Fundamentals Review
The nurse is interviewing a client who was admitted to the health care facility with difficulty breathing. When beginning the interview, the nurse observes that the client is too breathless to answer. What would be most appropriate for the nurse to do? Defer the non-urgent questions until a more suitable time. Make the client comfortable in Fowler's position. Administer oxygen and continue with the interview. Request that the client answer the question.
Defer the non-urgent questions until a more suitable time. Explanation: The nurse should collect information about urgent problems and defer other questions until a more suitable time. Sitting in Fowler's position may not ease the client's difficulty in talking. The nurse should administer oxygen and let the client rest, since interviewing may aggravate the client's condition. Requesting that the client answer the question to facilitate the care plan is incorrect because the client is having difficulty talking.
The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason? Detect abdominal masses. Determine abdominal firmness. Assess softness of abdominal muscles. Assess degree of abdominal distention.
Detect abdominal masses. Explanation: The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal distention.
A hospital nurse is coming on shift for a night shift and is receiving a change-of-shift report from a colleague. The colleague states that one client refused a prepared medication that was scheduled for 1800. The colleague has left the medication in a paper cup in the client's drawer on the medication cart and asks the nurse to administer the medication when the client goes to bed for the night. How should the nurse respond to this scenario? Check the five rights prior to administration and then give the client the medication at bedtime. Ask a pharmacist or pharmacy technician to confirm that the medication is correct before administering it. Ask the client if he recognizes the tablet and then administer it at bedtime. Discard the medication and administer a dose of the correct drug from a labeled container.
Discard the medication and administer a dose of the correct drug from a labeled container. Explanation: The nurse administers only those medications that he or she has personally prepared. Consequently, the nurse should appropriately discard the medication that the colleague had prepared and then prepare the medication independently.
A home care client has an indwelling catheter connected to a leg bag. What can the nurse recommend to help prevent development of a urinary tract infection? Empty the leg bag at regular intervals. Always wipe from front to back after voiding. Restrict intake of fluids to decrease amount of urine. Take the tubing apart and wash it each day.
Empty the leg bag at regular intervals. Explanation: Clients with indwelling catheters are at risk for the development of a urinary tract infection. A full drainage bag may cause reflux of urine into the bladder, increasing the risk of a urinary tract infection. Reference:
The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include? "The upper and lower thighs are your base of support." "Both of your feet should rest on the floor." "Cross your legs alternately throughout the day." "Keep your knees bent, with the backs of the knees against your chair."
"Both of your feet should rest on the floor." Explanation: Proper sitting posture includes using the buttocks and upper thighs as the base of support, keeping both feet resting on the floor and the knees bent, with the backs of the knees away from the chair to avoid distal circulation concerns. The other choices are unsafe practices.
The nurse is preparing to perform a nutritional assessment for a client. Which question would be most appropriate to use when initiating the assessment? "Did you eat breakfast today?" "How many meals do you eat each day?" "Can you tell me what you've eaten in the last 24 hours?" "How often do you eat out?"
"Can you tell me what you've eaten in the last 24 hours?" Explanation: The assessment should begin with questions regarding the client's dietary habits and should elicit information about average daily food and fluid intake. A 24-hour diet recall would be the best question to gather this information. Then the nurse can gather more specific data such as meals eaten, meal pattern, and other areas such as eating out.
How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation? "Client states, 'I don't see the point in trying anymore.'" "Client makes statements indicating a loss of hope." "Client states that rehabilitation will be unsuccessful." "Client is demonstrating signs and symptoms of depression."
"Client states, 'I don't see the point in trying anymore.'" Explanation: Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.
An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply. "Did you experience dizziness prior to the fall?" "Can you tell what you were doing before you fell?" "Did you have pain in your hip prior to the fall?" "Did you attempt to get up without the assistance of staff?" "Is it possible you may have tripped over a rug or a cord?"
"Did you experience dizziness prior to the fall?" "Can you tell what you were doing before you fell?" "Did you have pain in your hip prior to the fall?" "Is it possible you may have tripped over a rug or a cord?" Explanation: Falls can occur at any age. Hip fractures are among the most serious fall-related injuries. Fractures can cause pain, permanent disability, and even death. It is important to ascertain possible causes that led to the fall. Dizziness, cords, and rugs can increase the possibility of a fall. Asking the client about pain in the hip prior to the fall may indicate that it was a pathological fracture in the hip. Asking what the client was doing prior to fall will also help determine if there was an environmental factor causing the fall. Asking if the client attempted to get up without staff assistance is assuming that the client cannot ambulate on one's own.
The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask? "Why do you see so many different providers?" "Which provider seems to take the best care of you?" "Do you get all of your medications filled at the same pharmacy?" "How long have you been seeing a variety of providers?"
"Do you get all of your medications filled at the same pharmacy?" Explanation: Polypharmacy is a concern in the older adult population. The nurse will want to know if medications are filled at the same pharmacy, as this is often where pharmacists will note discrepancies in medications prescribed or duplicate orders written by different providers. The other questions posed are not helpful.
A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. What question would the nurse ask to assess for complications or side effects of chemotherapy related to skin, nails, or hair? "Have you noticed any changes in your skin color?" "Have you noticed a change in the texture of your hair?" "Have your mouth and lips become sore and inflamed with ulcers?" "Have your nails become dry and brittle?"
"Have your mouth and lips become sore and inflamed with ulcers?" Explanation: The nurse must be aware of side effects of chemotherapy, such as hair loss, stomatitis (inflamed and sore lips and mouth) and mouth ulcers, and hair loss. Hair will not particularly have a different texture until it regrows. The chemotherapeutic agents cause cellular death of the rapid cell division of the hair and gastrointestinal system. Most agents do not affect the skin or nails and do not cause excessive hair growth.
A nurse must perform an integumentary inspection on a client. Which statement most effectively explains why the nurse will be assessing the client's skin? "I will be inspecting your skin to determine if there are any conditions requiring treatment." "I will be inspecting your skin to report findings to your health care provider." "I am inspecting your skin to get a baseline of your skin and to check if any conditions require treatment." "I am inspecting your skin to get a baseline of your skin status."
"I am inspecting your skin to get a baseline of your skin and to check if any conditions require treatment." Explanation: The nurse should explain that inspecting the skin is performed to get a baseline as well as to determine if any conditions require treatment. All other answer options are partially correct but do not provide a complete answer by the nurse.
A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. Which would be most appropriate to include? "Store eyeglasses away from the bed at night to prevent breakage." "Make sure the client has socks on at bedtime in case of the need to use the restroom." "Install handrails in stairways and bathrooms." "Use small rugs in the bathroom to keep feet warm at night."
"Install handrails in stairways and bathrooms." Explanation: The nurse should ask the caregiver about the need to install handrails on stairways and in the bathroom for safe usage. Non-skid slippers should be used for nighttime trips to the bathroom. Eyeglasses should be kept at the bedside when not in use so the client can see pathways clearly. The nurse should encourage the older adult to use a nightlight in the bedroom, as this could help the client to find one's way should he or she need to get out of bed.
The nurse is assessing the skin of a veteran who has returned from deployment overseas. Which response by the nurse reflects the best strategy to gain cooperation of the client? "May I look at your skin to determine if there are any issues?" "Take off your clothes so I can look at your skin." "I need to look at your skin to see if you have any problems." "I am going to look at your skin now."
"May I look at your skin to determine if there are any issues?" Explanation: Asking permission to look at the client's skin and explaining why prepares the client for the assessment and may gain the clients cooperation. The nurse will need to consider the possibility of posttraumatic stress disorder (PTSD) or other emotional issues related to the client's military service. By directing the client and not explaining the assessment it is likely the client will resist the nurse.
A client in his 40s has asked the nurse how much sleep he should be getting in order to maximize his health and well-being. How should the nurse respond? "Most adults need between 7 and 9 hours, but everyone is different." "It's important to get a minimum of 8 hours sleep each night." "More sleep equals better health, so the more sleep you can fit into your schedule, the better." "Sleep needs depend a lot on age, and at your age, 6 to 7 hours usually suffice."
"Most adults need between 7 and 9 hours, but everyone is different." Explanation: Sleep needs and routines are highly individual, but most adults require between 7 to 9 hours of sleep.
The nurse is reviewing discharge instructions for a client who was prescribed amoxicillin to be taken twice a day. Which statement by the client would require further teaching? "If I develop a rash, I will contact my health care provider." "Once I start feeling better, I should stop taking the antibiotic." "I should store this antibiotic at room temperature away from excessive heat and moisture." "I can take this antibiotic on an empty stomach."
"Once I start feeling better, I should stop taking the antibiotic." Explanation: Causes of antibiotic drug resistant bacteria include prescribing antibiotics for viruses or self-limiting bacterial infections, not completing the full course of prescribed therapy, taking someone else's antibiotics, and sharing antibiotics with others. The nurse should instruct the client to continue taking the prescribed antibiotic even when feeling better. The client does not need additional instruction if he or she recognizes the need to call the health care provider if a rash develops or knows to store the antibiotic capsules at room temperature away from excessive heat and moisture. Taking an antibiotic on an empty stomach is not necessarily an indicator of the need for additional teaching. Some antibiotics can be taken or are required to be taken on an empty stomach. Not all antibiotics need to be taken with food or after eating.
A client who has been reluctant to have the hair shampooed for 1 week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." What response by the nurse is appropriate? "How often do you wash your hair?" "Tell me about what you do to take care of your hair." "Please tell me what products you use for washing your hair." "Tell me why you do not want me to wash your hair."
"Tell me about what you do to take care of your hair." Explanation: The client needs his or her hair washed to prevent infection and to promote adequate hygiene. The nurse should ask the client about usual personal hygiene practices and documents the client's responses. This will help the nurse determine the client's hair hygiene routine and how it can be used in the hospital setting. The questions should be open-ended and nonthreatening. Asking why the client does not want the nurse to wash the hair may make the client respond in a defensive manner. The other responses are not open-ended and are better suited as follow-up questions. This approach should help the client work through possible concerns or barriers.
The nurse is assessing an adult client who is experiencing heart disease. The client has stated a belief that stress at work is causing the problem. What information is important for the nurse to assess? Select all that apply. "Where will you go on your next vacation?" "Tell me about your job." "How many hours do you work each week?" "What shift do you work?" "What type of jobs have you had in the past?"
"Tell me about your job." "How many hours do you work each week?" "What shift do you work?" Explanation: Stressors at the workplace may increase the risk of heart disease. Thus, for this client, the nurse should ask questions about the job, such as hours and shifts. Questions about the location of the next vacation trip and prior jobs are not important or necessary.
A client who has been diagnosed with a cold is upset that antibiotic therapy was not prescribed. Which nursing response is most appropriate? "The common cold is a virus and will not respond to antibiotics." "We can ask the PCP for an antiviral medication." "Sometimes antibiotics work for colds and sometimes they do not." "Antibiotics have too many side effects anyway."
"The common cold is a virus and will not respond to antibiotics." Explanation: The best response from the nurse is to educate the client about the common cold and how it is treated. An antiviral medication is not effective for the common cold. Antibiotics do not work to cure colds as a virus causes them. While antibiotics do cause side effects they are not appropriate for use in this client.
The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? "This antibiotic is the best choice since the causative organism is not known." "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." "Drug resistance can develop when the wrong antibiotic is used for pneumonia." "Pneumonia is usually caused by multiple organisms."
"This antibiotic is the best choice since the causative organism is not known." Explanation: Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness. The side effects of all antibiotics are similar. The antibiotic can cause resistance when used excessively in the absence of infection. Pneumonia may or may not be caused by multiple organisms; however, this isn't the best answer regarding the medication.
The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition? "This happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid." "This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart." "This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." "There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement."
"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." Explanation: When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may cause the heart rate to slow and result in syncope in some clients.
A client is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the client to ambulate with her crutches? "Try to avoid putting too much pressure on your armpits with the tops of the crutches." "Keep your elbows well away from your sides in order to keep yourself as stable as possible." "Keep your crutches as close as possible to your feet when you're walking." "When you rise from a chair, use your left foot to stabilize yourself."
"Try to avoid putting too much pressure on your armpits with the tops of the crutches." Explanation: When using crutches, a client should avoid pressure on the axilla in order to prevent skin breakdown. Elbows should be kept close to the sides and the crutches should come no closer than 12 inches from the feet. When rising from a chair, the client should extend her left foot in order to prevent weight-bearing.
The nurse is teaching the caregiver of a toddler about the importance of calcium to help the toddler's teeth and bones develop properly. Which client statement reflects that nursing teaching has been effective? "Vitamin A helps calcium absorption." "Vitamin D helps calcium absorption." "Too much calcium can cause bone softening." "Muscles store excess calcium."
"Vitamin D helps calcium absorption." Explanation: Adequate amounts of vitamin D, parathyroid hormone, ascorbic acid, lactose, several other amino acids, and physical activity assist in calcium absorption. Inadequate amounts of vitamin D, insufficient exposure to sunlight, decreased amounts of ascorbic acid, decreased physical activity, and emotional stress may decrease calcium absorption.
The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? "You are free to move onto the stretcher without assistance, but I will supervise for your safety." "I can only allow you to transfer without assistance with a physician's order, so I will help you now." "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go."
"You are free to move onto the stretcher without assistance, but I will supervise for your safety." Explanation: If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A physician order is not necessary for a transfer from a stretcher to a bed. The client can move independently and therefore does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.
The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed? 1 medium banana handful of walnuts ½ cup of pineapple 3 ounces of chicken
1 medium banana Explanation: The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes. The nurse will mark off a banana from the menu of a client with latex sensitivity.
A physician at the health care facility orders 500 mg of a medication to be administered by the oral route, four times a day for a client. The medication is available in a liquid form of 250 mg per 5 ml. What quantity of the medication should the nurse administer to the client? 10 mL 15 mL 20 mL 30 mL
10 mL Explanation: The nurse needs to administer 10 mL of the medication as per the physician's prescription in the medication order. The nurse uses the following formula in order to calculate the amount of medication to administer: Desired Dose/Dose on Hand (supplied dose) × Quantity. Applying the formula to the information provided in the medication order: 500 mg/250 mg × 5 mL = 10 mL.
A client has just returned from surgery with a Foley catheter in place. The nurse anticipates that the catheter will be removed within what time frame after the operation? 24 hours 36 hours 48 hours 72 hours
24 hours Explanation: The longer an indwelling catheter remains in the bladder, the greater the chance of health care-associated infection (HAI). The CDC recommends removal of indwelling catheters within 24 hours postoperatively whenever possible
A nurse is caring for a restrained client who has suicidal tendencies. How should the nurse intervene to decrease the risk of injury? Assess for circulation, movement and sensation Remove restraints two at a time, every 2 hours Confirm that the restraint is as tight as possible Ensure client can move enough to maintain personal hygiene
Assess for circulation, movement and sensation Explanation: Risk for Injury is the most appropriate nursing diagnosis for the client who is restrained because the client has the tendency to harm oneself. It is important to choose the correct size of restraint. Choosing the wrong size of restraint could harm the client further. A nurse would not remove two restraints at a time so that the client can perform activities of daily living; the nurse should only remove one at a time. An important aspect of restraints is checking for circulation, movement and sensation. The purpose of restraints is to restrict movement, so any movement that would allow for maintaining personal hygiene would be contraindicated.
A nurse provides a back massage to a client before bedtime to promote relaxation. What is the nurse's priority action before beginning this intervention? Raise the client bed to an appropriate height Place the client in a comfortable position. Assess the client for presence of pain Obtain and warm scent free lotion
Assess the client for presence of pain Explanation: The first action taken by the nurse prior to commencing massage is to determine if the client is experiencing any pain. Massage can either alleviate or aggrevate pain. It is an important first step for the nurse to assess the presence of pain to prevent further discomfort to the client. In addition, this initial assessment can allow the nurse to determine if pain is preventing the client restful sleep. Pain medication may be needed in addition to non-pharmacological interventions, such as massage. Raising the bed to the appropriate height is important for injury prevention and client comfort, however, the nurse will only take this action after the client's pain level is assessed. The nurse will place the client in a comfortable position and obtain a scent free lotion after it has been established that massage is a suitable intervention if the client is in pain.
An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client? Assess the color of the stoma. Apply device for stool collection. Perform stoma irrigation. Have the client perform self stoma care
Assess the color of the stoma. Explanation: A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.
A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement? Assess the factors that the client believes contribute to the problem. Obtain a PRN order for a sedative hypnotic from the client's physician. Educate the client on relaxation techniques and reduce noise levels on the unit. Facilitate a change in the client's diet to ensure more carbohydrates at dinner.
Assess the factors that the client believes contribute to the problem. Explanation: Assessment is the first step in the nursing process. Consequently, the nurse should determine the factors contributing to the client's problem before performing interventions such as obtaining an order for a sedative hypnotic medication, changing the client's diet, or educating the client on relaxation techniques.
The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care? Encourage the client to dress oneself using assistive devices Suggest the client have a family member assist him or her Offer techniques first and have client return demonstration Assist the client in dressing oneself after offering alternative techniques
Assist the client in dressing oneself after offering alternative techniques Explanation: Self-care refers to a person's ability to perform primary care functions in bathing, feeding, toileting, and dressing without the help of others. Nurses play an important role in helping clients learn or relearn self-care. The ability for the client to independently perform appropriate self-care improves a person's health status and emotional well-being. After a CVA, an adult client would need help relearning how to dress, not learning to dress. Encouraging the client to use assistive devices is not an appropriate intervention for dressing and undressing. Suggesting a family member assist may not be appropriate and cause the client to feel embarrassed or helpless. Likewise, having the client return demonstration is not appropriate as the client knows visually how to do this task, but is unable to perform dressing themselves.
An older adult client recently suffered a stroke. The client is bedbound from the resultant paralysis of the right arm and right leg. Which intervention by the nurse is the best strategy to maintain skin integrity? Perform active and passive range-of-motion (ROM) four times daily. Provide a diet high in carbohydrates. Scoot the client up in bed with assistance. Avoid hot water during bathing.
Avoid hot water during bathing. Explanation: The skin is the body's first line of defense against infection. As such, skin strategies, such as avoiding hot water during bathing will help maintain skin integrity. Performing active and passive ROM four times daily will help to prevent contractures and maintain muscle tone but it does not directly prevent skin breakdown. Providing a well-balanced diet containing protein, not carbohydrates, helps to maintain epidermal cells. Scooting the client up in bed creates a shearing force that may cause development of a pressure injury.
A nurse is caring for a client with urinary incontinence. When providing continence training to the client, what should the nurse tell the client about the Credé maneuver? Bend forward and apply hand pressure over the bladder. Massage lightly or tap the skin above the pubic area. Relax the urinary sphincter in response to physical stimulation. Perform isometric exercise to improve the ability to retain urine.
Bend forward and apply hand pressure over the bladder. Explanation: The Credé maneuver is the act of bending forward and applying hand pressure over the bladder. Cutaneous triggering involves lightly massaging or tapping the skin above the pubic area. The voiding reflex is the spontaneous relaxation of the urinary sphincter in response to physical stimulation. Kegel exercises are isometric exercises to improve the ability to retain urine within the bladder.
A client who experienced a cesarean birth rates pain as a 9 on a 10-point scale. The nurse medicates the client for pain. This is an example of the nurse practicing which ethical principle? Justice Fidelity Beneficence Nonmaleficence
Beneficence Explanation: Beneficence means doing or promoting good. The treatment of the client's pain is the nurse's act of doing good. Justice refers to treating clients fairly and impartially. Fidelity refers to keeping one's promises and acting faithfully. Nonmaleficence refers to preventing or not causing harm to the client.
A nurse is caring for a client with long hair. What intervention will best promote care of long hair during hospitalization? Brushing it out then braiding or tying it back. Applying a leave-in conditioner and brushing it. Shampooing the hair and scalp, followed by drying and brushing the hair. Using a commercially prepared shampoo in a cap and then drying and brushing the hair.
Brushing it out then braiding or tying it back. Explanation: Nursing responsibilities for hygiene include providing care of the hair. Applying leave-in conditioner, shampooing either with shampoo or a commercially prepared shampoo in a cap, and drying and brushing the hair are all steps to performing hair care. To promote hair care and protect long hair from matting and tangling, the nurse should braid or pull it back.
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability. Don a second pair of sterile gloves over the first pair. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field.
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. Explanation: It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.
A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? Fowler's low Fowler's protective supine semi-Fowler's
Fowler's Explanation: Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high Fowler's position.
A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning? Habitual laxative use is the most common cause of chronic constipation. If laxatives are not effective, the client should begin to use enemas. A laxative that works by a different method should be used. Chronic constipation is nothing to be concerned about.
Habitual laxative use is the most common cause of chronic constipation. Explanation: Occasional use of laxatives is not harmful for most people, but clients should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of chronic constipation.
A nurse is examining an adult client with inflammation of the gums. The nurse observes bleeding gums. What additional information should the nurse acquire to help determine next steps? How many cavities the client has had How often the client sees the dentist for oral care How often the client brushes and flosses the teeth The client's history of oral surgery
How often the client brushes and flosses the teeth Explanation: The assessment points to gingivitis. Gingivitis is a condition in which there is inflammation of the gums that bleed easily when the person brushes the teeth. This condition can be fixed with longer and more frequent brushing and flossing. Knowing how often the client brushes and flosses the teeth will help determine if the cause is from dental plaque from poor oral hygiene or another cause. Knowing the history of oral surgery and cavities or how often the client sees the dentist is important, but it is not helpful in determining next steps related to the finding.
A nurse is withdrawing a dose of heparin from a vial and notices that a significant volume of air is mixed with the medication that is now in the syringe. How can the nurse increase the pressure in the vial to reduce the chance of bubbles in the syringe? Inject air into the vial equal in volume to the medication that will be withdrawn. Warm the vial in his or her hands for a few seconds prior to withdrawing the medication. Place the vial on a stable surface and withdraw the drug from the bottom of the vial. Roll the vial in his or her hands several times prior to removing the medication.
Inject air into the vial equal in volume to the medication that will be withdrawn. Explanation: Filling the syringe with a volume of air equal to the volume that will be withdrawn from the vial provides a means for increasing pressure within the vial; this reduces the likelihood of bubbles in the syringe.
A nurse provides care for an adolescent who is diagnosed with mononucleosis. Which crucial information does the nurse include in client education about the condition? Select all that apply. It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. Mononucleosis is called the "kissing disease" so refrain from kissing. Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. Cover coughs or sneezes to reduce the risk of spreading infection. The Epstein-Barr virus (EBV) causes mononucleosis.
It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. Mononucleosis is called the "kissing disease" so refrain from kissing. Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. Cover coughs or sneezes to reduce the risk of spreading infection. The Epstein-Barr virus (EBV) causes mononucleosis. Explanation: The Epstein-Barr virus (EBV), along with cytomegalovirus (CMV), causes a form mononucleosis that spreads through bodily fluids, with the most common way being through saliva. Mononucleosis can be spread by sharing food, drinks, or silverware with a person who has it, or if an infected person coughs or sneezes near others. EBV can be spread through various body fluids including saliva, blood, and semen so it can be spread by kissing and sexual contact.
A nurse is caring for a client who has been diagnosed with insomnia. Which nursing intervention would help the nurse relieve the client's condition? Maintain a calm and quiet environment free from noise. Administer sedatives as prescribed by the health care provider. Motivate the client to sleep because it may affect health. Engage the client in some diversional activities.
Maintain a calm and quiet environment free from noise. Explanation: Maintaining a calm and quiet environment is the most appropriate nursing activity to relieve insomnia. Motivating the client to sleep by telling the client that it may affect health may cause anxiety in the client. Engaging the client in diversional activities at bedtime may increase sleeplessness. Sedatives can be administered as prescribed, but they should be used as last resort. These other activities may not relieve insomnia in the client.
A nurse is caring for a client who has been prescribed codeine, an opioid medication to relieve severe postoperative pain. Which responsibility does the nurse have to complete when handling opioid medications? Select all that apply. Place the medication in the container with other prescribed medications. Maintain an accurate account of the use of the medication. Record each medication used from the stock supply. Count each opioid medication at the change of each shift. Place the medication with other medications on the nursing unit.
Maintain an accurate account of the use of the medication. Record each medication used from the stock supply. Count each opioid medication at the change of each shift. Explanation: When handling opioid medications, the nurse should have an accurate account of the use of the medications and a record of each medication used from the stock supply, and the nurse should count each opioid at the change of each shift. Opioid medications are controlled substances, meaning that federal laws regulate their possession and administration. The nurse should not place the medication in the container with other prescribed medications or place the medication along with other medications on the nursing unit. An individual supply is placed in a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay.
x A home care nurse visits a client who is confined to bed and is cared for by an adult child with substance use disorder. The home is cluttered and unclean, and the nurse notes that the client is wet with urine, has dried feces on the buttocks, and shows signs of dehydration. After caring for the client, the nurse contacts the health care provider and reports the incident to Adult Protective Services. What ethical principle is the nurse practicing? Justice Autonomy Nonmaleficence Fidelity
Nonmaleficence Explanation: In this scenario the nurse is practicing nonmaleficence. The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm. Autonomy means to respect the rights of clients or their surrogates to make healthcare decisions. Justice means to treat client fairly and equitably. Fidelity means to keep promises.
A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety? Assist the client in taking a stand-up shower Obtain a shower chair so the client can take a sit-down shower Give the client a bed bath Give the client a towel or bag bath
Obtain a shower chair so the client can take a sit-down shower Explanation: This client is still able to bathe by oneself but has difficulty standing for long periods of time. In order to foster independence and provide the client with a safe bathing environment, a sit-down shower with shower chair would be most appropriate.
"Pedal pulse: left: unable to detect; right: 92 beats/min and regular Left calf w/ erythema, approximately 10cm X9 cm Left calf warm to touch Left calf tender to palpitation Blood pressure 124/78" An 18-year-old client is brought to the urgent care clinic reporting severe left leg pain. Which assessment(s) should the nurse prioritize for this client? Select all that apply. Pedal pulses Skin color Temperature of skin Tenderness to palpation Blood pressure
Pedal pulses Skin color Temperature of skin Tenderness to palpation Explanation: The nurse should conduct a focused assessment and concentrate on the left calf, prioritizing the absence pedal pulse, erythema, warmth, and tenderness. The blood pressure is also important but the priority is the initial focused assessment.
In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action? Discard the remaining drug. Place the date on the vial and retain for future use. Draw up the remaining medication to give at the next time of administration. Send the vial with the remaining drug back to the pharmacy.
Place the date on the vial and retain for future use. Explanation: The nurse will place the date on the vial and retain it for future use since the vial is indicated for multiple uses. Other actions are incorrect.
Which intervention would the nurse implement to prevent infections in a client who is neutropenic as a result of chemotherapy and radiation therapy? Protective isolation precautions Airborne precautions Contact precautions Droplet precautions
Protective isolation precautions Explanation: Protective isolation may be used in high-risk situations to prevent infection for people whose body defenses are known to be compromised. Clients who are neutropenic as a result of chemotherapy, radiation therapy, or immunosuppressive medications are prime candidates. Airborne precautions are used to protect against microorganisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents. Contact precautions are used with organisms that can be transmitted by hand or skin-to-skin contact, such as during client care activities or when touching the client's environmental surfaces or care items. Droplet precautions are used for microorganisms transmitted by larger particle droplets, which disperse into air currents.
An 84-year-old resident of a long-term care facility developed the early signs and symptoms of Alzheimer disease several months ago and has experienced a significant decline in food intake as the disease has progressed. What action should the nurse take in order to promote nutrition for this client? Provide a wide variety of new foods to increase the client's interest. Provide consistency in the time and place for eating each meal. Eliminate spices and seasonings from the client's food whenever possible. Provide the client with a minced or pureed diet that is easier to chew and swallow.
Provide consistency in the time and place for eating each meal. Explanation: Clients with cognitive deficits may benefit from consistency in the time and place for eating. New and unfamiliar foods are unlikely to appeal to this client and there is no need to completely eliminate seasonings and spices. A minced or pureed diet is easier to chew and swallow, but this unusual texture is unlikely to promote increased interest in eating.
A nurse is preparing to perform oral care for a client who has full dentures. Which action(s) should the nurse take? Select all that apply. Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Rinse the dentures with water or normal saline if the client is dehydrated. After cleaning, insert the lower denture followed by the upper denture. Use a sterile 4 × 4 in (10 × 10 cm) gauze to remove debris from the gums and mucous membranes. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.
Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Rinse the dentures with water or normal saline if the client is dehydrated. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning. Explanation: Putting paper towels or a washcloth in the sink protects against breakage. The nurse should provide privacy to the client during removal of the dentures, which many people are embarrassed by. A toothbrush and paste are appropriate to clean dentures. Although the nurse can rinse the dentures with normal saline, plain water is fine. Upper dentures should be placed before lower dentures. A toothbrush and paste, not sterile gauze, should be used to clean gums and mucous membranes. Reference:
A client has a prescription for an opioid analgesic every 3 to 4 hours and received the last dose 3 hours earlier. Which action is most appropriate for the nurse to take in response to the client's request for pain medication on this first postoperative day? Provide the client with pain medication. Tell the client that the pain cannot be severe. Document and ask the client to wait 1 hour. Contact the physician for a change in medication.
Provide the client with pain medication. Explanation: Inadequate or poor pain assessment is a leading factor in poor pain control, because the health care professional may not know a client has pain. The nurse must provide the next dose of pain medication.
The nurse has received a medication order over the telephone from a provider. What is the next appropriate nursing action? Prepare the medication for administration. Repeat or read back the order. Document the order in the electronic health record (EHR). Identify the client by last name and date of birth.
Repeat or read back the order. Explanation: In keeping with National Patient Safety Goals, the nurse will read back the order, then proceed to document the order in the EHR, prepare the medication, and identify the client by two identifiers prior to administration.
A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of medication. Which measure would be most effective at protecting a toddler from accidental poisoning with medication? Closely monitor the toddler's activity throughout the day. Make sure medications are clearly labeled as such. Request childproof caps on all prescription medications. Store all medications a designated kitchen cabinet.
Request childproof caps on all prescription medications. Explanation: The most effective measure is to request childproof caps, which a toddler will not have the skills to open. Monitoring activity is helpful, but an accident can occur in a split second. Toddlers cannot read, so having medications labeled does not prevent problems. While a medications can be stored in a designated cabinet, it is important that the cabinet be high and far enough out of reach from toddlers. Some families may chose to lock cabinets for an additional safeguard.
A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Rescue anyone who is in immediate danger. Evacuate clients and staff. Activate the fire alarm on the unit. Attempt to extinguish the fire.
Rescue anyone who is in immediate danger. Explanation: The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? supine prone Sims' Fowler's
Sims' Explanation: Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.
The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. Stop the administration of the enema and notify the physician. Stop the administration of the enema momentarily. Increase the flow of the enema until all of the solution has been administered.
Stop the administration of the enema momentarily. Explanation: If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.
A nurse observes that a client coughs and chokes when eating. What instructions should the nurse prepare for this client? Instruct the dietary department to prepare a liquid diet. Tell the client to chew his food very thoroughly. Instruct the client to avoid drinking beverages with meals. Restrict milk and other dairy products in the diet.
Tell the client to chew his food very thoroughly. Explanation: The nurse should suggest that the client chew the food thoroughly and encourage repeated swallowing attempts. Preparing a liquid diet or restricting milk and beverages is not a solution for preventing choking during meals.
A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client? Primary prevention Secondary prevention Tertiary prevention Residual prevention
Tertiary prevention Explanation: Tertiary prevention in health care deals with rehabilitation of the client. Teaching the client to walk with a walker is tertiary prevention. Primary prevention refers to health promotion or illness prevention. Secondary prevention refers to screening and early detection of disease.
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? The dose that is delivered when the client activates the machine is preset. Thorough client education is necessary to prevent overdoses. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. An antidote is automatically delivered if the client exceeds the recommended dose.
The dose that is delivered when the client activates the machine is preset. Explanation: PCAs are designed to make it impossible for the client to exceed the client-specific dosing parameters programmed into the machine. PCAs do not administer antidotes, and they are almost always used to deliver opioid analgesics. The client does not need to be educated about overdoses.
A client nearing the end of life requests that the client be given no food or fluids. The physician orders the insertion of a nasogastric tube to feed the client. What is the primary concern of the nurse providing care? The nurse must follow the physician's orders. The nurse is unable to provide care for the client. The nurse faces an ethical dilemma about inconsistent courses of action. The physician's order creates a barrier to establishing an effective nurse-client relationship.
The nurse faces an ethical dilemma about inconsistent courses of action. Explanation: In an ethical dilemma, two or more clear moral principles apply but support mutually inconsistent courses of action. In this case, the nurse must decide what to do based on ethical decision-making and take action that can be justified ethically based on that process. The nurse does not need to follow the physician's order in this case as the nurse knows the client's wishes. Although the physician's order may create a barrier to the nurse-client relationship, this concern is secondary to the ethical dilemma it poses to the nurse. The nurse should continue to provide care.
The nurse is preparing to begin a health assessment with a new client. Which nursing consideration will help to establish a safe and appropriate environment for conducting the health assessment? There is adequate time to perform the assessment. The room is private, quiet, warm, and has adequate light. Family members are present to answer specific questions. The assessment should be conducted after all tests and procedures.
The room is private, quiet, warm, and has adequate light. Explanation: The nurse and client should be in a room (or area) that is private, quiet, and warm enough to prevent chilling, and it should have adequate lighting, either by sunlight or overhead fixtures. Family members may remain, especially if they are needed to explain activities to the client. The assessment does not need to be conducted after all tests and procedures, as the information obtained in the assessment may be needed prior to any procedures and tests. Time for the assessment should be mutually agreed upon, but the priority is that the space be accommodating for the nurse and client.
A nurse places a client in the position shown in the accompanying photo. What position is the client assuming? Fowler Sims Supine Trendelenburg
Trendelenburg Explanation: In the Trendelenburg position, the head is lower than the feet.
A client with chronic obstructive pulmonary disease (COPD) has been prescribed an inhaled bronchodilator. Which technique should the nurse implement in order to ensure safe and complete delivery of the prescribed medication? Use a spacer or extender with the metered-dose inhaler. Provide oxygen therapy 30 minutes prior to administration. Provide multiple puffs of the medication in rapid sequence. Place the inhaler as deeply into the client's mouth as is comfortable.
Use a spacer or extender with the metered-dose inhaler. Explanation: The use of an extender or spacer ensures that the client receives as much of the inhaled medication as possible. MDIs are placed 1 or 2 inches (2.5 or 5 cm) in front of the mouth, not deeply into the mouth. Oxygen therapy prior to administration does not aid in delivery. Multiple puffs, if ordered, are given after 1 to 5 minutes.
The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care? Dip the IV catheter into an antiseptic before use. Clean the site with a disinfectant. Use a sterile intravenous catheter. Wear a mask and gown for the procedure.
Use a sterile intravenous catheter. Explanation: Any item entering sterile tissues or the vasculature must be sterile. Therefore, an IV catheter must be sterile. It should not be dipped in an antiseptic before use. A chemical used on lifeless objects is called a disinfectant, whereas one used on living objects is an antiseptic. The nurse would clean the IV site with an antiseptic, not a disinfectant, before insertion. An IV insertion does not require the nurse to wear a mask and gown.
The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home? Place throw rugs in high traffic areas. Install 60 watt light bulbs in stairways. Use night-lights in bedrooms and bathrooms. Use ladders and step stools to reach high items.
Use night-lights in bedrooms and bathrooms. Explanation: The risk of falls increases with a person of advanced age, impaired mobility, or both. Ways to prevent falls include the use of night-lights in bedrooms and bathrooms to provide light if the client needs to get up in the night. Other interventions include removal of throw rugs, making sure that stairways are well-lit (100 watt bulbs), and never attempting to reach items that are beyond reach or physical ability.
A nurse is preparing to administer an intramuscular injection to a client. Which would be appropriate for the nurse to do to reduce discomfort? Select all that apply. Use a large-gauge needle. Use the Z-track technique. Have the client lie prone with toes outward. Apply ice to the site before administration. Apply pressure to the site when withdrawing the needle.
Use the Z-track technique. Apply ice to the site before administration. Apply pressure to the site when withdrawing the needle. Explanation: To minimize injection discomfort, the nurse would use the smallest-gauge needle possible, use the Z-track technique, have the client lie prone with toes inward, numb the site with ice before administration, and apply pressure to the site when withdrawing the needle. Reference:
The nurse is teaching a client how to instill multiple opthalamic medications. Which teaching points will the nurse include? Select all that apply. Wait 5 minutes between administration of different eye drops There are devices available that can help you with instilling the drops Dispose the medication after 28 days to prevent bacterial contamination Rub your eyes after instilling the drops to distribute them evenly The order in which you instill each medication is not important.
Wait 5 minutes between administration of different eye drops There are devices available that can help you with instilling the drops Dispose the medication after 28 days to prevent bacterial contamination Explanation: Complex ophthalmic medication regimens can involve the instillation of multiple types of drops up to four times daily. When more than one eye medication is prescribed, it is best to wait 5 minutes between instillation of eye drops. For people having difficulty instilling eye medications independently, devices are available that can facilitate administration. Eye drop solutions should be disposed of every 28 days to prevent bacterial contamination of the eye. Blinking, rather than rubbing, distributes the drug over the surface of the eye. Depending on which medications are prescribed, the order in which they are instilled can impact efficacy. It is important to teach clients to carefully follow the sequence of administration as it has been ordered.
Which type of mobility aid would be most appropriate for a client who has poor balance? a cane with four prongs on the end (quad cane) a single-ended cane with a half-circle handle a single-ended cane with a straight handle axillary crutches
a cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.
Based on Maslow's hierarchy of needs, when prioritizing a client's plan of care, what would be the nurse's priority? allowing the family to see a newly admitted client ambulating the client in the hallway administering pain medication teaching the client to self-administer insulin
administering pain medication Explanation: In Maslow's hierarchy of needs, pain relief addresses the client's basic physiologic need. Activity, such as ambulation, is a higher level need above the physiologic need. Allowing the client to see his family addresses a higher level need related to love and belonging. Teaching the client is also a higher level need related to the desire to know and understand and is not appropriate at this time, as the basic physiologic need of pain control must be addressed before the client can address these higher level needs.
The nurse is caring for a client with pneumonia who requires administration of medications. When does the nurse document administration in the medication administration record (MAR)? when preparing medications for administration during administration at the bedside at the end of the nurse's shift after completion of administration of each drug
after completion of administration of each drug Explanation: The nurse documents administration after giving medications each time. The nurse never documents administration of medications ahead of delivery, nor does the nurse document during the actual delivery time. Nurses do not wait until the end of the shift to document medication administration.
During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following? an increase in the client's blood pressure a decrease in the client's blood pressure an increase in the client's respiratory rate a decrease in the client's respiratory rate
an increase in the client's blood pressure Explanation: When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart, which elevates the client's blood pressure.
After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat? bouillon, apple juice, and gelatin fat-free broth, ginger ale, and custard cream of wheat, cranberry juice, and milk clear broth, hot tea, and yogurt
bouillon, apple juice, and gelatin Explanation: Clear liquid diets contain foods that are clear liquids at room temperature or body temperature, such as gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. Full liquid diets contain all the items on a clear liquid diet, but also include milk and milk drinks, custards, puddings, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes.
The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify? class A class B class C No fire extinguisher should be used to attempt to extinguish an electrical fire.
class C Explanation: Class C fire extinguishers contain dry chemicals and are used to extinguish electrical fires. Other answers are incorrect.
The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe? decreased irritation and pain in subcutaneous tissue less frequent administration of the medication more rapid administration of the medication decreased risk for infection
decreased irritation and pain in subcutaneous tissue Explanation: This technique is Z-tracking. The Z-track technique allows the medication to be administered into the muscle tissue with no tracking of medication in the subcutaneous tissues as the needle is removed, resulting in less pain and irritation.
A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction? facing toward the body angled to the left side toward the right side facing away from the body
facing away from the body Explanation: When setting up a sterile field, the drape is placed in the center of the work surface at or above waist level, with the outer flap facing away from the body.
A nurse is preparing to move a client up in bed. How can the nurse best demonstrate the principles of correct body mechanics? facing the direction of movement twisting the body at the waist when lifting keeping body weight higher than the center of gravity keeping feet together to provide a solid base of support
facing the direction of movement Explanation: When using proper body mechanics, the nurse should face the direction of movement and avoid twisting the body. Maintaining balance involves keeping the spine in vertical alignment, the body weight close to the center of gravity, and the feet spread for a broad base of support.
An elderly client with pneumonia has been prescribed the use of a bronchodilator by the physician. What should the nurse monitor in a client taking an inhaled bronchodilator? heart rate body temperature pupil dilation physical mobility
heart rate Explanation: The nurse should monitor the heart rate and blood pressure of the elderly client who uses inhaled bronchodilators. It is important to monitor the vital signs, because these medications commonly cause tachycardia and hypertension. Either or both of these effects increase the risks of complications, especially in elderly clients with underlying cardiovascular disease. The nurse need not monitor the client's body temperature, pupil dilation, or physical mobility, because these are not related to the administration of bronchodilators.
During the physical assessment of a client, the nurse uses the head-to-toe approach. What are the advantages of this approach? Select all that apply. helps prevent overlooking some aspect of data collection reduces the number of position changes required of the client makes the problem easily identifiable because the findings tend to be clustered takes less time because the nurse doesn't have to constantly move around the client examines the same areas of the body several times before the assessment is complete
helps prevent overlooking some aspect of data collection reduces the number of position changes required of the client takes less time because the nurse doesn't have to constantly move around the client Explanation: The head-to-toe approach helps to prevent overlooking some aspect of data collection, reduces the number of position changes required of the client, and takes less time because the nurse doesn't have to constantly move around the client. Findings tend to be clustered, making the problem more easily identifiable in the body systems approach. However, in using the body systems approach, the same areas of the body are examined several times before the assessment is completed.
A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing? hemorrhoids diarrhea paralytic ileus constipation
hemorrhoids Explanation: Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. This is unrelated to paralytic ileus or diarrhea; hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Diarrhea is a condition in which feces are discharged from the bowels frequently and in a liquid form. Paralytic ileus is an obstruction of the intestine due to paralysis of the intestinal muscles.
"The client is 61 years old, tripped over a sidewalk curb, and incurred a fractured leg. The client denies any previous falls. The client is prescribed oxycodone every 4 hours as nedded for pain and has received one dose. Vital signs are pulse 88, beats/min and regular, respirations 20 breaths/min and blood pressure 126/78." The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply. age of 61 years history of a fall fractured leg administration of oxycodone vital signs
history of a fall fractured leg administration of oxycodone Explanation: Risk factors for falls include a history of a fall (cause for this hospitalization), a gait imbalance due to a fractured leg, and the administration of oxycodone, an opioid analgesic. The client's age (less than 65 years) and vital signs that are within normal limits are not risk factors for a fall.
The nurse is conducting a home care visit for a new mother who delivered a baby 3 days ago. Which finding within the home requires immediate nursing intervention? hot water heater thermostat set at 130 degrees F (54.4 degrees C) infant's sleepwear is made from flame-resistant fabrics one fire extinguisher noted in the kitchen electrical outlets with covers over them
hot water heater thermostat set at 130 degrees F (54.4 degrees C) Explanation: The nurse will intervene if the hot water heater thermostat is set above 120 degrees F (48.8 degrees C). This could cause burning to an infant's skin. Other findings enhance safety within the home.
The primary health care provider prescribes an otic medication. The nurse interprets this as indicating which location for administration? skin in the ear in the eye between cheek and gum
in the ear Explanation: Otic medications are placed in the ear. Cutaneous medications are applied to the skin. Ophthalmic medications are placed in the eye. Buccal medications are placed between the cheek and gum.
A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? increased bowel sounds abdominal tenderness areas of distention muscular resistance
increased bowel sounds Explanation: The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds. Abdominal tenderness, distension, and muscular resistance, wouldn't be expected following a small volume enema.
A nurse is ambulating a client who has had a cerebrovascular accident (CVA). The client has paresis on the right side of the upper body. Where would the nurse stand to walk the client? on the weak side on the strong side in front of the client in back of the client
on the weak side Explanation: When a client has weakness or paralysis on one side, the nurse stands on the weaker side and stabilizes the client by putting one arm around the client's waist. The client's weak arm is supported in the axillary area. It would be ineffective to stand on the client's strong side as it would leave the client vulnerable to injury on the side which support is needed. As the client requires support and fall prevention on the weak side, standing in front of or back of the client will not be effective - the nurse should not attempt to "cushion" or "catch" a fall, instead, the aim is to prevent a fall altogether.
A nurse is preparing to assess the integumentary system for texture, temperature, moisture, and edema. Which assessment technique will the nurse use? palpation inspection percussion auscultation
palpation Explanation: Palpation uses the sense of touch to assess the patient for texture, temperature, moisture, and edema. Therefore, the nurse will use palpation. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.
A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? standing at the top of the bed and having a colleague stand at the bottom of the bed placing the bed in its lowest position to reduce the client's risk for falls positioning a friction-reducing sheet under the client to facilitate movement using back muscles to gently and gradually pull the client to the side
positioning a friction-reducing sheet under the client to facilitate movement Explanation: After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.
A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. What measures should be undertaken by the nurse to promote sleep? Select all that apply. administration of diuretics promoting daytime exercise providing a back massage increasing the intake of stimulating chemicals assisting with progressive relaxation
promoting daytime exercise providing a back massage assisting with progressive relaxation Explanation: In order to promote sleep in a client, the nurse could use the following measures: promoting daytime exercise, providing a back massage, and assisting the client with progressive relaxation. However, the nurse should reduce the intake of stimulating chemicals to promote sleep in a client. Diuretics may awaken those who take them with a need to empty the bladder. For this reason, diuretics generally are administered early in the morning so that the peak effect has diminished by bedtime.
Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? places bed at lowest setting provides slippers for ambulation clears a path from bed to bathroom has client sit in bed for a few moments before standing
provides slippers for ambulation Explanation: Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls.
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? acute pain chronic pain referred pain limited pain
referred pain Explanation: Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.
A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication? read and compare labels on the medication with the medical record review the client's medication, allergy, and medical history administer medication within 30 to 60 minutes of the scheduled time allow sufficient time to prepare the medication with minimal distraction
review the client's medication, allergy, and medical history. Explanation: To avoid any potential complications, the nurse should review the client's medication, allergy, and medical history. The nurse should read and compare the label on the medication with the medical record at least 3 times (before, during, and after preparing the medication) to ensure that the right medication is given at the right time by the right route. Administering the medication within 30 to 60 minutes of the scheduled time demonstrates timely administration and compliance with the medical order. Allowing sufficient time to prepare the medication with minimal distraction promotes the safe preparation of medications.
The home health nurse is assisting a client and the family in planning the client's return to work after an extensive illness. On which level of Maslow's hierarchy of basic needs does the client's need for self-fulfillment fit? physiologic safety and security love and belonging self-actualization
self-actualization Explanation: Maslow's highest level of human needs is self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. The other answers are incorrect because self-fulfillment does not fit on any of them.
A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention? stool softeners and increased fluid intake supplementary oxygen and chest physiotherapy calorie restriction and dietary supplements frequent turns and application of skin emollients
stool softeners and increased fluid intake Explanation: The most common side effect of opioid use is constipation. Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.
A nurse suspects that a client has abdominal ascites and prepares to assess the abdominal girth. How should this assessment be completed? stretching a tape measure around the largest diameter and making guide marks on the skin measuring from the top of the pubic bone to the top of the umbilicus and marking the height lying the client supine while percussing across the abdomen for dullness and marking the location measuring length and width of abdomen and documenting the anterior and posterior diameter
stretching a tape measure around the largest diameter and making guide marks on the skin Explanation: If the abdomen appears unusually large, the nurse checks its girth (circumference) daily by using a tape measure around the largest diameter. To ensure that he or she always measures from the same location, the nurse makes guide marks on the skin with an indelible pen. The other options are inappropriate ways to complete the assessment.
A nurse is examining the urine specimen of a dehydrated client. What is a characteristic odor of the urine voided by a dehydrated client? aromatic foul strong pungent
strong Explanation: Urine voided by a dehydrated client has a strong odor. A normal urine specimen has a faintly aromatic odor. A client with a urinary tract infection would have foul-smelling urine. Certain foods could contribute to the pungent odor of urine in a normal client.
