and should be avoided. Also avoid artificial sweeteners. 4. Incorrect: Although spinach, and asparagus can be consumed in moderation, they still contain purines, so it is not as good of a choice as the vegetable soup, toast and skim milk.

A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.

2. Correct: Including a daytime exercise program is a sleep hygiene recommendation that will increase the quality of sleep. The exercise program increases metabolism and reduces stress. Activities after 1700 should be avoided if they a strenuous. 1. Incorrect: As the cycle of falling to sleep begins, the temperature of the hands and feet increases and the core temperature decreases. When the client takes a warm bath or shower, this will increase the temperature of the hands and feet. It is the cooling down of the body after the warm bath that promotes sleep. By taking a cool bath the temperature of the hands and feet will decrease at a faster pace. 3. Incorrect: Antihistamine are drugs that counteract histamine in the body. A side effect of histamines is sleepiness, which might assist one to fall asleep. Routine use of antihistamines is not recommended for insomnia, since tolerance for the antihistamines can occur and the medication is intended for short term use. 4. Incorrect: Scanning the news feeds on the computer is not a sleep hygiene recommendation. The news feeds can be disturbing and the light from the computer has a stimulating effect .

Immediately following a below-the-knee amputation (BKA), the nurse positions the client to prevent complications. What intervention related to position of the residual limb is a priority at this time? 1. Flat on the bed 2. Elevate foot of the bed 3. In a position of comfort 4. In a dependent position

2. Correct: It is normal to experience post-operative swelling after a BKA. Immediately after surgery, the foot of the bed should be elevated to reduce swelling. An ACE compression bandage will be used to reduce swelling and prevent hemorrhage. The other positions would not be as appropriate since swelling is an issue after a below-the-knee amputation. 1. Incorrect: Flat on the bed will not relieve swelling. Post-operatively for a BKA, hemorrhage and swelling are the biggest concerns immediately following surgery. 3. Incorrect: Position of comfort may increase swelling. Immediately following a BKA, elevating the foot of the bed and the ACE compression wrap are used to present hemorrhage and swelling. Positioning for comfort is not appropriate. 4. Incorrect: Placing in a dependent position will increase swelling. Swelling post-operative is a normal occurrence and elevating the foot of the bed and the use of an ACE wrap will help prevent swelling.

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

2. Correct: Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client. 1. Incorrect: Increasing meat at mealtimes would be detrimental to the client's health. When protein is taken into the body, a healthy liver will convert this into urea that is then excreted by the kidneys. However, this client's impaired liver is not able to make that conversion; therefore, the ammonia levels would continue to increase. The nurse can discuss with the client other foods that might safely be added to meals. 3. Incorrect: While it is true this client is dehydrated, the issue is that the client wants to increase the amount of meat at mealtimes. This response does not address the client's request nor does it provide any teaching that would help the client once discharged. 4. Incorrect: Although this response indicates that the nurse is focusing on the client's issue with food, this reply does not address the request for more meat with meals. This would be the appropriate opportunity to educate the client on the need to limit daily protein in the diet.

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. "I will soak my feet for 30 minutes a day." 2. "I will avoid using a heating pad on my feet." 3. "I can use scissors to remove the corns on my toes." 4. "I enjoy walking without my shoes around the house."

2. Correct: One of the long-term complications of diabetes is peripheral neuropathy. As the neuropathy progresses the feet have reduced sensation and may eventually become numb. The client should avoid using heating pads and hot water bottles. Due to the decrease sensation of the feet, the client is in danger of blistering and burning the feet. 1. Incorrect: A complication of diabetes is an increased risk of foot infections. The client is immunocompromised which impairs the leukocytes that destroy bacteria. The client should not allow moisture to accumulate between the toes. 3. Incorrect: Due to the possibility of the client experiencing peripheral neuropathy, the client should not remove any corns from their toes. If a cut occurs while removing the corn, the client is a risk for an ulcer developing. A primary healthcare provider should prescribe the appropriate treatment for corns. 4. Incorrect: Walking without appropriate shoes is dangerous for the client diagnosed with diabetic peripheral neuropathy. After stepping on an object, the client cannot feel the damage to the skin which could result in a scratch or cut.

The nurse observes an unlicensed assistive personnel (UAP) performing AM care for a client with a plaster leg cast applied 12 hours ago. Which action by the UAP should the nurse intervene? 1. Lifting the affected leg with the palms of the hands 2. Covering the affected leg with a blanket to avoid chills 3. Placing plastic over the entire cast prior to bathing 4. Elevating the casted leg on two pillows

2. Correct: Plaster cast take 24-48 hours to completely dry. During this time they release heat. The new cast should not be covered so that heat from the cast can evaporate. If the heat is not allowed to dissipate, drying will take longer. 1. Incorrect: Plaster cast take 24-48 hours to completely dry. During this time the cast should be handled carefully as to avoid indentations. Handling the cast carefully with the palms and not the fingertips will prevent indentations. Indentations in the cast could cause skin breakdown inside the cast. 3. Incorrect: Yes, will keep cast from getting wet. Plaster casts should never get wet. The plaster cast does not hold up well in water. Wet casts can also irritate the skin underneath.4. Incorrect: Yes, may elevate the leg. Fractures are prone to swelling. Elevating fractures while casted is a common occurrence. Elevation prevents swelling.

The telemetry unit nurse is assessing a newly admitted client following a fall at home. The client has been diagnosed with a left sided cerebrovascular accident (CVA), including aphasia, and a sprained wrist. What is the most effective method the nurse could use to assess the client's pain? 1. Monitor vital signs for elevations. 2. Observe client's non verbal behaviors. 3. Assess sleeping position client chooses. 4. Ask client to point to the pain rating scale.

2. Correct: The client has had a left sided stroke which damages the left hemisphere of the brain. Although the question does not specify whether this is receptive or expressive aphasia, the client may have great difficulty identifying the location or amount of pain. Because of the client's difficulty in communicating at this time, the nurse must rely on non-verbal cues such as facial expressions, vocalizations (moaning, crying) or client attention to the injured portion of the body (massaging or holding the painful area). 1. Incorrect: Despite the fact that vital signs often become elevated in the presence of pain, this is not a reliable indicator, particularly since the vital signs could be impacted by the recent CVA. Additionally, tolerance to pain varies, and changing vitals would not provide the most accurate data about the severity or even the location of the client's pain. 3. Incorrect: This method is the least reliable approach in evaluating client discomfort. Waiting for the client to fall sleep delays effective treatment, assuming the client is able to rest at all while experiencing pain. Also, the nurse is assuming that the client would be able to position self in a manner indicating what area is most painful. The impact of a stroke in the left brain might prevent the client from accurately locating or identifying the exact painful area. 4. Incorrect: The client has had left hemisphere damage to the brain with resulting aphasia. There is no data provided in the question regarding the category of aphasia; therefore, the nurse would be aware the client may not be able to indicate the correct location or severity of pain, even if utilizing the smiling face picture scale. This client also may not be able to understand instructions on the use of the scale, or to self evaluate the actual level of pain.

The nurse is teaching a client regarding herbal therapy. What is the main goal of herbal therapy? 1. To treat a specific disease or symptom by taking prescription medications. 2. To restore balance within the body by supporting the client's self-healing ability. 3. To avoid the use of toxic chemicals within the body. 4. To incorporate Eastern healing practices into Western medicine.

2. Correct: The main goal of herbal therapy is to restore balance within the body by supporting the client's self-healing ability. When teaching clients, the main goal should always be included.1. Incorrect: The main goal of drug therapy is the treatment of a specific disease or symptom. Herbal therapy should not treat diseases. They are for support only. 3. Incorrect: The main goal of herbal therapy is to restore balance and support healing. Many times herbal therapy is considered less toxic but the question is asking for the main goal of herbal therapy.4. Incorrect: Not the main goal of herbal therapy. This is not the main goal of herbal therapy. The main goal is to restore balance within the body by supporting the client's self-healing ability.

The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? 1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward." 2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg." 3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand." 4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg, and advance affected leg and the crutches to the step."

2. Correct: This client will need additional instruction. The client should place their crutches on the step below first. Then move the affected leg down to the next step. The client should follow with the unaffected leg. 1. Incorrect: This is a correct statement by the client. The crutches are to be moved 6 to 12 inches forward and then the client steps past the crutches. 3. Incorrect: The client is describing the correct steps in rising from a chair. Both crutches are placed in one hand. The client should then push off from the chair with one hand. 4. Incorrect: The client should advance their unaffected leg up to the next step and place their weight on unaffected leg. Then the affected leg and the crutches should be advanced to the next step.

A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.

2. Correct: This method is correct for the three-point gait. Client has to bear weight on the unaffected foot and both crutches. The affected leg does not touch the ground. 1. Incorrect: This is the four-point alternate gait. This type of gait is used commonly when =both legs are weakened. 3. Incorrect: This is the two-point alternate gait. Two point requires at least partial weight bearing on each foot. 4. Incorrect: This is the swing-to gait. This gait is indicated for individuals with limited use of lower extremities and trunk instability.

The nurse is providing discharge dietary instructions to a client diagnosed with full thickness burns to the right hand. To promote tissue healing, which food examples should the nurse provide to the client? Select all that apply 1. Pasta 2. Oranges 3. Brown rice 4. Chicken breast 5. Electrolyte drink

2., & 4. Correct: During the healing process vitamin C intake will promote collagen synthesis, increase healing time and decrease capillary fragility. An orange is high in vitamin C. The body requires an increased consumption of protein during the wound healing process. The increased protein intake results in greater collagen formation. 80 % of the calories of a chicken breast are from protein. 1. Incorrect: Due to the low level of protein, pasta is not the correct choice for food that promotes wound healing. 3. Incorrect: The intake of brown rice will not promote tissue healing. There is no protein or Vitamin C here. 5. Incorrect: One cup of an electrolyte drink does not contain protein or vitamin C.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? Select all that apply 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2., 3., 4. & 5. Correct: Preschoolers typically require 11 - 13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical. The nurse should determine if the child has difficulty falling asleep. If so, perhaps more restful nighttime rituals should be implemented.1. Incorrect: Preschoolers typically require 11-13 hours of sleep per day. Nine hours is not enough.

A nurse is helping a client to maintain normal voiding habits while recovering from a cesarean section. What methods should the nurse initiate? Select all that apply 1. Have the client recline slightly while using bedside commode. 2. Encourage the client to push over the pubic area with hands. 3. Suggest the client read or listen to music. 4. Pour warm water over the perineum. 5. Stay and talk with client while waiting for urge to void.

2., 3., 4. Correct: Encourage the client to push over the pubic area with the hands or lean forward to increase intraabdominal pressure and external pressure on the bladder. Reading or listening to music will help to decrease anxiety and tension. Pouring warm water over the perineum promotes muscle relaxation. 1. Incorrect: Assist the client to a normal position for voiding. For males, standing. For females, squatting or leaning slightly forward when sitting. These positions enhance movement of urine through the tract by gravity. 5. Incorrect: Provide privacy. Many people cannot void in the presence of another person.

Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain? Select all that apply 1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints. 4. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 5. Place client on Nothing By Mouth (NPO) status. 6. Administer Normal Saline (NS) at 125 mL/hour.

2., 3., 4., & 6. Correct: Apply local massage gently to affected areas to help reduce muscle tension. Massage also warms the area and promotes vasodilation. Supporting and elevating affected joints will decrease swelling, thus decreasing pain. Physiological manifestations of vital signs aid in evaluation of pain and effectiveness since pain is unique to every person. The nurse should also assess pain with an objective scale by having the client rate the pain 1-10.​ The NS provides hydration and is appropriate in sickle cell crisis. ​Hydrating the client makes it easier for the abnormally formed RBCs to pass through vessels. 1. Incorrect: Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses. Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis.5. Incorrect: The sickle cell client should not be kept from eating or drinking. Hydration is an important component of therapy. Dehydration promotes sickling process.

A nurse is educating several unlicensed assistive personnel (UAP) about a dietary prescription for clear liquids. Which selections by the UAP indicate to the nurse an understanding of a clear liquid diet? Select all that apply 1. Vanilla custard 2. Lemon jello 3. Tomato juice 4. Sprite 5. Banana popsicle

2., 4., & 5. Correct: These are considered clear liquids. You can see through them. The banana popsicle and lemon jello in a liquid state can be seen through. 1. Incorrect: This would be on a full liquid diet. A full liquid diet allows clear liquids along with thin hot cereals, strained cream soups, juices, milkshakes, custard, pudding and liquid nutritional supplements. 3. Incorrect: This would be on a full liquid diet. A full liquid diet allows clear liquids along with thin hot cereals, strained cream soups, juices, milkshakes, custard, pudding and liquid nutritional supplements.

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? Select all that apply 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

3. & 5. Correct: A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the oral mucosa. Phenytoin causes gingival overgrowth, swelling and bleeding of the gums. This can make oral hygiene more difficult. 1. Incorrect: This client can perform oral hygiene with minimal assistance. Knee surgery and opioid pain medication do not interfere with oral hygiene. 2. Incorrect: Movement for one side of the body is controlled by the opposite side of the brain. If stroke affects the right side of the brain, then you will have trouble with the left side of your body. Since this client is right handed and his left side is affected, the client can perform oral hygiene. 4. Incorrect: This client can perform oral hygiene with minimal assistance. There is no information in this option that would put this client at risk for ineffective oral hygiene.

A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair.

3. CORRECT: The nurse is observing the client ambulate with a walker prior to discharge, to determine whether the client is using the assistive device safely. The nurse becomes concerned upon noting the client sliding the walker during ambulating. The correct use of a walker involves the client lifting and placing the walker approximately one-foot length ahead, then stepping into the non-moving walker. It is important for the walker to remain stationary when the client takes a step forward. 1. INCORRECT: This action by the client is appropriate. Proper, gripping footwear should be worn by the client at all times when ambulating. This prevents the possibility of slipping and falling. There is no cause for concern with this action. 2. INCORRECT: Another smart move is to verify the cross bars are securely locked before ambulating. When a walker is folded for storage, the locks are unlatched. When the walker is open, the locks must click into place to verify the device is safe for ambulating. No concerns here. 4. INCORRECT: When a client sits down, the walker can be placed to either side of the chair. The most important factor is for the client to use the walker to safely maneuver into the chair rather than placing the walker aside before sitting down. Placing the walker next to the chair after being seated is appropriate.

A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."

3. CORRECT: The true test of learning is for the client to be able to actually complete a self-care task independently. There is nothing wrong with the client referring to written instructions to complete the task. 1. INCORRECT: While it is beneficial for another family member to be familiar with the process of ostomy irrigation, having the spouse recite the steps does not ensure the client has learned successfully. 2. INCORRECT: Though the client has attended all the teaching sessions presented on performing self-ostomy care, that fact does not guarantee the client could actually successfully complete the task. 4. INCORRECT: A surgeon generally will order daily irrigation of a new ostomy to help establish a consistent bowel pattern. Only the surgeon can determine when the client may discontinue ostomy irrigation.

70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

3. Correct: Caffeine and some medications may interfere with sleep. 1. Incorrect. The client is concerned about the sleep problem, and the nurse should address the client's concerns. Sleep disturbances can also indicate depression. This option is denying their concerns. 2. Incorrect. Elders actually require less sleep because they are less active. Elderly do not need as much sleep. 4. Incorrect. Elders are likely to have more disturbed sleep. They usually do not need more sleep.

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

3. Correct: Just because a client is a frequent visitor to the emergency department reporting migraines does not mean that the client is addicted to narcotics or that the client is not really experiencing the pain. Pain is what the client says it is and assessment is priority. 1. Incorrect: This is delay of treatment and does not address the pain. The nurse should have the client rate the pain in order to become objective data. 2. Incorrect: This is the primary healthcare provider's decision and also indicates you think the pain is not real. Assessment by the nurse and primary healthcare provide are warranted. Don't delay treatment. 4. Incorrect: Assessment of the eyes could be an option since eye strain can lead to headaches. Rating their pain would be the priority assessment however.

What turning method should the nurse use to turn a client who has a spinal injury? 1. Lateral transfer 2. Slide sheet procedure 3. Logrolling 4. Mechanical lift transfer

3. Correct: Logrolling is used for the client who has a spinal injury. This technique keeps the client's body in straight alignment at all times. 1. Incorrect: Lateral transfer uses a spinal board to move the client from one bed to another. 2. Incorrect: Slide sheets enable clients to be slid up a surface or over to their side, that is, up the bed or rolled over in the bed. The difference is that all of the body may not be kept in perfect alignment as with logrolling. 4. Incorrect: A mechanical lift is used to move client from a bed to chair or chair to bed.

Which response by the nurse is appropriate when responding to a client who reports eliminating all dairy foods from their diet because of lactose intolerance? 1. "Take calcium tablets since they can be used as a total supplement for dairy products." 2. "You can take lactose enzymes which will eliminate the effects of lactose intolerance." 3. "Valuable nutrients found in milk include calcium and protein." 4. "Consume more leafy green vegetables to maintain calcium levels."

3. Correct: Milk contains both calcium and high-quality protein. 1. Incorrect: Dairy products provide for both calcium and protein. 2. Incorrect: Lactose enzymes may help but will not eliminate the problem. 4. Incorrect: People generally do not eat enough green leafy vegetables to get enough protein.

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

3. Correct: Phantom limb pain (PLP) may be experienced in the amputated part after surgery. The client may describe the PLP as crushing, cramping, and burning. Complementary therapy is a non-pharmacological comfort measure that can be utilized to reduce the client's PLP. Instructing the client to implement guided imagery techniques will assist the client in reducing PLP. 1. Incorrect: Placing the client in various positions in bed by the nurse will not reduce the client's PLP. The client's PLP can be addressed with complementary therapy and medications such as calcitonin, beta-blockers, antiepileptics, antispasmodics or antidepressant medications. 2 Incorrect: Rewrapping the ace bandage on the stump by the nurse will not reduce the phantom limb pain. Wrapping the stump will decrease edema, secure the dressing, and assist in shrinking the limb. 4. Incorrect: Range of motion exercises will decrease the possibility of flexion contractures of the hip and knee. The improved flexion of the hip and knee with range of motion will not decrease PLP.

What intervention should the nurse take when providing oral care for the unconscious client? 1. Brush teeth with a stiff toothbrush. 2. Use thumb and index finger to hold the client's mouth open while brushing teeth. 3. Position the client on their side. 4. Rinse by injecting water into the center of client's mouth.

3. Correct: Placing client on side helps fluid run out of the mouth. 1. Incorrect: A soft bristled brush should be used. 2. Incorrect: Fingers should not be placed in client's mouth. 4. Incorrect: Should be injected into the sides of the client's mouth.

Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans

3. Correct: The serving size of 150 g of yogurt has a calcium content of 240 mg. 1. Incorrect: The serving size 50 g of lettuce has a calcium content of 19 mg. 2. Incorrect: The serving size of 182 g of apple has a calcium content of 11 mg. 4 Incorrect: The serving size of 90 g cooked green beans has a calcium content 50 mg.

The nurse identifies that additional teaching about skin care is needed when an 80 year old client makes what statement? 1. "I shower 3 - 4 times per week." 2. "I apply moisturizers at least daily." 3. "I bathe in the tub at least 6 times per week." 4. "I drink 64 ounces (1.89 L) of liquid per day."

3. Correct: This client will require additional teaching about skin care. The client should not bath 6 times a week. Due to the elderly client's diminished secretion of natural oils and perspiration, the client should decrease the number of times per week that the client either bathes or showers. 1. Incorrect: This is a true statement that the older adult should bathe or shower 3 - 4 times a week. Due to normal aging changes the client should decrease the number of times per week that the client either bathes or showers. 2. Incorrect: This statement does not require further teaching. The composition of the skin changes as a person ages. The epidermis will thin and the sebaceous gland produces less oil. Applying a moisturizer at least daily will protect the epidermis and compensate for less oil being produced. 4. Incorrect: Older people may experience dry skin patches. Drinking liquids will increase the skin's sweat production which will decrease dry skin patches. Drinking 64 ounces (1.89 L) per day should be enough to keep the elderly person hydrated.

The nurse is teaching crutch walking to a client with a fractured lower leg with a non weight bearing cast. Which crutch gait would be most appropriate for the nurse to teach? 1. Swing through 2. Two point 3. Three point 4. Four point alternating

3. Correct: Three point gait. All of the weight bearing is done by the unaffected leg and the crutches. The injured leg does not touch the ground during the performance of this gait. This is most appropriate for the client with a lower leg cast. 1. Incorrect: The swing through alternating gait would require some form of weight bearing on the fractured leg. This would not be an acceptable form of crutch walking for this client. 2. Incorrect: The two point alternating gait would require some form of weight bearing on the fractured leg. This would not be an acceptable form of crutch walking for this client. 4. Incorrect: The four point alternating gait would require some form of weight bearing on the fractured leg. This would not be an acceptable form of crutch walking for this client.

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.

3. Correct: Wound care on burns is a painful process, particularly with partial thickness burns (formerly referred to as second degree) because nerve endings are intact and exposed. Pre-medicating is a priority action, since pain medication can take up to 30 minutes to activate within the body. Clients are more cooperative and heal faster when pain is well controlled. 1. Incorrect: Proper visualization during wound care is vital, as is client comfort during the procedure. However, completion of this process does not require the client to be in an upright position. In fact, that may be counter productive at this time. Additionally, whether the right leg needs elevated depends on the size or location of the burn on the right leg, and that information has not been provided in the question. 2. Incorrect: While it is true that any wound culture must be obtained prior to cleaning the affected area, this action is not presently the nurse's first priority. Consider the nursing process and choose another option. 4. Incorrect: Therapeutic communication is an on going process during any client interaction, particularly when the nurse needs to explain an upcoming procedure. Allowing the client to express fears, verbalize concerns or ask questions enhances cooperation. Although this exchange of information is occurring throughout this period of time, the nurse has another priority action that should be completed first.

A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation? Select all that apply 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling.

3., 4. & 5. Correct: Compression stockings put gentle pressure on the leg muscles. Studies in healthy people have shown that wearing compression stockings minimizes the risk for developing DVTs after long flights. It is important for passengers to keep moving their legs to help the blood flow, even when waiting in the airport terminal. Alcohol and coffee contribute to dehydration, which can lead to thickened blood and increased risk for DVT. 1. Incorrect: Do not cross legs at all. 2. Incorrect: The client should get up and move around at least every 2 hours. When walking, the muscles of the legs squeeze the veins and move blood to the heart.

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? 1. "I must include a lot of fluid in my daily routine." 2. "I need to take my antibiotics at the same time daily." 3. "Rest and mild exercise are important for my recovery." 4. "Decreasing fiber in my diet can help prevent recurrences."

4. CORRECT. Diverticula are small, bulging pouches that can form in the lining of the digestive system, most often the lower portion of the colon. Diverticulitis is an inflammation in those pouches, which fill with retained material causing infection and inflammation. To diminish the chances of an exacerbation, the client is taught to increase fiber in the diet. This client's comment indicates the need for further instruction. 1. INCORRECT. A client with diverticulitis needs large quantities of fluid daily to prevent dehydration and to avoid possible bowel blockage. Sluggish bowels also increase the potential for bacterial growth and a recurrent infection. This statement is accurate and does not require additional teaching. 2. INCORRECT. Most clients hospitalized with diverticulitis will continue to take oral antibiotics for a period of time after discharge. Consistency with medication is always important to maintain adequate blood levels of the antibiotic. The client has made an accurate statement so no further teaching needed. 3. INCORRECT. Once the client is discharged home, rest will be important to recovery. However, a mild form of daily exercise, such as short walks, can help with recovery by boosting the body's own immune system. It is obvious the client comprehends the nurse's teaching and will not require further instruction here.

A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? 1. Cancel physical therapy and allow client to leave. 2. Ask client to stand with crutches to check the size. 3. Tell client insurance will not permit use of old crutches. 4. Send client with crutches to physical therapy for evaluation.

4. CORRECT. The physical therapy department is best qualified to assist a client in adjusting to the use of crutches prior to discharge. Because the client wants to use older crutches, it is even more important for a physical therapist to determine whether it is safe for the client to do so. Physical therapy can evaluate the condition of the old crutches, the client's ability to manage that equipment and to walk safely with those crutches. 1. INCORRECT. It is permissible for a client to use previously owned medical equipment. However, the stability of that equipment and the client's ability to use the equipment safely must be evaluated by physical therapy. Cancelling physical therapy would also violate the physician's orders and place the client at risk for injury upon discharge. 2. INCORRECT. While the nurse may be able to adjust the old crutches to the client's height, crutch safety and walking should be evaluated by physical therapy to be certain the previous equipment is appropriate. 3. INCORRECT. Insurance does not designate whether assistive medical devices can be reused by clients or if a new device must be purchased. It is cost effective to reuse durable medical equipment if it is appropriately suited to the client's current needs.

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

4. CORRECT: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently. 1. INCORRECT: This statement by the client indicates a positive attitude about the need to lose weight and the intention of following the prescribed diet. Obesity is one of several main factors that can lead to the development of DVTs. 2. INCORRECT: Prolonged sitting, or even lying down, can increase the incidence of blood clots or DVTs. If the client does a lot of sitting during the day, it is advisable to walk around every few hours to reduce stasis. The client is acknowledging the need to increase mobility regularly, which is an indication of compliance. 3. INCORRECT: Placing pressure directly on vessels by crossing the legs compresses both veins and arteries, thus increasing the potential for blood clots or dislodging an unknown clot. The client has acknowledged the need to keep legs uncrossed and the benefit of having family provide reminders.

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicates to the nurse that the prescribed treatment for constipation has been effective? 1. "My child drinks 1000 mL of fluids daily." 2. "My child is eating more fruit every day." 3. "I administered the prescribed oil-retention enema 6 days ago to my child." 4. "My child has had a soft, formed, brown stool every day for 6 days without straining."

4. Correct: A client is assessed as constipated when they have hard stools, difficulty passing the stool, and incomplete passage of stool. The desired outcome of constipation therapy is for the child to have soft, formed, bowel movements. The mother states that the child has had soft, formed, brown stools every day for the last 6 days. 1. Incorrect: Can you evaluate the effectiveness of the treatment plan by the parent describing how much fluid the child consumes in 24 hours? No. This is an action based on the need to increase the fluid intake to help decrease constipation. This is not an evaluation of the prescribed treatment for constipation. 2. Incorrect: This statement is a description of the classification of food that the child is eating. The effectiveness of the prescribed plan for the constipation is not addressed. 3. Incorrect: The mother is describing the completion of a prescribed treatment. The results of the enema are not listed, and it does not evaluate the prescribed treatment for constipation.

The family of an elderly client are concerned about emotional well-being since the loss of the spouse two years ago. What alternative therapy could the nurse recommend for this client? 1. Massage 2. Bioelectromagnetics 3. Accupressure 4. Animal-assisted therapy

4. Correct: Animal-assisted therapy is the use of specifically selected animals as a treatment modality in health and human service settings. It has been shown to be a successful intervention for people with a variety of physical or psychological conditions. The contributions companion animals make to the emotional well-being of people include providing unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy toward others; a reason to get up in the morning, and a source of reassurance. 1. Incorrect: Massage therapy is the scientific manipulation of the soft tissues of the body. It is believed to aid the body to heal itself. 2. Incorrect: This uses electromagnetic fields to affect the functioning of cells, tissues, organs and systems. 3. Incorrect: Acupressure is a treatment rooted in the traditional Eastern philosophy of life energy, that flows through the body along pathways. It opens up blocked pathways to relieve pain.

The nurse is teaching a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

4. Correct: Biologically-based therapies use substances found in nature such as herbs, foods, and vitamins.1. Incorrect: Energy therapies use energy fields. Substances found in nature are biologically-based therapies.2. Incorrect: Mind-body interventions use the mind to help affect the function of the body. Substances found in nature are biologically-based therapies.3. Incorrect: Body-based methods use movement of the body. Substances found in nature are biologically-based therapies.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion. 1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket. 2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket. 3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket.

The hospice nurse has been assigned a new client who is being cared for at home by family members. Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time? 1. Providing care for the client, allowing the family to rest. 2. Providing education regarding the symptoms the client will likely experience. 3. Allowing the family to express their feelings and actively listening. 4. Communicating the client's impending death to the family while they are together.

4. Correct: Communicating news of the client's impending death to the family while they are together. The nurse's most important role in the care of the family is compassionate communication. The family needs to be informed about the situation so that they are prepared for the client's death and can provide support to one another. 1. Incorrect: Providing respite time when death is imminent is not a priority. Family should be allowed to spend time with the client. They will, more than likely, want to be with the client in the last hours.2. Incorrect: When death is imminent, education of what to expect is appropriate, but does not take priority over compassionate communication. Compassionate communication is most important at this time.3. Incorrect: Silence and listening sends a message of acceptance and comfort. Although important, allowing for expression of feelings is not more important than preparing the client for the imminent death.

How does the nurse identify the correct size of crutches for a client? 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel.

4. Correct: Measuring the client from 2 inches below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches. This is the correct size while a client is standing. 1. Incorrect: This is not the correct way to choose the correct size crutches. Without the proper fit safety is a concern. 2. Incorrect: This is not how to choose the correct size of crutches. The client should not rest their weight on the crutch pad as this can cause damage to the brachial plexus nerve. 3. Incorrect: This is not how to choose the correct size of crutches. The shoulders should be relaxed, the hand piece should be adjusted to provide a 20°- 30° elbow flexion. The 2 inch drop below the axilla allows the weight to be pressed against the sides and the hands absorb the weight. The crutch should not be placed against the axilla or the brachial plexus nerve could be damaged.

A client who has right sided weakness and weighs 280 pounds (140 kg) needs to be transferred from the bed to the chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1. Stand at the client's right side. 2. You are physically fit and at lesser risk for injury. 3. Using proper body mechanics will prevent you from injuring yourself. 4. Use the mechanical lift and with another UAP, transfer the client to the chair.

4. Correct: Mechanical lifts are used to transfer clients who are unable to assist with the move or is large in size. The client weighs 280 pounds (140 kg). Because the client weighs 280, another UAP should assist with the transfer. 1. Incorrect: It is an appropriate intervention to stand on the weak side of the client, if this was the only listed intervention. Due to the size of the client, a mechanical lift should be utilized to transfer the client. 2. Incorrect: Being physically fit will not prevent a person from injuring themselves when transferring a client from the bed to a chair. The use of a mechanical lift is recommended due to the size of the client. 3. Incorrect. Using proper body mechanics will be very important when performing many nursing skills. Proper body mechanics will not prevent injury, because the client's weight is too greater to safely transfer from the bed to the chair without a mechanical lift.4

The nurse instructs a client taking isoniazid for the treatment of tuberculosis (TB) regarding appropriate food choices. Which food choices indicate to the nurse that teaching has been successful? 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon with crackers. 4. Pear salad with lettuce.

4. Correct: Pears are acceptable fruit. Foods high in tyramine can cause headaches, fast or irregular heartbeats, nausea and vomiting and sensitivity to light. Foods high in tyramine such as aged cheeses, certain meats, liver, moked fish, sour cream, raisins, bananas and avocados should not be eaten when taking isoniazid. 1. Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as salad with bleu cheese dressing can result in severe reactions when client is taking isoniazid. 2. Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as smothered liver with onions can result in severe reactions when client is taking isoniazid. 3. Incorrect: Avoid foods high in tyramine. Foods high in tyramine such as smoked salmon can result in severe reactions when client is taking isoniazid.

Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.

4. Correct: Skin breakdown on the foot is priority. Healing is likely to be impaired and the abrasion can be an entry point for microorganisms. There maybe other risk factors observed in the assessment; however, this finding should receive priority.1. Incorrect: Vitiligo is a skin problem commonly associated with type I diabetes. The melanin containing cells are destroyed, resulting in patches of discolored skin. Vitiligo poses no harm to the client.2. Incorrect: Scleroderma affects people with type 2 diabetes causing thickening of the skin to the upper back and neck. Scleroderma poses no harm to the client. 3. Incorrect: Redness should be noted and reasons found; however, this is not the priority finding. Redness/flushing can be due to many conditions but poses no obvious harm to the client.

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity

4. Correct: Specific gravity is an indicator of hydration status and urine osmolality. In a dehydrated client, specific gravity is increased, indicating highly concentrated urine.1. Incorrect: White blood cells should not be found in the urine unless an infection is present. Dehydration does not cause white blood cells in the urine. 2. Incorrect: Protein should not be found. Presence of protein indicates renal disease. In order to have proteinuria there must be damage to the glomeruli 3. Incorrect: Ketones should not be present. They are found in clients with poorly controlled diabetes or hyperglycemia, because ketones are a by-product of fat breakdown. Fats are broken down and used for energy when glucose cannot be transported into the cells because of lack of insulin.

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

4. Correct: The client does not have to be exposed during the bed change and should be covered with a bath blanket as the top sheet is removed. A bath blanket covers the client as once section at a time of the body is exposed and bathed. This allows for the most privacy and protects self-esteem.1. Incorrect: Closing the door is very important but the client's privacy should be maintained at all times even from the nurse administering the bath. A bath blanket promotes privacy and protects the self-esteem.2. Incorrect: Introducing yourself to the client and explain procedures shows respect. These two actions do not provide for privacy and preserve the self-esteem of the client.3. Incorrect: If help is needed during an occupied bed bath to protect the client and provide for safety, help should be obtained. The nurse should use measures to protect privacy and preserve the client's self-esteem.

In what position should the nurse place a client diagnosed with gastric reflux? 1. Orthopneic 2. Semi-Fowler's 3. Sims' 4. Reverse Trendelenburg

4. Correct: The entire bed is tilted with the foot of the bed lower than the head of the bed. This position promotes gastric emptying and prevents esophageal reflux. 1. Incorrect: Orthopneic position has the client sit in the bed or at the bedside. A pillow is placed on the over-bed table, which is placed across the client's lap. The client rests arms on the over-bed table. This position allows for chest expansion and is especially beneficial to clients with COPD. 2. Incorrect: The head of the bed is elevated 30 degrees. This position is useful for clients who have cardiac, respiratory, and neurological problems and is often optimal for clients who have a nasogastric tube in place. 3. Incorrect: Sims' or semi-prone position has the client on the side halfway between lateral and prone positions. Weight is on the anterior ileum, humerus, and clavicle. The lower arm is behind the client while the upper arm is in front. Both legs are flexed but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee. This is a comfortable sleeping position for many clients, and it promotes oral drainage.

The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward.

4. Correct: The left shoulder should be adducted. The position of adducting the shoulder forward promotes improved chest expansion and decreases strain on the shoulder. 1. Incorrect: The right leg is positioned forward in the left lateral position. For the right lateral position, the left leg is positioned on a pillow in front of the right leg. 2. Incorrect: Both legs should not be extended for the right lateral position. The left leg should be positioned forward with the knee flexed to decrease the internal rotation of the femur. 3. Incorrect: Inversion of the feet is described as positioning the ankles toward the midline of the body. The feet should be positioned in the neutral position to maintain proper ankle alignment.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Correct: This is a correct statement. The goal of palliative care is to help the client living with a chronic, life threatening illness. It focuses on the client's symptoms and the relief of these symptoms. Palliative care helps the client obtain their best quality of life throughout the course of their illness. 1. Incorrect: Palliative care is not aimed at cure. It is provided to clients who have chronic, life threatening illnesses. 2. Incorrect: Palliative care can begin at diagnosis. Hospice care is usually offered when the person has 6-12 months or less to live. 3. Incorrect: The client does not need to give up his or her primary healthcare provider. This is not a requirement of palliative care.

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

4. Correct:The nurse is evaluating client statements for any lack of understanding and the need to provide further instruction. With Celiac disease, intestinal villi become inflamed whenever gluten is introduced to the gut through food intake. However, fresh fruits and vegetables do not contain gluten; therefore, fresh apples and strawberries would definitely be acceptable foods for this client. This statement by the client is inaccurate, indicating the need for further explanation by the nurse. 1. Incorrect:The client correctly acknowledges that some episodes of abdominal discomfort may still occur, since it is nearly impossible to totally eliminate gluten. Despite buying "gluten-free" products, occasionally small amounts of gluten may contaminate foods and causing symptoms to resurface. Eating in a restaurant may also be a challenge for those with Celiac disease. Because the client recognizes these possible symptoms, teaching was successful. However, the question asks for evidence the client needs further instruction. 2. Incorrect: This is an accurate statement by the client about Celiac disease. Because inflammation of the intestinal villi may lead to poor absorption of nutrients or anemia, clients may indeed need to take supplements for extended periods of time. This response does not indicate any problems with the client's comprehension of teaching. 3. Incorrect: It is important for a Celiac client to eat as healthy and diverse a diet as possible, since malnutrition occurs secondary to poor nutrient absorption in the bowel. Protein is a vital component in the diet, including such choices as eggs, dairy and beans. Those foods creating the worst symptoms include grains like wheat, rye, and barley as well as the "malt barley" used as a thickening agent in certain products. The client has precisely stated that a breakfast including eggs but minus the wheat toast would be appropriate, evidence that teaching was successful.

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? Select all that apply 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins

5., & 6. Correct: Fruits provide valuable amounts of water, fiber, and antioxidants, all of which may help lower your risk for kidney stone symptoms. Many fruits are considered low-oxalate, meaning they contain less than 2 milligrams per serving. These include bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums and nectarines. Canned fruits, including peaches, pears, and dried fruits such as raisins, are also low in oxalate. 1. Incorrect: 1 cup of cooked spinach contains 1510 mg of oxalate. 2. Incorrect: Raspberries are the most significant fruit source of oxalate. One cup of raspberries contains 48 mg of oxalate. 3. Incorrect: 1 oz (28 g) of almonds contains 122 mg of oxalate. 4. Incorrect: One cup of 100% bran cereal contains 75 mg of oxalate.

The charge nurse is evaluating a newly hired LPN/VN graduate. Before assigning a client to be prepped for a colonoscopy, the nurse asks the LPN/VN to verbalize the correct steps for completing an enema. In what order should the LPN/VN verbalize the steps for an enema? Assist client to a side lying position. Insert lubricated tip into rectum. Raise enema bag 18" to 20". Add warm water to the enema bag. Explain procedure to the client.

The Correct Order Explain procedure to the client. Assist client to a side lying position. Add warm water to the enema bag. Raise enema bag 18" to 20". Insert lubricated tip into rectum.

The primary healthcare provider has prescribed ear irrigation for a client with earwax accumulation. In what order would the nurse perform the procedure? Aim syringe at back side of ear canal. Remove any debris in the outer canal. Squeeze syringe with moderate force. Tilt client's head to the opposite side. Fill bulb syringe with luke warm water. Pull ear pinna upward and backward.

The Correct Order Fill bulb syringe with luke warm water. Tilt client's head to the opposite side. Pull ear pinna upward and backward. Aim syringe at back side of ear canal. Squeeze syringe with moderate force. Remove any debris in the outer canal.