Basic Physical Care

A nurse is preparing a client for bronchoscopy. Which instruction is appropriate for the nurse to give to the client?

"Don't eat for 6 hours prior to the procedure."

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?

Continue to monitor and record hourly urine output.

The nurse is teaching an older adult how to prevent falls. What should the nurse tell the client?

Instruct the client to rise slowly from a supine position.

A teenager suffers a broken leg as a result of a car accident and is taken to the emergency department. A plaster cast is applied. Before discharge, the nurse provides the client with instructions regarding cast care. Which instructions are appropriate? Select all that apply.

-Support the wet cast with pillows until it dries. -Avoid putting straws or hangers inside the cast.

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse?

"I will find you a computer that is not being used so you can enter the order into the computerized order entry system."

The client is to have pneumatic compression devices applied. The client is hesitant to have the device applied. What is the best response by the nurse?

"This device will help push blood from the small vessels to the large vessels in your legs and prevent you from developing a blood clot."

The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do?

Assess the client to determine why she wants to sit up.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T-tube. What should the nurse do to determine the effectiveness of the T-tube?

Assess the color and amount of drainage every shift.

A nurse is working within the managed care delivery model. Which is true regarding managed care?

All systems reflect the values of efficiency and effectiveness.

The nurse notes an order for elbow restraints for a client in the intensive care unit. The client has an antecubital IV line. What should the nurse do?

Ask the health care provider to order a different type of restraint.

A client had abdominal surgery 2 days ago and has copious drainage. The nurse uses Montgomery straps when changing the dressing. Which is the expected outcome of using these straps?

Avoid skin breakdown.

The nurse is providing care for a client who is scheduled for a requested surgical procedure. The nurse walks into the client's room during an argument between the client and a family member who is against the procedure. The family member threatens to drag the client out of the room. What action should the nurse take first?

Call for assistance.

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client?

Client is recovering from abdominal surgery.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Deficient fluid volume

The nurse is preparing to administer a continuous enteral feeding. Which action is most important for the nurse to include in the plan of care?

Elevate the head of the bed.

The nurse has been providing care for a client who has been restrained with a body restraint for the past 3 days due to self-destructive behavior. Which action should the nurse prioritize when providing care to this client?

Ensure a new order for the restraints is written every 24 hours.

A client on prolonged bed rest has developed a pressure injury. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?

Evaluate client protein levels.

A client is upset the nurse has put a belt restraint on them. Which action should the nurse take when teaching the client and their family members about the use of this restraint?

Explain that its purpose is to help prevent injury to the client.

The nurse is applying leather restraints to a client who has exhibited violent behavior. What is the best way for the nurse to secure the restraints to prevent frozen joints in the arm?

Flex the arm slightly to allow room for movement.

A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks if the nursing assistant has been validated on obtaining fingerstick glucose readings. The nursing assistant does not have the skill validated, but has observed it many times and reports confidence in the ability to perform the skill. What should the nurse do?

Go with the nursing assistant into the client's room, and validate the nursing assistant's ability to perform the procedure.

When administering a tube feeding to a client through a percutaneous feeding tube, how should the nurse position the client?

Head of bed elevated 30 to 45 degrees

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs.

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what?

nonmaleficence

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should take which precaution?

Minimize urinary catheter use and duration of use in all clients.

A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy?

Monitor the appearance, size, and number of stools.

A client in a long-term care facility has signed a form stating that they do not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next?

Notify the physician that the client has no vital signs.

The nurse is planning care for a hospitalized client who is blind. What should the nurse do to ensure safety for this client?

Orient the client to the room environment.

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first?

Remove the client from the room.

The nurse is inserting an IV for a client and hears sizzling noises. The nurse looks up and sees sparks flying from the light in the ceiling. What is the next action by the nurse?

Remove the client from the room.

When the nurse is removing personal protective covering, what action should this nurse (see figure) take to avoid spreading nosocomial infections?

Remove the face mask.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

Return the residual and begin the feeding.

A client has a nursing diagnosis of Ineffective airway clearance related to retained secretions. When planning this client's care, the nurse should include which intervention?

Teaching the client how to deep-breathe and cough

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises?

The alveoli expand and increase the lung surface available for ventilation.

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The catheter bag is placed on the client's lap for safe transport.

A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia.

The nurse is caring for four clients. For which client would it be most appropriate for the nurse to collaborate with a healthcare provider regarding hospice care?

a client with late-stage acquired immunodeficiency syndrome (AIDS)

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advance directive. The client asks for an explanation of advance directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is:

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status.

These pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first?

a quiet 2-year-old with nasal flaring who is sitting in a tripod position

A nurse and an unlicensed assistive personnel (UAP) are caring for four clients together on the telemetry unit. Which nursing action can be delegated safely to the UAP?

applying electrodes in the correct position for ECG monitoring

The nurse is documenting the assessment of a wound on a client's foot. Which assessment would be included as subjective data?

area around the wound is tender to touch

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

baked beans, hamburger, and milk

A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity?

carbohydrate

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant?

completion of range of motion on limbs restrained

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. Which is the expected outcome of inserting the NG tube in the client's gastrointestinal tract?

decompression

A laissez-faire nurse-manager takes which action?

delegates to staff responsibility for selecting a new nursing care delivery system (model)

A partner of a client diagnosed with Kaposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that the client "has just given up. I know with medication my partner will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving?

denial stage

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

ground beef patties.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used?

handling of the dislodged radiation source.

A client with a history of obesity has come to the clinic seeking help to improve their health and prevent further weight cycling. When developing the care plan, the nurse should point out which factor to best assist this client?

identifying the client's internal and external cues related to eating

The nurse is developing a primary disease prevention program for older adults. Which topic should the nurse include in the teaching plan?

immunizations for influenza

The nurse is preparing a 45-year-old female client for a vaginal examination. The nurse should place the client in which position?

lithotomy position

A nurse is performing a sterile dressing change. Which action contaminates the sterile field?

pouring solution onto a sterile field cloth

An older adult has pruritus on the arms and legs and is scratching the affected areas. Which is the priority nursing care for this client?

preventing infection

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

raising all side rails while the client is in bed

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

to clear secretions from the tubing

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Fowler

The nurse would most likely expect to manage a percutaneous feeding tube as part of daily care for which client?

90-year-old client with dysphagia following a stroke

What should the nurse instruct a client who has cerumen buildup in the ear to do? Select all that apply.

-Wash the external ear with a washcloth. -Instill cerumenolytic drops in the ear canal. -Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.

The nurse is preparing to take a meal tray to the client. The nurse understands that the client follows a kosher diet. Which foods noted on the tray would be of a concern to the nurse?

turkey and cheese sandwich

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is

weight

A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?

to reduce or prevent edema of the legs and feet

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder?

to reduce stress on the abdominal incision

A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care?

Good Samaritan laws are designed to protect the caregiver in emergency situations.

A nurse is caring for a postsurgical client with two types of drains. Which task(s) can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

-Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. -Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain.

A nurse manager identifies fall prevention as a unit priority. Which actions can the nurses implement to meet these goals? Select all that apply.

-Use bed alarms to remind clients to call for help getting up. -Maintain a clear path to client bathrooms. -Make hourly rounds to client rooms.

Which action by the client indicates that the client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy?

The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips.

The nurse gives a client an oral narcotic analgesic medication to treat postoperative pain. Which follow-up assessment most clearly indicates that the treatment was effective?

Within 30 minutes the client says that the pain is reduced.

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort?

assault

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle?

autonomy of the client

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care?

documenting the situation and providing support for the victim

A nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should

remove the warm compress for at least 15 minutes after each 20-minute application.

The client reports lower back pain that increases when bending over, coughing, or lifting objects. The health care provider diagnoses a herniated disc. What teaching will the nurse complete with the client regarding pain associated with a herniated disc? Select all that apply.

-anterior or posterior longitudinal ligament thins out -nucleus pulposus herniates, compressing the nerve root -tearing of the disk, causing protrusion and compression of the spinal cord

The nurse is writing a medication order that a health care provider provided by telephone. Which should be included when writing the order? Select all that apply.

-date the order is written -medication dosage -route of administration -medication ordered

The nurse is recording the intake and output for a client: D5NS 1,000 ml, urine 450 ml, emesis 125 ml, Jackson-Pratt drain #1 35 ml, Jackson-Pratt drain #2 32 ml, and Jackson-Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.

654

The nurse was caring for a client who died from blood loss following the birth of their child. The death was not expected as the client did not have any medical conditions. Which initial action is most appropriate for the nurse manager to implement?

Initiate a root cause analysis on the event.

An unconscious client is to be placed in a right side-lying position. The nurse should intervene when observing the client in which position?

The left arm is rested on the mattress with the elbow flexed.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

The urine output is more than 35 mL per hour.

The quality assurance nurse is reviewing orders on a client's chart. Which order transcribed by the nurse would require the quality assurance nurse to speak with the nurse manager?

Tom B. Smith 12/28 sertraline hydrochloride 25 mg oral twice Frank Bill, MD

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay?

assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems

A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics?

fidelity

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy

The charge nurse notes that a client in a long-term care facility has bilateral soft wrist restraints applied. The client has a history of brain injury and has previously required restraints due to behaviors that could cause injury to the staff or the client. What documentation should the charge nurse check for in the chart? Select all that apply.

-a provider's order for bilateral wrist restraints -a note from the nurse on the client's behaviors that required restraints -a description of alternatives to restraints that were used

The nurse has been assigned to a client who is hearing impaired and reads speech. Which care measure(s) should the nurse incorporate when communicating with the client? Select all that apply.

-Avoid being silhouetted against strong light. -Do not block out the person's view of the speaker's mouth. -Face the client when talking. -Ensure the client is familiar with the subject material before discussing.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?

Inform the anesthesiologist.

When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate?

administering fluids to the client

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain?

compressing it and then plugging it to establish suction

A client is readmitted to the facility with a warm, tender, reddened area on the right calf. Which contributing factor should the nurse recognize as most important?

recent pelvic surgery

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client?

registered nurse (RN) with 2 years of experience

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

"I will administer the enema while lying on my left side with my right knee flexed."

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.

-Assess the client's current condition and vital signs. -If no acute injury, get help, and carefully assist the client back to bed. -Notify the client's health care provider (HCP) and family. -Document as required by the facility.

The nurse is preparing to provide education to a client in a community health center. How should the nurse determine if it is appropriate to include someone else in the teaching for support?

Ask the client if they have someone that they would like to be included in the teaching.

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

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

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

The health care provider (HCP) has prescribed hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain for a client who underwent right total knee replacement. When the nurse reassesses pain following administration, the client reports pain is still a 9 on a 10-point scale. When the nurse informs the HCP, the HCP states that one hydrocodone/APAP tablet should be sufficient and refuses to issue a new prescription. Which measure should the nurse select to act as an advocate for the client?

Follow the chain of command to obtain adequate pain relief for the client.

As the nursing supervisor walks past a client's room, they hear a family member berate and threaten the nurse if they do not change what they are doing to provide care for the client. The nurse apologizes and tries to explain what they are doing, but the family member only becomes more aggressive and hostile. What action should the nursing supervisor take first?

Inform the family member this is verbal abuse and must stop.

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. What should the nurse do?

Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed?

Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.