concept

a home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. which of the following information should the nurse include in the plan of care?

"rest in semi-fowler's position"

a nurse is contributing to the plan of care for a client to achieve the outcome of functional healing of a fracture. which of the following nursing interventions is the highest priority to assist in the meeting this outcome?

maintain immobilization and alignment for the client

a patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. the patient asks the nurse to describe how this pain relief method works. the nurse should reply that biofeedback involves

measuring skin tension and using learned techniques to relieve pain

a nurse is caring for a client who has a hearing loss in her left ear. which of the following nursing actions should the nurse take?

minimize background noise to decrease distractions.

a nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. the initial assessment reveals long-term use of opioids for chronic pain. which of the following provider prescriptions for initial pain relief should the nurse question?

pentazocine (Talwin)

a nurse is collecting data from an older adult client who has a femoral head fracture 24 hours ago and is in Buck's traction. which of the following findings is an indication of fat embolism syndrome?

petechiae on the chest

a nurse is collecting data on a client who has a femur fracture. which of the following findings is a manifestation of fat embolism syndrome?

petechiae over the client's chest

a nurse is caring for a client who is unconscious and has lost the corneal reflex. which of following actions should the nurse take?

place a patch over the eye

a nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. which of the following actions is appropriate to prevent hip dislocation?

place a wedge pillow between the legs

a nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured mandible. the client's jaw is wired shut to repair and stabilize the fracture. the nurse should recognize which of the following is the priority action?

prevent aspiration

a client who is postoperative returns to the unit in skeletal traction. when collecting data from the client, the nurse should expect which of the following findings?

redness at the pin sites, warmth at the pin sites

a nurse is caring for a client who has a new below the knee amputation. which of the following actions should the nurse take?

rewrap the stump 3 times a day

a nurse is attempting to obtain information from a child who is hearing impaired. which of the following actions should the nurse take?

speak slowly while facing the child

a nurse at an outpatient surgery center is reinforcing discharge teaching with a client's partner following surgical removal of a cataract. which of the following information should the nurse include in the teaching?

the client should wear dark glasses while outside.

a nurse is collecting data from a client who has a suspected cataract. the nurse should collect data from which of the following areas to confirm the diagnosis?

the lens of the client's eye

a client returns to the surgical unit from the PACU in skeletal traction. the nurse should take action to correct which of the following problems with the tractions setup?

the weight rest against the foot of the bed

a nurse is about to use the Wong-Baker FACES pain scale to assist a patient in assessing his pain level. Which of the following should the nurse know in order to use this pain scale?

this scale is useful for adult patients who have cognitive impairments

a nurse is collecting data from an infant who has otitis media. the nurse should expect which of the following findings?

tugging on the affected ear lobe

a nurse at an urgent care center is reinforcing information with a new employee about the difference between sprains and strains. which of the following examples should the nurse include as a cause of sprain injury?

twisting a ligament while walking

a nurse is assisting with the preparation plan for a client ho has vision loss. which of the following strategies should the nurse include in the plan?

use of auditory or tactile materials

a nurse is caring for a client who is postoperative following a below the knee amputation and will soon undergo a fitting for a leg prosthesis. which of the following is an appropriate nursing intervention for the client at this time?

wrap the stump with an elastic bandage in a figure-eight configuration

a nurse is elevating discharge instructions for a client following a right cataract extraction. which of the following client statements indicates the teaching is effective?

"i will take a stool softener until my eye is healed"

during a pain assessment, a nurse asks questions about the quality of an adult patient's pain. which of the following statements by the patient refers to pain quality?

"my pain feels like i'm being stabbed by a knife"

a nurse in an urgent care center is caring for a client who has a forearm fracture. the parent tells the nurse that the provider said it was a greenstick fracture and asks what that means. which of the following descriptions should the nurse provide?

"the bone cracked lengthwise but didn't break all the way through"

a nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. which of the following statements should the nurse include in the teaching?

"this test will measure the intraocular pressure of the eye"

a nurse is reinforcing teaching with a client who has glaucoma. which of the following statements should the nurse make?

"without treatment, glaucoma can cause blindness"

a nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. which of the following statements by the client indicates an understanding of the teaching?

"i should call the clinic before taking any over the counter medications

a nurse is reinforcing teaching with a client who has chronic open angle glaucoma. the client has been prescribed pilocarpine ophthalmic solution. which of the following statements by the client demonstrates an understanding of the teaching?

"i should expect to have burred vision for up to two hours after using this medication"

a nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction. which of the following statements by the client indicates an understanding of the teaching?

"i will bend at the knees if i need to pick something up off the floor"

a nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. which of the following statements should the nurse make?

"Russell's traction uses a sling under the knee to treat a fracture of the femur"

a nurse is caring for a 3 year old client who has persistent otitis media. to help identify contributing factors, the nurse should ask the parents which of the following questions?

"does anyone smoke in the same house as your daughter?"

a nurse is reinforcing teaching about cast care to a school age child following application of a fiberglass cast for a radius fracture. which of the following statements by the child indicated an understanding if the teaching?

"i can put an ice pack on the area of my cast that itch"

a nurse is caring for a client who just had cataract surgery. which of the following comments from the client should the nurse report to the provider?

"i need something for the horrible pain in my eye."

a nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction from the left eye with placement of an intraocular lens implant. which of the following statements by the client indicates a need for further teaching?

"i will change my eye patch dressing every other day"

a nurse is reinforcing teaching with the mother of a 2 month old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia. which of the following statements by the mother indicates an understanding of the teaching?

"i will check my baby's skin three times each day"

a nurse is caring for a client who is postoperative following a right total hip arthroplasty. in which of the following positions should the nurse place the client's right leg?

abduction

a nurse is preparing to administer ear drops to a 2 year old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. which of the following techniques should the nurse use when instilling the medication?

apply clean gloves and clean the outer ear prior to instilling drops

a nurse is preparing to administer ofolxacin otic drops to an adult client who has otitis externa. which of the following actions should the nurse take?

apply gentle pressure with finger to the tragus of the ear

a nurse is reinforcing discharge teaching with a client following a cataract extraction. which of the following should the nurse include in the teaching?

avoid bending at the waist

a nurse is caring for a client who has a new diagnosis of primary open-angle glaucoma and a prescription for timolol ophthalmic drops. for which of the following adverse effects should the nurse monitor the client?

bradycardia

a nurse is preparing a 4 year old child for discharge following a bilateral myringotomy with tympanostomy tube placement. the mother asks what to do if the tube fall out. the nurse should give the parent which of the following instructions?

call the health care clinic to report that the tubes have fallen out

a nurse is caring for a patient just transferred from the PACU following an abdominal hysterectomy. The patient is receiving PCA with IV morphine sulfate 2mg every 15 min with a 30 mg/4hr lockout. one hour after the patient has returned to the unit, the patient tells the nurse that her pain is still unbearable. the nurse checks the PCA monitor and determines that the patient has made six attempts within the last hour. which of the following actions should the nurse take after performing a pain assessment?

check the IV site and PCA pump for proper functioning

a nurse is caring for two patients of different cultural backgrounds. both patients returned from the same type of surgery 2 hr ago. which of the following should the nurse expect to be the same for both patients?

class of medication to treat acute postoperative pain

a nurse is monitoring a client for complications of immobility. which of the following findings should the nurse expect?

contractures of extremities, crackles in the lungs, pressure ulcers

a nurse is caring for a client who has a fractured tibia and is in a cast. which of the following findings is a manifestation of compartment syndrome?

decreased capillary refill

a nurse is collecting data from a client who has a possible cataract. which of the following manifestations should the nurse expect the client report?

decreased color perception

a nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. which of the following actions is the nurse's priority?

describe the environment to the client

a nurse is admitting a client who has a partial hearing impairment. which of the following actions is the nurse's priority?

determine if the client uses a hearing aid

a nurse is planning to instill ear drops to a toddler and must straighten the ear canal by pulling the auricle of the ear. the nurse should plan to pull the auricle in which of the following directions?

down and backward correct technique for infants and children under 3

a nurse is reinforcing teaching with a client who has an ankle sprain. which of the following instructions should the nurse include?

elevate the affected ankle to the level of the heart

a nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. which of the following actions should the nurse take?

elevate the head of the bed.

a nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. which of the following actions should the nurse take?

ensure the affected extremity is resting at a 20 degree angle

a nurse is caring for a child who has Legg-Calve-Prethes disease and is in Buck's traction. which of the following actions should the nurse take?

ensure the rope knots are away from the pulleys

a nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. which of the following is a pain management protocol that should be used by the nurse in this situation?

have an opioid antagonist available during the administration

a home health nurse is caring for a client who has emphysema and has difficulty with mobility. the client spends most of his day in a relining chair. which of the following physiological responses to prolonged immobility should the nurse expect?

increased calcium excretion

a nurse is collecting data from a client who has open-angle glaucoma. which of the following findings should the nurse expect?

loss of peripheral vision

a nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of an intracular lens. which of the following should the nurse include?

lying on the unaffected side can prevent complications