Chapter 8 and 9 quizlet

the nurse applies wrist restraints prescribed to prevent a client from putting out nasogastric tube how should the nurse determine that the restraints are not too constrictive?

place two fingers under the restrain to determine snugness

a nurse is planning care for a client who devlops dyspnea and feels tired after completing her morning care. which of the following actions should the nurse include in the clients plan of care ?

schedule rest periods during morning care

the nurse should institute which interventions for a client diagnosed with c-dif?

wear gloves and gown while in the room caring for the client. use soap and water, not alcohol-based hand rub and hand hygiene

A nurse is reinforcing teaching with a client about hand hygiene. Which of the following client statements indicates a need for further teaching?

"I should wash my hands until they appear clean."

Warm water tub bath

-given to reduce muscle tension -water temp 105f degrees

the nurse is caring for a client with a health care associated infection caused by meticillin-resistant staphylococcus aureus contact precautions are prescribed for the client the nurse prepares to irrigate the wound and apply a new dressing. which protective interventions should the nurse use to perform the procedure?

1.put on a mask 2. don gown and gloves 4. wear a pair of protective goggles

the nurse is assisting with planning care for a client with an internal radiation implant which should be included in the plan of care?

1.wearing gloves when emptying the clients bedpan 2.keeping all linens in the room until the implant is removed. 3 wearing a film dosimeter badge when in the client's room wearing a lead apron when provided direct care to the client

Cool water tub bath

98.6 -Relieves tension -Lower body temperature

A nurse is assisting a client with range-of-motion exercises of the thumbs. Which of the following terms should the nurse document when the client extends his thumb to the side, away from his hand?

Abduction

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client bending her head backward as far as it will go?

Hyperextension

A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?

Keep the client's personal items within reach.

A nurse is preparing to lift a box of supplies in the supply room. Which of the following body mechanics should the nurse plan to use?

Keeping the box close to his body as he lifts it

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client tilting her head sideways and downward toward one shoulder and then the other shoulder?

Lateral flexion

a nurse is beginning a complete bed bath for a client, after removing the clients gown and placing a bath blanket over him which of the following areas should the nurse wash first ?

Face

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

Flexion

A nurse is reinforcing teaching with a client who has a neck injury. When describing range-of-motion exercises, the nurse should explain that the neck is which of the following types of joints?

Pivot

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. which of the following bed positions should the nurse use for safe care of the client?

Semi-Fowler's

A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Transparent

the nurse enters a clients room and finds that the wastebasket is on fire. the nurse quickly assists the client out of the room. Which is the next nursing action?

activate the fire alarm

Hot water tub bath

113-115 -relieves muscle soreness and muscle spasms

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client reaching across her body toward the opposite side of the bed?

adduction

a nurse is preparing to perform denture care for client which of the following actions should the nurse plan to take?

brush the dentures with a toothbrush and denture cleaner

A mother calls a neighborhood nurse and tells the nurse that her 3 - year old child has just ingested liquid furniture polish. which action should the nurse instruct the mother to take first ?

call the poison control center.

A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client bending her wrist upward in the direction of the outer surface of the forearm?

extension

A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client making a fist with her hand?

flexion

A nurse is assisting a client with range-of-motion exercises of the feet and ankles. Which of the following terms should the nurse use when documenting the client turning the sole of her foot inward and aligning it with the body's midline?

inversion

a nurse is performing mouth care for a client who is unconscious which of the following actions should the nurse take ?

turn the clients head to the side

a licensed practical nurse (lpn) attends a session about bio-terrorism agents including anthrax which statement by an attendee demonstrate the need for further teaching about anthrax?

anthrax bacteria produces a neurotoxin leading to a serious. possibly fatal paralysis .

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching ?

b. "lower my center of gravity the more stability i have" c. " to broaden my base of support, i should spread my feet apart" D. " when i lift an object, i should hold it as close to my body as possible"

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night ?

sit on the side of her ed and rest her arms over pillows on top f her bedside table.

the emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. which should be the initial nursing action ?

Activate the agency emergency response plan

the nurse enters the nursing lounge and discovers that a chair is on fire the nurse activates the alarm closes the lounge door, and obtains the fire extinguisher to extinguish the fire. the nurse pulls the pinon the fire extinguisher which is the action should the nurse perform

Aim at the base of the fire

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her

the nurse obtains a prescription to restrain a client using a belt safety restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint which observation if made by the nurse indicates unsafe application of the restraint?

a safety knot is made in the restraint strap

sitz bath

a warm soak of the perineal area to clean perineal wounds and reduce inflammation and pain child birth

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

A reddened area over the sacrum

nurse manager is reviewing guidelines for preventing injury with staff nurses. which of the following instructions should the nurse manager include?

A. request assistance when repositioning a client b. avoid twisting your spine or bending at the waist. D. use smooth movements when lifting and moving clients

A nurse is reinforcing infection control practices for hand hygiene with a group of unit nurses. Which of the following information should the nurse reinforce in the teaching?

Change gloves between tasks on the same client

A nurse is orienting a new assistive personnel (AP) to the unit. Which of the following actions should the nurse identify as an indication that the AP needs further instruction?

Washes and rinses her hands for 10 seconds

a nurse is instructing a client who has diabetes mellitus about foot care. which of the following guidelines should the nurse include?

1. inspect the feet daily 2. use moisturizing lotion on the feet 3. wear cotton socks

An older adult client falls and fractures her hip while a nurse is assisting her to the bathroom. The client sues the nurse for negligence. The nurse should identify which of the following principles as the standard that will legally determine her liability for the client's injury?

Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

Determine the client's ability to help with the transfer