FON: Final

A nurse is reinforcing teaching with an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

"I will wear gloves and a gown when bathing a client who has open skin lesions."

A nurse is reinforcing discharge teaching with a client who has Acquired Immunodeficiency Disorder Syndrome. Which of the following statements should the nurse make regarding home infection control?

"I'll clean up blood spills immediately with hot water."

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

"As long as I change my gloves between clients, it is not necessary to wash my hands."

A nurse is caring for a client following the surgical placement of a colostomy. Which statement by the client indicates an understanding of the dietary teaching for client with colostomy?

"Eating yogurt can help decrease the amount of gas that I have."

A nurse is reinforcing teaching for with a client about healthful sleep habits. Which statement should the nurse identify as an indication that the client needs further instructions? Study about improving sleeping pattern.

"I watch television until I fall asleep at night."

A nurse is reinforcing teaching about pain control with a client who has acute pain following a subtotal gastric resection. Which client statement indicates an understanding of pain control? Study about pain management using pharmacologic and non-pharmacologic modalities.

"I will call for pain medication before the previous dose wears off."

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will place a bath seat in my shower to use when I bathe. Rationale a bath he can reduce slipping and falling in the bathtub or shower"

A nurse is reinforcing teaching with a client who has stomatitis (mouth or chancre sore/cold sore). Which of the statement by the client indicates a need for further teaching? What does stomatitis indicates?

"I will season foods with dried spices before cooking" (Stomatitis, a general term for an inflamed and sore mouth)

A home health nurse is conducting a home-safety risk appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client?

Water heater temp. 54.4 degree celcius (130 degree fahrenheit) Throw rugs

A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which statements should the nurse give? How should the nurse response to this statement by the patient?

"I'll notify the charge nurse of your request to have only male staff members assigned to care for you"

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which statement response is appropriate from the nurse? Study about therapeutic communication.

"It sounds like you're having a difficult time."`

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which statement by the client indicates the need for further teaching?

"It's unfortunate that I have to be in the hospital for this treatment"

A nurse is reinforcing teaching with a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

"Make sure the client wash their hands before they eat."

An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

"Wear "Wear mask when entering the client's room." (surgical)

A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

"i will move the tube so he cannot see it. (moving the tube so it is not within the clients visual field is an appropriate distraction technique)"

A nurse is planning a diet for a client who has an iron deficiency. To increase the client's iron intake, which foods should the nurse provide in the client's diet?

(can't find but here are food high in iron) Oranges and dark green leafy vegetables, Apricots red meat, oysters kidney beans, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

(cannot find it but here's info) - If the nasogastric tube is in the stomach, the pH of the contents will be acidic & should be 3.5 or lower.

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a prescription for a chest x-ray. Which of the following priority actions should the nurse plan to take?

(cannot find) check for metal? or tattoos?

A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take? Look for what is passive needle-safety device.

(passive design is a safety mechanism that deploys automatically during use.) (i can't find the answer but here's info) Never recapping needles that have been used. Utilizing needles with passive safety devices. Utilizing a one-handed scoop method for recapping a needle. Breaking an ampule by bending the top toward the nurse.

A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which foods should the nurse instruct the client to include in his daily diet? Cabbage ​Cheddar cheese White rice ​Bananas

*Bananas

A nurse is reinforcing teaching about a high-fiber diet with a client who has constipation. Which statement indicates the client understands the best choice for a high-fiber diet? Study food high in fiber.

- "My breakfast choice is ½ cup of bran cereal."

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Which steps concerning emergency actions should the nurse must take?

- RACE: Remove clients; Activate fire alarm/ call 911; Contain the fire by shutting doors, etc.; Extinguish fire using extinguisher.

A nurse is collecting data regarding the pain level of a 3-year-old child on the second postoperative day following an appendectomy. Which of priority actions should the nurse take?

- Use the FACES scale to assess the child's pain.

A nurse is reinforcing discharge teaching with a client who had a total hip arthroplasty. Which of the following information should the nurse include in the teaching? (select all apply)

-clean the incision daily with soap and water -sit in a straight-back armchair -use a raised toilet seat

A nurse is caring for a group of clients. For which of the following tasks should the nurse wear gloves?

-empty urine from an indwelling collection bag -providing oral care -changing ostomy bag

A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow.

1. perform hand hygiene 2. place package on work surface 3. open outermost flap away from self 4. open side flap, pulling to the side 5. open innermost flap toward self 6. use inner surface of package as sterile field

1.) A nurse is reinforcing discharge teaching with a client who is receiving intermittent enteral feedings through a gastrostomy tube. Study about care for client receiving enteral (NGT or GT feeding). another question: 2.) A nurse is reinforcing discharge teaching with a client who is receiving intermittent enteral feedings through a gastrostomy tube. Which of the following client statements requires further teaching by the nurse? 3.) A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

1.) D. The nurse allows the client to rest in a supine position during feeding 2.)"I can crush and mix my medication with my formula." 3.) test the pH of gastric aspirate

There's two that i found so i just put both: 1.) As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of priority actions should the nurse take? 2.)A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

1.) Leave a night light on in the client's room 2.) - Brace all side rails on the clients bed. - Obtain a prescription to restrain the clients PRN. - Check on the client hourly- Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg

A nurse is calculating the fluid intake for an infant patient at the end of an 8-hr shift. The nurse should record how many mL of intake on the client's record. i can't find but here's another question similar: A nurse is calculating the fluid intake for an infant at the end of an 8-hr shift. For oral intake, the infant had 10 mL of medication, 3 oz of formula, and 2 oz of juice. In addition, the infant had IV fluid infusing at 20 mL/hr via an IV pump. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)

320

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

When the client moves, he should move the cane forward first

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

A. Keep the box close to his body as he lifts.

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

Airborne (negative pressure room)

A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations that the client has an infection?

An increase in neutrophils. Localized edema

A nurse is reinforcing teaching with a client who has neutropenia. Which of the following priority instructions should the nurse include in the teaching?

Avoid crowded places

A nurse is preparing a sterile field. Which of the following actions should the nurse take first?

B. Reach around the pack and open the top flap away from the body (Follow sterile technique during the procedure.)

A nurse is planning to reinforce teaching with a client about the need to follow a low-potassium diet. Which foods should the nurse instruct the client to avoid?

Yogurt & orange juice

A nurse is reinforcing teaching with a client who has strained her back muscles while preparing to move to a new apartment. Which priority instructions should the nurse include?

Bend at the knees when picking up an object. Rationale bending at the knees help the client maintain her center of gravity then when she lives in the object, she should use her leg muscles, not her back muscles, to lift it.

A nurse on a unit is caring for a client who asks to review his medical record. What would be the appropriate response the nurse should make?

You will have to sign a written request for access to your record

A nurse is caring for a client who is threatening to commit suicide. Which appropriate assessment questions should the nurse ask? Study about therapeutic communication.

Can't find but here's info: When questioning the client about suicide, always use a follow-up question if the first answer is negative. For example: the client says, "I'm feeling completely hopeless." The nurse says, "Are you thinking of suicide?" Client: "No, I'm just sad." Nurse: "I can see you're very sad. Are you thinking about hurting yourself?" Client: "Well, I've thought about it a lot."■ Establish a trusting therapeutic relationship.■ Limit the amount of time an at-risk client spends alone.■ Involve significant others in the treatment plan.■ Carry out treatment plans for the client with comorbid disorders, such as a dual diagnosis of substance abuse.

A nurse is caring for an older adult client who has dysphagia and left- sided weakness following a stroke. Which of the following priority action should the nurse take?

add thicker to fluids

A nurse is caring for a client who has schizophrenia and begins to talk about fantasy subjects. Which priority intervention by the nurse is appropriate? How are you going to response to a client with hallucination or delusion to ensure safety?

Encourage the client to focus on reality-based issues

A nurse is caring for a client who has a cognitive impairment and repeatedly pulls on his NG tube. Which of the priority interventions should the nurse consider before requesting a prescription for restraints? (select all apply)

b.assist the client with toileting at frequent intervals c.use of an electronic position-sensitive device d. provide diversionary activities for the cliente.involve the family in the client's care.

A nurse observes an assistive personnel (AP) entering the room of a client who is under contact precautions without wearing personal protective equipment (PPE). Which of the following priority action should the nurse take?

Give the AP the appropriate PPE

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections? Think of types of infections.

HCI (health care associated infection

A nurse is preparing an in-service about HIV for a group of newly hired assistive personnel. Which priority statement should the nurse include about HIV transmission?

HIV is transmitted through contact with infected body fluids.

A nurse is reinforcing teaching with a client about following a low- cholesterol diet after coronary artery bypass grafting. Which food choices reflects the client's understanding of these dietary instructions? Study foods considered of non-saturated fats classification.

beans

A nurse is planning care for a group of clients. When planning the assignment for an assistive personnel (AP), which activities should the nurse consider unsafe for the AP to perform? Study what can be delegated to an AP. A. Assisting an older adult client to take acetaminophen (Tylenol) crushed in applesauce. B. Administering a cleansing enema to a client who is preoperative. C. Obtaining a urine specimen for a urinalysis from a newly admitted client. D. Obtaining the vital signs of a client admitted with a history of angina.

I don't know this one but there's another similar question and this is the answer: Observe a confused surgical client who has multiple tubes

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which statement should the nurse identify as an indication that the client needs further reinforcement of teaching? Study about crutch walking instructions for patient.

I have a set of my brother's crutches in my basement I can also use.

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. What actions are necessary to keep the patient safe?

I will avoid crossing my legs for the first 3 months after surgery

A nurse is reinforcing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I will wear synthetic clothing and woolen socks when using my oxygen

A nurse is reviewing the prescriptions for a client who had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?

Instruct the client to restrict flexibility of the hip past 120°

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Irrigating a client's abdominal wound is correct. The nurse should wear protective eyewear when irrigating a wound because wound exudate and fluids could splash into her eyes. and Suctioning a client's new tracheostomy tube is correct. The nurse should wear protective eyewear when performing tracheal suctioning because the client's secretions could splash into her eyes.

A nurse on a medical unit is reinforcing teaching with a group of assistive personnel about handling clients' bed linens safely. Which priority instructions should the nurse include?

Tie linen bags securely at the top

A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator mask when caring for a client who has which of the following disorders?

Tuberculosis measles

A nurse has accidentally punctured his fingers with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Wash the puncture site with soap and water.

A nurse is planning to reinforce teaching with a client who has hemorrhoids. Which information should the nurse plan to include in the instructions? Study care for client with hemorrhoid and constipation.

Follow a high-fiber diet to establish bowel regularity (because hemorrhoids are swollen veins, often resulting from straining during bowel movements due to constipation. The nurse should encourage clients to follow high fiber diet to promote regular, soft stool.)

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Opening a sterile package over the middle of the sterile field

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client's infection? Think of the Infection Cycle.

Performing hand hygiene before, during and after direct contact with the client.

A nurse is reinforcing teaching with a group of assistive personnel (AP) about infection control measures on the unit. The nurse should remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequency and consistently

a nurse is caring for a client who is suspected to have laryngeal tuberculosis (TB). What priority action should the nurse plan to take to safely care for this client?

Place the client in a private room with a special ventilation system

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which method should the nurse use when disposing of the soiled dressing?

Place the dressing in a biohazardous waste container

A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needle stick injuries. Which of the following actions should the nurse recommend?

Place uncapped needles in a puncture-proof container after use.

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?

Provide the client a diet high in vitamin C.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include?

Relief of urinary retention Measurement of residual urine after urination Presence of an open perineal wound

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. What foods should the nurse select as a component of the client's meals?

Steamed vegetables

A nurse is reinforcing teaching with a middle-age client who is at high risk for osteoporosis and is taking oral calcium gluconate. Which instruction should the nurse include in the teaching?

Take vitamin D supplements

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should monitor the client for which expected outcomes after catheter removal?

Temporary urinary retention (Until the bladder regains its full tone, it is common for clients to develop urinary retention, If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.)

A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the priority finding indicates that the client is meeting this goal?

The client slides an object across the floor rather than lifting it.​Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. Other: - client should keep back straight and bend at the knees - client should keep feet wide

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which criteria should the nurse include in applying restraints?

The nurse has already considered alternatives to restraints: Restraints physically prevent a client from moving freely in the environment.

A charge nurse is observing a staff nurse caring for a client who has multiple skin lesions from a varicella zoster infection. What priority action should the charge nurse identify as an indication that the nurse understands the precautions to take when caring for a client who has this infection?

The nurse wears a high-efficiency particulate air (HEPA) filter mask

A nurse is reinforcing teaching with a group of clients about first aid care for a bee sting. Which information should the nurse reinforce in the teaching?

can't find but heres info: If you can, remove the stinger as soon as possible, such as by scraping it off with a fingernail. ... Wash the affected area with soap and water. Apply a cold compress. Take an over-the-counter pain reliever as needed. ... If the sting is on an arm or leg, elevate it.

A nurse is caring for a client who is HIV positive and is 1 day postoperative following an appendectomy. Which of the following actions requires the nurse to wear a gown as personal protective equipment(PPE)?

changing a wound dressing

A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. The nurse should explain which food sources contains iron that is most easily absorbed by the body?

chicken

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

close the curtains around the client's bed

A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which priority intervention should the nurse include in the plan of care?

d. Limit the number of health care workers entering the room.

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

describe the environment to the client (make sure they're close to nurse's station.)

A nurse is contributing to a teaching plan about the prevention of hepatitis A. The nurse should include that which of the following activities can spread hepatitis A? Study about Hepatitis A and how can you be protected from it?

eating uncooked food

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following priority instruction should the nurse include in the teaching?

empty the ostomy pouch when it is 2/3 full

A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following priority nursing measures should the nurse implement?

get the client to sleep at the same time each night.

A nurse has completed morning care for a client who requires airborne precautions. Which personal protective equipment (PPE) should the nurse remove first?

gloves

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 reclining chair. Which physiological responses to prolonged immobility should the nurse expect?

increased calcium excretion

A nurse is working a night shift and caring for several clients at risk for falls. Which priority patient situation and actions should the nurse take?

instruct client to use call lightplace fall risk band on each of the clients

A nurse is preparing to help with transferring a client who can partially assist to a gurney. Which priority action should the nurse take?

lower the head of the bed

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment is should the nurse wear when caring for the client?

mask

With whom should a nurse share her password for access to the facility's computer system? -no one -the nurse manager -the facility's information system representative -the unit clerk

no one

A nurse is removing an isolation gown that has waist ties in the front after caring for a client who requires contact precautions. Which of the following steps should the nurse take?

remove the gloves and unties the neck ties (in order of: remove gloves, gown, eyemask, surgical mask)

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which priority action should the nurse take?

reposition the client at least every 2 hrs

A nurse enters a client's room and sees smoke coming from the client's trash can. Which of the following priority action should the nurse take first?

rescue the client from immediate danger.

A nurse delegates the application of wrist restraints for a client who is confused to a CNA. The CNA padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

retie the restraint straps with a slipknot check circulation

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client?

standard precautions

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

surgical mask/mask

A nurse is preparing to transfer a client from a bed to a chair. Which of priority action should the nurse take?

the nurse counts to three

A nurse is reinforcing teaching with a community group about the prevention of viral hepatitis (Hepatitis A). Which of the following information should the nurse include in the teaching?

thoroughly cook foods prepared with tap water

A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of menu choices should the nurse recommend? What food examples should be included.

turkey and cheese sandwich with scalloped potatoes

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following priority action should the nurse take?

turn the client on his side before starting oral care

While collecting data from an older adult client, the nurse learns that the client has had difficulty sleeping at night for several months. When evaluating the client's sleep disturbances, the nurse should factor in which of the principles that can affect older adults and sleep?

turn the client on his side before starting oral care

A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

wear an N95 respirator mask

A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who had an episode of urinary incontinence in bed and is now sitting up in a chair. Which action by the AP indicates the need for the nurse to intervene? Study on caring for incontinent patient.

which is over the bed to straight in the fitted sheet

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the interventions should the nurse use to help maintain the client's skin integrity?

​Provide the client with a diet high in protein.​Inadequate protein, iron, vitamins, and calories increase the risk for skin breakdown.