Basic Physical Care - PassPoint NCLEX

The nurse instructs a group of colleagues on actions to take to prevent back injuries when providing client care. Which statement by a colleague indicates that additional teaching is required? "A back belt prevents injuries." "It is safer to use an assistive device." "A lift team will help prevent back injuries." "An assistive device reduces the risk of client injury."

"A back belt prevents injuries." The use of a back belt does not prevent back injury. Research has shown that it is safer for the care provider to use an assistive device when transferring or repositioning a client. Utilizing specially trained lift teams help prevent back injuries. The use of an assistive device when transferring a client reduces the risk of client injury.

A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply. "I am not able to provide that information." "You should know better than to ask that question." "You will need to ask your manager." "Client privacy is part of the hospital code of conduct." "The client is in room 313."

"I am not able to provide that information." "Client privacy is part of the hospital code of conduct."

staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which action would the nurse employ to be a leader? Follow unit and hospital policy in daily situations. Tell the staff on the unit how to do their job effectively based on current research and relevant experience. Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills. Ask the nursing administration for the authority to make decisions that will affect the staff.

Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills.

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? Deflate the cuff of the tracheotomy during suctioning. Instill acetylcysteine into the tracheotomy before suctioning. Apply negative pressure as the catheter is being inserted. Hyperoxygenate the client before suctioning.

Hyperoxygenate the client before suctioning. Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter.

The nurse is preparing a client for surgery. Although the client can speak English, English is the client's second language. The client has completed high-school level education. When the nurse asks the client what type of surgery is scheduled, the client is unable to provide an answer. What should the nurse do next? Explain the procedure in detail to the client, and assess the client's understanding. Continue to follow the preoperative procedures required to prepare the client for surgery. Notify the health care provider that the client cannot explain the scheduled surgery. Document the client's response in the electronic medical record.

Notify the health care provider that the client cannot explain the scheduled surgery. The nurse should ask the health care provider to explain the surgery to the client again and ensure the client understands the procedure and the risks. If necessary, the nurse can call an interpreter. It is the role of the health care provider to explain the surgical procedure, not the nurse. The nurse cannot continue to prepare the client until the health care provider has explained the surgery and the client agrees to proceed. The nurse should then document the client's response and nurse's action after notifying the health care provider of the need to reexplain the procedure to the client.

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. Report signs of redness or inflammation at the site. Wear sterile gloves to change the fluids. Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Cleanse the port with alcohol wipes. Place the IV bag on a table level with the client's arm.

Report signs of redness or inflammation at the site. Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Cleanse the port with alcohol wipes.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? Bathe daily. Eat a high-carbohydrate diet. Shift your weight every 15 minutes. Move from the bed to the wheelchair every 2 hours.

Shift your weight every 15 minutes. The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? The tissue surrounding the wound is red and hot. The wound drainage is serous. The skin around the wound is edematous. The granulation tissue is at the wound edges.

The granulation tissue is at the wound edges. Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? The nurse dries from finger tips down toward elbows. The nurse dries from forearms up toward fingers. The nurse keeps hands lower than elbows while washing. The nurse uses at least 3 to 5 mL of liquid soap.

The nurse dries from forearms up toward fingers. Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind? The current reimbursement system recognizes the family's nontechnical value priorities. Nurses should avoid asking the family caregivers to conduct the skilled task. Family caregivers are always perceived to be supportive of good care. The nurse needs to be creative in integrating the technical and relational aspects of care.

The nurse needs to be creative in integrating the technical and relational aspects of care.

A client says to a nurse, "I have trouble sleeping and wake up several times during the night." What instructions should the nurse provide to the client? Select all that apply. Walk quietly through the house. Do a relaxing activity such as meditation. Perform nonstrenuous exercises. Stay in bed with eyes closed. Watch TV.

Walk quietly through the house. Do a relaxing activity such as meditation.

The client is ordered heparin IV and the nurse questions if the dose of heparin is safe according to the client's age and weight. What actions should the nurse implement? Select all that apply. Administer the IV as ordered, but document concerns. Administer the IV heparin as ordered. Withhold the dose at this time. Call the health care provider and discuss concerns. Administer half the medication and document concerns.

Withhold the dose at this time. Call the health care provider and discuss concerns.

A client undergoing chemotherapy tells the nurse, "I don't want to get out of bed in the morning because I'm so tired." What information should the nurse include in the care plan? education on the use of filgrastim. individually tailored exercise program. weight lifting when not experiencing fatigue. bed rest until chemotherapy is completed.

individually tailored exercise program.

The nurse needs to renew a registered nurse license. What evidence of competence may be required with each license renewal? Select all that apply. providing evidence of continuing education submitting to a criminal background check retaking the national license examination providing evidence of practice hours submitting an employee evaluation

providing evidence of continuing education submitting to a criminal background check

The nurse is placing patches on both eyes of client with detachment of the retina. What is the expected outcome of patching? decreased irritation caused by light entering the damaged eye reduced rapid eye movements protection of the injured eye from infection minimized eye strain on the uninvolved eye

reduced rapid eye movements Patching the eyes helps decrease random eye movements that could enlarge and worsen retinal detachment. Although clients with eye injuries frequently are light sensitive, and preventing infection is important, the specific goal is to reduce rapid eye movements. Using the uninvolved eye would not cause eye strain, but random movements of one eye will involve the other eye.

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 keep the area covered with the warm soaks. remove the warm compress for at least 15 minutes after each 20-minute application. alternate warm compresses with cold compresses. question the order because heat increases edema.

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

Which positioning technique is most effective when there is only one person to assist the client to move from the left side to the right side if the client has hemiparalysis? rolling the client onto the side sliding the client to move up in bed lifting the client when moving the client up in bed having the client help lift off the bed using a trapeze

rolling the client onto the side

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 sitting on the toilet." "I will administer the enema while lying on my left side with my right knee flexed." "I will administer the enema while lying on my right side with my left knee flexed." "I will administer the enema while lying on my back with both knees flexed."

"I will administer the enema while lying on my left side with my right knee flexed." Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? "I will have orange juice, farina, and coffee." "Today I can have apple juice, chicken broth, and vanilla ice cream." "For breakfast I will choose pineapple juice, a bran muffin, and milk." "I can have oatmeal, custard, and tea."

"Today I can have apple juice, chicken broth, and vanilla ice cream."

In which circumstance may the nurse legally and ethically disclose confidential information about a client? A single client's human immunodeficiency virus (HIV) status to the family members A diagnosis of pancreatic cancer to a client's significant other A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency The fact that a woman is 32 weeks pregnant with twins to the partner from whom she is legally separated

A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency A nurse may lawfully disclose confidential information about a client when the welfare of a person or group of people is at stake. A healthcare provider must inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder; disclosing the condition is in the best interest of public safety and the client's well-being.

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate? Check the patency and amount of drainage from the NG tube. Administer an analgesic and antiemetic as ordered. Irrigate the NG tube with water and give an analgesic as ordered. Explain that nausea is common because the NG tube irritates the gag reflex.

Check the patency and amount of drainage from the NG tube.

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? Clean from the center outward in a circular motion. Remove the drain before cleaning the skin. Clean briskly around the site with alcohol. Wear sterile gloves and a mask.

Clean from the center outward in a circular motion.

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 has mild cognitive impairment. Client is being treated for a wound infection. Client needs minimal assistance to ambulate. Client is recovering from abdominal surgery.

Client is recovering from abdominal surgery.

The nurse is caring for a client who wishes to stop medical treatment. Which action by the nurse best demonstrates the role of the nurse as a client advocate? Ask the client what has lead to this decision. Inform family members of the client's wishes to stop treatment. Communicate the client's wishes to the healthcare provider. Encourage the client to continue with medical treatment.

Communicate the client's wishes to the healthcare provider.

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. Position the client on the left side. Warm the formula before administering it. Inject air into the feeding tube to verify placement.

Elevate the head of the bed.

A nurse is caring for a postsurgical client with two types of drains. Which activities can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Assess the drainage of an open drainage system, such as a Penrose drain. Document drain site and surrounding tissue status. Stabilize an open drainage system, such as a Penrose drain. 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.

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 client has a risk for skin breakdown due to incontinence. Which nursing actions for the client will help with decreasing this risk? Select all that apply. Have scheduled toileting every 2 hours. Cleanse the perineal area daily and after each incontinent episode. Encourage the client to decrease fluid intake. Apply adult briefs for the client and change every 8 hours. Maintain a voiding record to determine any patterns of incontinence.

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

What should the nurse do to ensure safety for a hospitalized blind client? Require that the client has a sitter for each shift. Request that the client stays in bed until the nurse can assist. Orient the client to the room environment. Keep the side rails up when the client is alone.

Orient the client to the room environment.

The nurse is placing an intravenous (IV) catheter in a client who has a risk of impaired skin integrity due to dehydration. Place the steps in order for this procedure. All options must be used. 1 Palpate and select an appropriate vein. 2 Cleanse client's skin with an antiseptic. 3 Hold skin taut 1-2 inches below the site. 4 Insert catheter and observe for blood return. 5 Stabilize catheter and flush with saline.

Palpate and select an appropriate vein. Cleanse client's skin with an antiseptic. Hold skin taut 1-2 inches below the site. Insert catheter and observe for blood return. Stabilize catheter and flush with saline.

The client is wearing graduated compression stockings and begins to report leg pain in the right leg. Place the steps in order taken to accurately assess this client. All options much be used. 1 Remove the stockings. 2 Assess the skin for redness and the leg for swelling. 3 Assess for warmth discrepancies in both legs. 4 Measure the calves of both legs. 5 Notify the healthcare provider.

Remove the stockings. Assess the skin for redness and the leg for swelling. Assess for warmth discrepancies in both legs. Measure the calves of both legs. Notify the healthcare provider.

The nurse walks into the room of a client who has a "do not resuscitate" prescription and finds the client without a pulse, respirations, or blood pressure. What should the nurse do first? Stay in the room, and call the nursing team for assistance. Push the emergency alarm to call a code. Page the client's health care provider (HCP). Pull the curtain, and leave the room.

Stay in the room, and call the nursing team for assistance.

In addressing health promotion for a patient who is a member of another culture, the nurse should be guided by which principle? Health promotion is a concept that is largely exclusive to American culture. A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development. The client may have a very different understanding of health promotion. The nurse should avoid performing health promotion education if this is not a priority in the client's culture.

The client may have a very different understanding of health promotion.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client rinses around the clean incision site, using gauze squares moistened with normal saline. The client rinses around the clean incision site, using gauze squares moistened with tap water. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.

The client rinses around the clean incision site, using gauze squares moistened with normal saline.

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 battery negligence right to refuse care

assault

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? by providing a tracheostomy plug to use for verbal communication by placing the call button under the client's pillow by supplying a magic slate or similar device by suctioning the client frequently

by supplying a magic slate or similar device

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination? changing gloves immediately after use standing 2 feet (61 cm) from the client speaking minimally when in the room wearing protective coverings

changing gloves immediately after use

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? compression lavage decompression gavage

decompression After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointestinal tract until peristaltic action returns. Compression may be used to control bleeding esophageal varices. Lavage is used to remove substances from the stomach or control bleeding. Gavage is used to provide enteral feedings.

When bandaging a client's ankle, the nurse should use which technique? figure-eight circular recurrent spiral reverse

figure-eight

A nurse is helping a client move up in the bed. Which action maintains good body mechanics? always keeping the bed in a low position having the client fold the arms across the chest raising the head of the bed having the client help as much as possible

having the client help as much as possible

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly identifying who will be responsible for making client care decisions deciding what type of dress code per nursing department will be implemented identifying salary ranges for various types of staff

identifying who will be responsible for making client care decisions

The nurse works in an institution that expects nurses to initiate referrals to social or spiritual resources. What might trigger a nurse to initiate such a referral? Select all that apply. impending death family conferences a client expressing a cultural concern a client requesting occupational therapy a client requesting time alone

impending death family conferences a client expressing a cultural concern

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury? moving close to the object leaning forward toward the object using the arms and legs to lift the object bringing the body close to the level of the object

leaning forward toward the object

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? nasal cannula venturi mask simple mask nonrebreather mask

nonrebreather mask A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

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? primary prevention secondary prevention tertiary prevention passive prevention

primary prevention

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality? potassium sodium chloride calcium

sodium Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM? functional nursing case management team nursing primary nursing

team nursing Team nursing is efficient and less costly to implement than primary or case management systems. Because staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost-effective, care is commonly fragmented and clients are less satisfied. Case management and primary nursing require more registered nurses than are available.

A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. the student nurse the nursing instructor the assigned nurse the physician the dietician

the student nurse the nursing instructor the assigned nurse

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? use of protective goggles during a cesarean birth placement of bloody sheets in a container designated for contaminated linens wearing of sterile gloves to bathe a neonate at 2 hours of age disposal of used scalpel blades in a puncture-resistant container

wearing of sterile gloves to bathe a neonate at 2 hours of age