NCLEX Basic Care and Comfort

What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest? Select all that apply. 1. "Clients on bedrest should be placed on therapeutic mattresses." 2. "I will assess for the skin every 4 hours." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."

1. "Clients on bedrest should be placed on therapeutic mattresses." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry." (1., 3., 4., & 5. Correct: Clients on bedrest should use a therapeutic bed or mattress. These prevent and treat pressure ulcers by molding to the body to maximize contact, redistributing weight, and reducing pressure. The Braden scale is the most preferred tool to assess risk of developing pressure ulcers. It looks at sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A pillow between the knees can decrease pressure on knees if they were touching. Protect the client from moisture by keeping clean and dry. 2. Incorrect: When a client is on bedrest the skin and subcutaneous tissue can not profuse adequately. Therefore, the skin should be assessed every 2 hours not every 4 hours.)

The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion? 1. "Please tell me how I can best help you control your pain." 2. "It is my job to teach you how to deal with your pain." 3. "I will be teaching you how to use guided imagery to decrease your pain." 4. "Your primary healthcare provider has prescribed pain medication for your pain. I will teach you about this medication."

1. "Please tell me how I can best help you control your pain." (1. Correct: This statement sends a couple of messages that are an important part of treatment planning and evaluation of care. First, it places the ownership and responsibility for controlling pain on the client. Second, it acknowledges that the client may be the best judge of what is needed, respecting the cultural meaning of pain, and acceptable ways of expressing/controlling pain. Third, it establishes the nurse's role in helping the client be more comfortable and in control of their condition. 2. Incorrect: This statement does not include or even consider the client. This statement reflects the role of the nurse. The focus should be on the client's needs. 3. Incorrect: This statement begins with what the nurse is planning to accomplish. This statement does not include or even consider the client. 4. Incorrect: What does the client think might help relieve the pain? What other options are there? The nurse begins the teaching session by what the primary healthcare provider has ordered. The nurse should assess the client's knowledge about pain management.)

During an assessment interview with a client, what alternative healing modalities should the nurse inquire about? Select all that apply. 1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?"

1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 5. "What alternative therapies have you used?" (1., 2., 3., & 5. Correct: These are all inquiries the nurse should make when conducting an assessment interview in order to find out about alternative healing modalities. Alternative or complementary medicine is used to describe over 1,800 therapies practiced around the world. Approximately 65 to 80% of the world's population use non-conventional (alternative) healing modalities. These alternative healing modalities can be such things as: Natural products (herbs, dietary supplements, etc.) mind and body practices (yoga, mediation, prayer, etc.), folk remedies and other non-traditional practices. 4. Incorrect: Prescription medications would be part of traditional, western medicine. Although the nurse needs to find out what prescription medications are being taken, it is not part of alternative medicine.)

Which interventions should be included in the plan of care for an adult client with constipation? Select all that apply. 1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake (unless contraindicated). 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal.

1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake (unless contraindicated). 4. Encourage client to increase fiber in the diet. (1., 2., 3. & 4. Correct: Clients should have ample time for defecation. Rushing the client may lead to a client ignoring the urge. Since clients may be hesitant to have a bowel movement in the presence of others, privacy should be provided. (The nurse may need to stay with weak or disabled clients.) Increasing fluid intake will lead to softer stools. This makes defecation easier. Fiber deficiencies may contribute to constipation. Fiber in the diet adds bulk to the stools which help them pass more readily through the intestines. 5. Incorrect: Ignoring the urge to defecate may increase the risk of constipation. Trying to defecate after a meal when peristalsis is increased may be helpful; however, if the urge occurs at other times, the client should go to the bathroom at that time to prevent constipation.)

The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? Select all that apply. 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses.

1. Check shoes for rough spots in the lining. 2. File toenails straight across. 4. Break in new shoes gradually. (1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first.)

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? 1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication.

1. Client will report a pain level of less than 2 on a Faces scale. (1. Correct: Yes, having a pain level of less than 2 is the best goal for pain and the use of a Faces scale, instead of a numerical scale is age appropriate. Sickle cell crisis is extremely painful, and often times, the pain is not completely relieved during the acute stage. 2. Incorrect: The goal should be client centered. This option is a nursing intervention, not a client goal. 3. Incorrect: We are focusing on client response, not limiting pain meds. The goal of a pain crisis should be aimed at reducing the client's pain. 4. Incorrect: Sickle cell crisis is very painful, and pain medication is needed.)

The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take? 1. Inform the primary healthcare provider of the observations made regarding quad cane use, and imbalance assessment. 2. Inform client that there are only a few assistive devices available to help with ambulation. 3. Instruct the client on proper quad cane use. 4. Notify the primary healthcare provider after consulting with the neighbor.

1. Inform the primary healthcare provider of the observations made regarding quad cane use, and imbalance assessment. (1. Correct: Inform the primary healthcare provider of the observations made regarding the quad cane. The client can not maintain proper balance with the assistance of one sided support. This client would most likely benefit from a walker. 2. Incorrect: The word "only" in the answer indicates that the choices for the client are limited. There are other interventions to assist with balance control. Therefore, this is not correct information or action for the nurse to take. 3. Incorrect: The client was observed using proper technique. Instruction on proper technique is not necessary. The nurse needs to identify the client problem which is imbalance. 4. Incorrect: Discussing the nurse's observation of the client with a neighbor would be a breach of client confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) protects the individual's personal health information.)

A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document? Select all that apply. 1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted 6. Infusing rate of IV fluid

1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted (1., 2., 3., 4., & 5. Correct: Perineal skin assessment should be assessed prior to insertion of the indwelling catheter. The following documentation is appropriate after inserting an indwelling catheter: Client teaching, color of the urine, date and time of the insertion and the type of catheter inserted. 6. Incorrect: Documenting the IV rate is not relevant to inserting the catheter. The infusion rate may need to be documented, but the question is asking about the documentation of the insertion of the indwelling catheter.)

Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)? Select all that apply. 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating.

1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. (1., 2., 3., & 4. Correct: All of these actions are correct to help alleviate dyspepsia. When a client has GERD, the stomach's contents reflux into the esophagus. Small frequent meals will decrease possible reflux by decreasing the stomach content. Smoking can relax the lower muscle of the esophagus. Drinking a carbonated drink may cause the stomach to expand. Both smoking and drinking a carbonated drink increase the potential of reflux. The action of omeprazole is to reduce the acid that is produced in the stomach. 5. Incorrect: The client should be positioned with the head of the bed (HOB) elevated for 2-3 hours after eating. This position will decrease the potential for esophageal reflux.)

The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include? Select all that apply. 1. Providing a back massage 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer

1. Providing a back massage 3. Distracting with music 5. Prayer (1., 3., & 5. Correct: These are types of alternative pain control that could be used in conjunction with traditional pain management. They can be used to provide relaxation and comfort; mind-body therapies such as meditation, guided imagery and hypnosis may be effective. Other measures may include: acupuncture, therapeutic touch, music therapy and spiritual practices such as prayer. These have been found to be effective in helping to reduce pain. 2. Incorrect: Pain medication is traditional, not alternative pain control. Also, pain medication should be provided prior to a rate of 5/10. 4. Incorrect: The client is likely not going to be able to exercise. Movement during pain may increase pain.)

The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? Select all that apply. 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises

1. Turn every two hours 2. Place a pillow between legs when turning 4. Encourage fluid intake 5. Encourage ankle and foot exercises (1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT). 3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a chair could do more injury and cause more pain.)

A school nurse is teaching a group of preteens with acne how to care for the skin. What points should the nurse include? Select all that apply. 1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terrycloth.

1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. (1., 2., 3., & 4. Correct: Washing the face frequently (at least twice a day) with mild soap or detergent and warm water will remove oil, dirt, and bacteria which increase inflammatory reactions and resulting acne. Oily creams and oil based cosmetics can block the ducts of the sebaceous gland ducts and the hair follicles making the acne worse. These should be avoided. Squeezing or picking at lesions will increase potential for infection and scarring. 5. Incorrect: Clean face gently, as trauma during acne breakouts may worsen the acne and cause scarring. When washing face, use hands, as terrycloth or other scrubbing material may cause acne sores to rupture.)

A postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. Intake: IV fluid-1,025 mL PRBC-250 mL Output: Urine - 1,350 mL NG tube - 75 mL Jackson Pratt - 22 mL Calculate the client's output for the shift in mL. Ans:______

1447 (1,350 mL + 75 mL + 22 mL = 1,447 mL)

The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? Select all that apply. 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.

2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques. (2., 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non-invasive, and show the client that the nurse cares. 1. Incorrect: Education regarding pain control does not help the client's pain and would not be appropriate while the client is experiencing pain.)

Which client will the charge nurse intervene on behalf when making rounds? 1. The client turned to left side 1 ½ hour ago. 2. Client who has been sitting in a chair for 2 ½ hours. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck's traction with foot boots.

2. Client who has been sitting in a chair for 2 ½ hours. (2. Correct: Limit sitting in a chair to less than 2 hours. Prolonged sitting or lying in one position predisposes the client to skin breakdown and other hazards of immobility. 1. Incorrect: Clients should be turned at least every 2 hours, so this client is within the acceptable time frame for being turned. 3. Incorrect: The client with hip replacement needs the abduction pillow. This prevents dislocation of the hip prosthesis by helping to maintain the femoral head component in correct position. 4. Incorrect: The client in buck's traction needs foot boots to avoid foot drop. Therefore, this is an appropriate intervention.)

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener. 2. Increase intake of fruit in the diet. 3. Monitor elimination habits for the next week. 4. Rest after each meal.

2. Increase intake of fruit in the diet. (2. Correct: Increased fiber intake may help to establish regular elimination habits. 1. Incorrect: Not the best initial suggestion. It's better to promote health maintenance routines than to just go with a medication, which could be a temporary fix. 3. Incorrect: The nurse should make a suggestion that will assist the client with normal elimination. This option does not suggest a way to fix the problem. 4. Incorrect: Increased activity is likely to result in more normal elimination. Resting after meals would not increase elimination frequency.)

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition? 1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea

2. Mucositis (2. Correct: Ulcerations in the oral cavity can make it difficult to chew food or be intolerant to certain foods due to discomfort and pain. Intake may be inadequate as a result of this. 1. Incorrect: Fatigue may make the client tire easily, but ulcerations in the oral cavity will be the primary reason for not wanting to eat. 3. Incorrect: Neutropenia leads to infection. This does not alter intake. 4. Incorrect: Diarrhea may need to be treated by making diet changes. However, the maintenance of nutrition should be focused on intake. The impact of the mucositis should be considered first for maintaining proper nutrition.)

The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Confusion and disorientation. 2. Scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.

2. Scared and lonely and grabs the nurse's hand for comfort. (2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question.)

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal.

2. Take the client to the dining room for all meals. (2. Correct: The client may be lonely and miss the interaction with others, but reluctant to go to the dining room. Eating with others may help to improve appetite and intake of food. The nurse can actively seek out the client and take this client to the dining room. Simply encouraging the client to go to the dining room may not be sufficient to get the client to go. 1. Incorrect: Eating alone may actually lead to reduce food intake. Eating is also a social activity. 3. Incorrect: A high protein supplement may increase caloric intake; however, to give that to the client 30 minutes before a meal will interfere with food intake at mealtime. 4. Incorrect: Assisting the client is important if the client cannot do it, however, there is no data to suggest that the client cannot eat independently. It is important to help the clients maintain their maximum level of independence.)

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client? 1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living

2. Use of pain intensity scale (2. Correct: The use of pain intensity scales is an easy and reliable method of determining the client's pain intensity. 1. Incorrect: Although respiratory and heart rate may decrease with guided imagery and pain reduction, the most objective measure is to ask the client to rate the pain. 3. Incorrect: First, ask the client if pain is present. If present, the client should be asked to rate the pain. Once pain has been rated, the client should be asked to describe the pain. 4. Incorrect: The client may be able to perform activities of daily living and still have pain. Therefore, this would not be an accurate means of assessing pain relief.)

The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level when making the stick. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick.

2. Warm the finger prior to the stick. (2. Correct: Warming the finger will increase circulation to the site, thereby increasing blood flow. 1. Incorrect: The finger should be dependent to enhance blood flow to the site, so it needs to be below the level of the heart to be effective. 3. Incorrect: The injector should be placed firmly against the skin; otherwise the client may get an insufficient stick and require another stick. 4. Incorrect: The finger should be in a dependent position to increase blood flow to the site so as to prevent the need for another stick.)

The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary? 1. "I can perform deep breathing exercises anywhere and at any time that I feel tension and anxiety." 2. "I should sit or lie in a comfortable position, making sure my back is straight." 3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion." 4. "When I have inhaled in as much as possible, I will hold my breath for a few seconds before exhaling."

3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion." (3. Correct: The proper method is to inhale slowly and deeply through the nose, allowing the abdomen to expand. The chest should be moving only slightly. 1. Incorrect: This statement demonstrates successful teaching. To relieve anxiety, deep breathing exercises can be initiated as needed. Inhaling slowly and deeply through the nose can be performed anytime, and no additional equipment is needed. 2. Incorrect: This statement demonstrates successful teaching. To initiate deep breathing exercises, the client should sit or lie down in a comfortable position. Maintaining a straight back will facilitate breathing deeply into the lungs. 4. Incorrect: This statement demonstrates successful teaching. Holding your breath after inhaling is a technique that assists the client to control their breathing pattern. The client has control over themselves by repeating the deep breathing exercise.)

A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction? 1. "I will not alter the height of my crutches." 2. "My body weight should be supported at the hand grips with my elbows flexed at 30 degrees." 3. "When I rise from a chair, I should position my crutches on my unaffected side." 4. "I will not lean on my crutches while standing."

3. "When I rise from a chair, I should position my crutches on my unaffected side." (3. Correct: The client should position crutches on affected side when sitting or rising from a chair. This will give the client more stability with position changes. 1. Incorrect: This is a correct statement by the client. Once the crutches have been properly fitted, they should not be altered by the client. 2. Incorrect: This is a correct statement by the client. Body weight should be supported at the hand grips, not under the arms. Elbows should be flexed 30 degrees. 4. Incorrect: Leaning on crutches under the arms can damage the nerves.)

The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation? 1. 1,000 2. 300 3. 500 4. 800

3. 500 (3. Correct: The client needs an extra 500 kcal/day above the usual allowance because the average woman will secrete between 425-700 kcals per day in her breast milk. By increasing the daily caloric intake by 500 kcal the client will offset these losses. 1. Incorrect: 1,000 kcal/day is more calories than are needed to offset the caloric loss of breastfeeding. 2. Incorrect: 300 kcal/day is not enough calories to offset the caloric loss of breastfeeding. 4. Incorrect: 800 kcal/day is more calories than are needed to offset the caloric loss of breastfeeding.)

Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)? 1. Irrigate a colostomy in a client who is 2 days postoperative. 2. Remove a fecal impaction in a client. 3. Apply a condom catheter to an incontinent client. 4. Insert a urinary catheter to obtain a urine sample.

3. Apply a condom catheter to an incontinent client. (3. Correct: With proper instruction a UAP may be delegated to apply a condom catheter. This is not an invasive procedure. 1. Incorrect: The care of a new postoperative colostomy should not be assigned to the UAP. This is an invasive procedure and assessments of the stoma, incision, and skin are essential. The RN can not delegate assessment to a UAP. 2. Incorrect: Removal of a fecal impaction is an invasive procedure. Because the bowel mucosa can be injured during this procedure, it is not appropriate to delegate this to the UAP. 4. Incorrect: Insertion of an indwelling urinary catheter is an invasive sterile procedure. The nurse must have knowledge of detailed anatomy and sterile technique. The UAP should not be delegated to perform this procedure.)

A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? 1. Medium rare steak, potato salad, peas and coffee 2. Ham sandwich, chips, fruit salad and juice 3. Broiled white fish, baked potato, mixed salad and tea 4. Baked chicken, vegetable medley, rice and milk

3. Broiled white fish, baked potato, mixed salad and tea (3. Correct: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed. 1. Incorrect: Although steak is allowed, all traces of blood must be gone. 2. Incorrect: No pork products are allowed, so no bacon, ham, or sausage. 4. Incorrect: Milk is not allowed at the same time as meat. There should be at least three hours separating the two.)

A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client? 1. Physical therapist 2. Nutritionist 3. Massage therapist 4. Occupational therapist

3. Massage therapist (3. Correct: The massage therapist provides alternative therapies that complement the medical pain control therapies being provided by the primary healthcare provider and the nurse. 1. Incorrect: A physical therapist is trained to improve and restore mobility. Due to the client's terminal status short term reduction of the pain is needed. 2. Incorrect: The nutritionist's main focus is on the client's nutritional status. This will not affect the pain level of the client. 4. Incorrect: The occupational therapist's main focus is to improve the client's ability to perform activities of daily living and work skills. Due to the terminal status of this client, pain management is the goal for this client.)

The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin? 1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed.

3. Place turn sheet under the client and use it to slide the client toward the top of bed. (3. Correct: Placing a turn sheet under the client before moving will prevent friction and shearing forces which may lead to an abrasion or skin tear. Pressure ulcers are more likely to develop in tissues where shear force injury has occurred. 1. Incorrect: This will not prevent shearing forces on the skin and may result in scratches to the skin if the staff are wearing rings or other jewelry. The shearing force is created by gravity pushing down on the client's body, creating a resistance to movement. It creates a downward and forward pressure on tissues beneath the skin. 2. Incorrect: Using powder may actually irritate the skin as it may be abrasive when client's weight pushes against it and the bed. 4. Incorrect: Another person to assist in controlling the head or holding the lower legs would be helpful; however, using three to move up without protecting the skin would not be beneficial to the client. Shearing force injury to the skin could still result.)

The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide? 1. Performing hand hygiene. 2. Explaining the procedure to the family. 3. Positioning the client in side-lying position. 4. Raising the head of bed 30 degrees.

3. Positioning the client in side-lying position. (3. Correct: Positioning the client in a side-lying position allows secretions to drain from the mouth and prevents aspiration. The most important aspect of care is the protection of the airway of this unconscious client. This is accomplished through proper positioning of the client in a side-lying position. 1. Incorrect: Hand hygiene is a key component of standard precautions. Hand hygiene is not a priority over preventing aspiration. 2. Incorrect: Informing the family about the procedure should be done, but is not the most important step in oral care. The nurse should explain the oral care procedure to the family. Maintaining the clients airway is the priority action. The client should be placed in the side lying position. 4. Incorrect: No, side lying is the appropriate position to allow drainage of secretions from mouth and prevent aspiration. Positioning the client with the HOB elevated to 30 degrees will not promote drainage of secretions from the client's mouth. The priority action is to maintain the client's airway.)

The primary healthcare provider (PHP) has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action? 1. Administer the injection. 2. Take vital signs. 3. Question prescription with primary healthcare provider. 4. Notify the nursing supervisor.

3. Question prescription with primary healthcare provider. (3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment. 1. Incorrect: Giving a placebo is fraudulent and unethical treatment. 2. Incorrect: Taking the vital signs does not take care of the problem of giving a placebo. 4. Incorrect: First, the nurse should discuss the prescription with the primary healthcare provider.)

The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct? Select all that apply. 1. Cut the toenails in a rounded fashion. 2. Wash the feet with warm water and betadine. 3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.

3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold. (3., 4., & 5. Correct: Shoes should be worn at all times to prevent injury. The client may step on something and not know that the foot has been injured. Inspection should be done daily, since many diabetics cannot feel if their feet have been injured. Feet may not be sensitive to hot and cold, which could cause injury. 1. Incorrect: Toe nails should be cut straight across to avoid an ingrown toenail. Additionally any skin cuts on the toes may result in infection. 2. Incorrect: Do not put harsh chemicals, such as betadine, on the feet. Betadine will dry the skin which may lead to cracks in the skin. This creates potential portals for infection to occur.)

As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number. Ans:______

30 (Rationale: BMI = kg/m² (180 ÷ 2.2) ÷ ((65 × 2.54) ÷ 100)² (180 ÷ 2.2) ÷ (165.1 ÷ 100)² (180 ÷ 2.2) ÷ (1.651)² ≈ 30 Ans: 30)

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. Measure distal NG tube from nose tip to earlobe to xiphoid process. Elevate head of bed to fowler's position. Have client swallow ice as NG tube advances into stomach. Advance NG tube upward and backward until resistance is met. Lubricate 2-3 inches of distal NG tube. Secure NG tube. Insert NG tube into unobstructed naris. Rotate catheter and advance into nasopharynx.

Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube. (First, elevate the client's head of bed to Fowler's position. Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward until resistance is met. Sixth, rotate catheter and advance into oropharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.)