Basic Physical Care NCLEX 3000

The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse plan to emphasize?

4. Lean meats and low-fat milk

An obese, malnourished client has undergone abdominal surgery. While ambulating on the 4th postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which of the following is the best initial action for the nurse to take?

4. Lift up the dressing to check the wound.

The nurse is caring for a client who has a history of falling at home. Which intervention by the nurse reduces the risk of falling while the client is hospitalized?

4. Placing the call bell close to the client and reminding him to call for assistance with ambulation

Which action would be contraindicated for a client who develops a temperature of 102° F (38.9° C).

4. Providing a low-calorie diet

When collecting data on a client with cellulitis of the right leg, which of the following would the nurse expect to find?

4. Red, swollen skin with inflammation spreading to surrounding tissues

Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?

4. Side-lying

The nurse is teaching a group of nursing assistants in a long-term care facility about standard precautions. Which statement best describes standard precautions?

4. Wearing gloves, a face shield, and a gown when contact with body fluids is possible

When preparing a client for bronchoscopy, the nurse should instruct the client to avoid:

4. eating.

Which group of clients is at increased risk for developing a wound infection?

4. Clients who are undernourished

Which task can the licensed practical nurse (LPN) appropriately delegate to the nursing assistant?

4. Encouraging a client to drink fluids

When leaving the room of a client in isolation, the nurse should remove which protective equipment first?

4. Gloves

The 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?

1. Baked beans, hamburger, and milk

The nurse is informed by the secretary that her client will soon be returning from the postanesthesia care unit. What should the nurse do when preparing a surgical bed?

1. Leave the bed in the high position when finished

Which of the following is an example of a primary preventive measure?

4. Avoiding overexposure to the sun

The physician has ordered a wet-to-dry dressing containing normal saline solution for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to accomplish which action?

2. Debriding the wound

The nurse is caring for a client with stomatitis. To make eating less painful, which foods should the nurse suggest?

2. Soft, bland foods

A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client?

1. Contact, 3. Standard

Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance?

2. Breath sounds clear on auscultation

The nurse notes that a client coughs frequently while eating. Which health team member should be notified of this finding?

2. Speech therapist

A client is prescribed acetaminophen (Tylenol) by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order?

2. Cirrhosis

To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?

1. By swabbing the labia minora from front to back

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take?

1. Clearing the client's airway

The licensed practical nurse is admitting a client to the medical-surgical floor. She asks the client if he has an advance directive. The client responds by saying, "I don't know what you mean." How should the nurse respond?

1. "An advance directive is a document that states your wishes about health care."

The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding of the counseling?

1. "My son can't eat wheat, rye, oats, or barley."

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.), 60 ml (9 a.m.). Based on these amounts, what should the nurse do?

1. Continue to monitor and record hourly urine output.

The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include?

1. Encourage a high-calorie, high-protein diet.

A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique?

1. Figure-eight

Standard precautions dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?

1. Frequent hand washing reduces transmission of pathogens from one client to another.

A 20-year-old male seeks care at a local emergency care center after spraining his ankle while playing football with his friends. The ankle is painful and swollen. Which actions should the nurse perform, as ordered by the physician?

1. Initially apply cold., 2. Instruct the client to elevate the ankle for 48 to 72 hours., 3. Provide crutch gait training., 5. If needed, apply an elastic bandage from the toes to midcalf.

The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed?

1. Irrigate continuously until the solution becomes clear or all of the solution has been used.

A client admitted with dehydration has urinary incontinence and excoriation in the perineal area. Which action would be a priority?

1. Keeping the perineal area clean and dry

A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in his abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time?

1. Notifying the client's primary physician, 2. Covering the wound with saline-soaked sterile gauze

The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair?

1. Parallel to the bed on the right side

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?

1. Primary prevention

A client is unable to take a deep breath effectively and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client compliance with ambulation and deep breathing, the nurse should:

1. administer pain medication before having the client deep-breathe, cough, or get out of bed.

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:

1. foot.

To check the effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:

1. oxygen saturation.

When moving a client in bed, the nurse can ensure proper body mechanics by:

1. standing with the feet apart.

When changing a sterile surgical dressing, the nurse must first:

1. wash her hands.

When the nurse enters a client's room, she finds him slumped over in his chair. What actions should the nurse take? Rank in chronological order. Use all the options.

2. Establish unresponsiveness., 1. Activate the resuscitation team., 4. Place the client on a firm surface., 6. Open the client's airway., 3. Check breathing; give two breaths if absent., 5. Check pulse; if absent begin compressions

The nurse is performing her morning assessment when the client says, "I had trouble sleeping last night." Which action should the nurse take first?

2. Gathering more information about the sleep problem

The physician enters an order into the computer for a client who underwent abdominal surgery 24 hours ago. The order states: "Get client out of bed to chair twice daily." Which action should the nurse take when she transfers the client to the chair?

2. Help the client sit up and dangle his legs over the side of the bed

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received appropriate skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

2. Inadequate protein intake

The nurse is caring for a client with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?

2. Monitor the appearance, size, and number of stools.

A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often?

2. Once per year

A client must undergo right thoracotomy for lung cancer. Which member of the health care team is responsible for obtaining informed consent from this client?

2. Physician

The nurse is caring for a client who sustained a chemical burn in his right eye. She is preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure?

2. Place absorbent pads in the area of the client's shoulder., 3. Wash hands and put on gloves., 5. Direct the solution onto the exposed conjunctival sac from the inner to outer canthus.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care?

2. Placing the client in isolation and using airborne precautions

The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

2. Pouring solution directly onto a sterile field cloth

When checking a client's incision 1 day after surgery, the nurse expects to see which finding as a sign of a local inflammatory response?

2. Redness and warmth

During discharge teaching, a client with a fractured toe asks the emergency department nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?

2. Relieves swelling by reducing blood flow to the injury site

Nursing care for a client includes removing elastic stockings at least once per day. What is the rationale for this intervention?

2. To observe the lower extremities

The physician orders a clear-liquid diet for a client. The nurse understands that this client's diet may include:

2. apple juice, chicken broth, and gelatin.

When following standard precautions, the nurse's primary responsibility is to:

2. consider all body substances potentially infectious.

To help minimize calcium loss from the bones of a hospitalized client, the nurse should:

2. encourage the client to walk in the hallway.

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

2. ground beef patties.

The 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 would:

2. remove the warm compress after 20 minutes for at least 15 minutes.

The physician prescribes acetaminophen (Tylenol) 650 mg by mouth every 4 hours for a client with a temperature of 102° F (38.8° C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 ml. How many milliliters of solution should the nurse administer?

20.3

A client who's scheduled for surgery asks the nurse to keep $50 for him until he returns from surgery. How should the nurse respond?

3. "I'll notify the business office to make arrangements for your money to be placed in the hospital safe."

Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately?

3. Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute

A 70-year-old client who's alert and oriented refuses to take his regularly scheduled medications. Which action should the licensed practical nurse (LPN) take?

3. Inform the physician; chart the medications as not given in the medication administration record, and document the reasons the client refused to take them.

In a client who had major surgery 5 days ago, which data collection finding would be the best indication of a wound infection?

3. Purulent wound drainage

A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?

3. Referring the client to a home health nurse for follow-up visits

A licensed practical nurse (LPN) hears the facility code that indicates an infant has been abducted from the nursery. Which action should the LPN take?

3. Report to an exit and be alert for anyone carrying packages.

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

3. To reduce or prevent edema in the legs and feet

To follow standard precautions, the nurse should carry out which of the following measures?

3. Wearing gloves when administering I.M. medication

A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should:

3. encourage increased fluid intake.

The nurse is caring for a client with a fractured hip. The client becomes combative, confused, and tries to get out of bed. His vital signs and pulse oximetry results are unchanged. The nurse should:

3. notify the nursing supervisor to see if a staff member can sit with the client.

A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should:

3. palpate the bladder above the symphysis pubis.

The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

3. washing hands.

The nurse is collecting admission data from a newly admitted client. Which question should the nurse include when asking the client about orthopnea?

4. "How many pillows do you use?"

The physician asks the nurse to join him to discuss palliative care options with a terminally ill client and his family. Which statement by the nurse indicates an understanding of palliative care?

4. "I'll assist with the client with his total needs."

A client who underwent surgery had the following intake on the day of surgery: Day shift: 500 ml packed blood cells; 236 ml platelets; 750 ml normal saline solution; 1 L dextrose 5% in normal saline solution Evening shift: 250 ml normal saline solution; 1 L dextrose 5% in normal saline solution Night shift: 1 L dextrose 5% in normal saline solution. How many milliliters of solution should the nurse document as the client's 24-hour intake?

4736

The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

4. Shearing forces

During data collection, the nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?

4. Tachypnea

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require:

4. a chest X-ray.

The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:

4. enhances collagen formation.

Which of the following clients would qualify for hospice care

1. A client with late-stage acquired immunodeficiency syndrome (AIDS)

The licensed practical nurse (LPN) is caring for a group of clients on a medical-surgical floor. Which client should she attend to first?

1. A client whose lower leg is red and swollen

A client is admitted with diarrhea and dehydration. A stool culture shows Clostridium difficile. The nurse should institute which isolation precaution for this client?

1. Contact

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the plan of care?

1. Putting on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA) respirator when entering the client's room

Several residents in a long-term care facility ask the nurse if they can share their aromatherapy with other clients in the dining area. Why shouldn't the nurse permit them to practice aromatherapy in the group environment?

1. Some residents may have an adverse sensitivity to the oils and fragrances.

A teenage boy 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?

1. Support the wet cast with pillows until it dries., 6. Avoid putting straws or hangers inside the cast.

A client with severe pain is prescribed hydromorphone (Dilaudid) 10 mg by mouth every 4 hours as needed for pain. The client rates his pain as eight on a one-to-ten scale, so the nurse prepares to administer a dose. The oral liquid contained in the unit's opioid stock contains 5 mg/5 ml. How many milliliters of solution should the nurse give to the client?

10

The nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for laboratory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1/2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinated coffee, tuna fish sandwich, 1/2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz of 1% milk, 16 oz of water Output: 1,300 ml of urine How many milliliters should the nurse document as the client's intake?

1380

The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching?

2. "Hold the cane on the opposite side from the injury."

A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the client's ankle for 30 minutes, which statement by the client suggests that ice application has been effective?

2. "My ankle looks less swollen now."

Which intervention should the nurse use when administering oxygen by face mask to a client?

2. Assist the client to the semi-Fowler position if possible.

A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps?

2. Assisting the client into Sims' position, 3. Washing hands and putting on gloves, 6. Encouraging the client to retain the solution for 5 to 15 minutes

When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?

2. Avoid wearing canvas shoes.

The physician orders chest physiotherapy for a client with respiratory congestion. When should the nurse plan to perform chest physiotherapy?

2. Before meals

The nurse is caring for a client who practices reflexology. When collecting client data, the nurse notes that the client's ankles are edematous. Which intervention by the nurse supports the client's beliefs in reflexology and helps reduce edema?

2. Elevating the client's legs

Which assessment finding would be most supportive of the nursing diagnosis, Impaired skin integrity?

3. Area of skin with persistent redness

When preparing a client with a draining vertical incision for ambulation, where should the nurse apply reinforced dressings?

3. At the base of the wound

The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

3. By supplying a magic slate or similar device

The nurse is caring for a dying client who's receiving comfort measures. Which intervention by the nurse is most effective in promoting comfort?

3. Combing the client's hair

A client has a surgical wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?

3. In a circle, from the center outward

For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the data collection?

4. "Is the pain worse when your toes are pointed toward your knee?"

The nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?

4. Dysuria

The nurse is caring for an unconscious client who suffered a stroke 4 days ago. When providing oral hygiene for this client, the nurse must take which essential action?

4. Placing the client in a side-lying position