NUR 313

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

1. Use a gait belt during ambulation. The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall. 2. Ensure the client is wearing socks before ambulating. The nurse should ensure the client is wearing nonskid shoes or slippers when ambulating to decrease the risk of a fall from slipping. 3. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating. The nurse should encourage the client to dangle her legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall caused from orthostatic hypotension. 4. Walk 2 feet behind the client during ambulation. The nurse should walk beside the client to provide physical support ambulating and decrease the risk of a fall.

Effects of Stress on Basic Human Needs

Physiologic Needs Change in appetite, activity, or sleep Change in elimination patterns Increased pulse, respirations, blood pressure Safety and Security Feels threatened or nervous Uses ineffective coping mechanisms Is inattentive Love and Belonging Is withdrawn and isolated Blames others for own faults Demonstrates aggressive behaviors Becomes overly dependent on others Self-Esteem Becomes a workaholic Exhibits attention-seeking behaviors Self-Actualization Refuses to accept reality Centers on own problems Demonstrates lack of control

A nurse is evaluating a clients use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The top of the cane is parallel to the client's waist.The top of the cane should be parallel to the client's greater trochanter. When walking, the client moves the cane 46 cm (18 in) forward.To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. The client holds the cane on the stronger side of her body.MY ANSWERThe client should hold the cane on the stronger side of her body to increase support and maintain alignment. The client moves her stronger limb forward with the cane.The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following should the nurse take? a) pad the clients wrist before applying the restraints b) evaluate the clients circulation every 8hr after application c) remove the restraints every 4hr to evaluate the clients status d) secure the restraint ties to the beds side rails

a) pad the clients wrist before applying the restraints The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

1. Tenderness when touched Tenderness when touched is an expected finding in a postoperative wound healing by secondary intention. Severe pain might indicate infection or underlying tissue destruction and should be reported. 2. Pink, shiny tissue with a granular appearance Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of wound healing. This is an expected finding in a postoperative wound healing by secondary intention. 3. Serosanguineous drainage Serosanguineous drainage, made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggests an infection and should be reported. 3. A halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed?

1 . Lock the wheels on the bed and stretcher. Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. 2. Instruct the client to raise his arms above his head. The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the transfer. 3 Elevate the stretcher 2.5 cm (1 in) above the height of the bed. The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. 4. Log roll the client. Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?

1. "Lunch trays should be here within the hour." This response is the nontherapeutic because it indicates that the client's immediate needs are not important. 2. "I am going to listen to your abdomen." A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered. 3. "I'll get you some water to drink." When a client is ready to resume a postsurgical diet, it is preferable to offer a choice of clear liquids, rather than water. Water provides hydration, but no other nutrients. 4. "I would wait a bit, or you could feel sick."This response reflects the nontherapeutic communication response of offering unsolicited advice to the client.

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

1. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury. 2. A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula Routine treatment for chronic lung conditions can include use of a transtracheal oxygen cannula; therefore, there is another client the nurse should plan to see first. The client will learn to use this device on his own, and the system can provide adequate oxygenation with a low flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32% oxygen delivery. 3. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar Routine treatment for a client who has an old tracheostomy includes administration of humidified oxygen or air via tracheostomy collar. Therefore, there is another client the nurse should plan to see first. The nurse should use humidification to promote loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the equivalent of administering oxygen at 6L/min. 4. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. Routine treatment for a client who has COPD is to administer low dose therapy. Therefore, there is another client the nurse should plan to see first. Clients who have COPD depend on a low oxygen level to drive their respiratory rate. Two liters per minute of oxygen is the equivalent of 28% oxygen delivery.

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

1. Abdominal binder. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed, however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first. 2. Montgomery straps The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips. 3. Hypoallergenic tape Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse should use a less restrictive intervention first. 4. Plastic tape Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less restrictive intervention first.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

1. Collect the specimen upon arising in the morning. The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container. 2. Force fluids during the day and collect the specimen in the evening. The nurse should encourage the client to force fluids, especially clear liquids, to help to thin respiratory secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen. 3. Collect the specimen after antibiotics have been started. The nurse should collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy to prevent interference with the laboratory results. 4. Collect 2 mL of sputum before sending the specimen to the laboratory. The nurse should collect 4 to 10 mL of sputum before sending the specimen to the laboratory to provide an adequate amount of sputum to test for culture and sensitivity.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

1. Drop the eye medication into the lower conjunctival sac. The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage. 2. Apply gentle pressure in the outer opening of the eye for 2 min. The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running down the duct or out of the eye. 3. Hold the eye dropper 0.5 cm (0.2 in) from the cornea. The nurse should hold the eye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea of the eye from injury by preventing the tip of the dropper touching the eye. 4. Instruct the client to close eyes tightly after administration. The nurse should instruct the client to close eyes gently when applying ointment or liquid to distribute the medication and to avoid expelling the medication or injuring the eye.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

1. Encourage the client to drink fluids before swallowing food. The client who has impaired pharyngeal swallowing is at risk for choking when liquids (especially thin liquids) are offered while eating solid foods. It is preferable to suggest "dry swallows" to clear the mouth between bites of food. 2. Offer the client tart or sour foods first. The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing. 3. Tilt the client's head backward when swallowing. The client who has impaired pharyngeal swallowing should tilt the head forward to promote swallowing. 4. Turn on the television. The client who has impaired pharyngeal swallowing should minimize distractions at mealtimes to concentrate on chewing thoroughly and swallowing.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

1. Exhale slowly to reach goal volume. The nurse should instruct the client to inhale slowly to reach goal volume and to decrease collapse of alveoli in the client's lungs. 2. Hold breath for 5 seconds after goal volume is reached. The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia. 3. Continue to deep breathe between each cycle. The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths, to reduce hyperventilation and fatigue. 4. Limit repeat pattern of breathing to 5 breaths. The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake, which helps to prevent the risks of atelectasis and pneumonia.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

1. Hold the irrigator 1.25 cm (0.5 in) above the eye. The nurse should hold the irrigator 2.5 cm (1 in) above the eye to prevent the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. 2. Direct the irrigation solution upward toward the upper eyelid. The nurse should direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. 3. Exert pressure on the bony prominences when holding the eyelids open. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. 4. Direct the irrigation from the outer canthus to the inner canthus of the eye. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

1. Instruct the client to defecate into the toilet bowl. The nurse should have the client defecate into a bedpan or a container for stool collection. The toilet water can dilute and contaminate the liquid specimen. 2. Transfer the specimen to a sterile container. The nurse should place the stool specimen a clean container using a tongue depressor. 3. Refrigerate the collected specimen. The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and prevent the specimen from getting cold. 4. Place the stool specimen collection container in a biohazard bag. The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification, and to prevent contamination with microorganisms.

A nurse is caring for a client who had a mastectomy and has a self-suctioning drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

1. Irrigate the tubing with sterile normal water once each shift. The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating. 2. Cleanse the opening with soap and water after emptying. The nurse should cleanse the drain opening with an alcohol wipe after opening it to decrease entry of microorganisms. 3. Maintain the tubing above the level of the surgical incision. The nurse should maintain the drainage tubing below the level of the incision to enhance drainage. 4. Collapse the device of air after emptying. The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

1. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube. The nurse should lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting to decrease the risk of irritation or injury to the mucosa. 2. Position the client on his right side. The nurse should position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema. 3. Insert the tip of the tubing 8 cm (3.1 in). The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. 4. Hold the enema container 61 cm (24 in) above the rectum. The nurse should hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

1. Maintain suction while removing the NG tube. The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastrointestinal mucosa. 2. Instill 100 mL of air into the NG tube before removal. The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube. 3. Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents. 4. Instruct the client to breathe in and out during the removal of the NG tube. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents.

A nurse is carin for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site.

1. Redness at the IV catheter entry site The client who has redness at the IV catheter entry site might have a local infection. The nurse should remove the IV, clean the site with alcohol, and start a new IV line in another location. 2. A palpable cord is felt along the vein used for the infusion The client who has a palpable cord felt along the vein might have phlebitis, which is inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a new IV line in another location. 3. Taut skin around the IV catheter site that is cool to the touch The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress, or a cold compress according to the type of infiltration. 4. Bleeding at the IV insertion site Bleeding at the IV insertion site might indicate the IV system is not intact. The nurse should check to determine if the IV system is intact and if the catheter is within the client's vein. The nurse might need to start a new IV line in another location if the bleeding does not stop after interventions.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

1. Renew the prescription for the use of restrains within 24 hr. The nurse should plan to renew the prescription for the restraints within 24 hr, and only after the provider has evaluated the client. 2. Secure the restraint with the buckle side next to the client's skin. The nurse should secure the client's restraints with the softer side next to the client's skin, with the buckle or velco closure on the outside. 3. Ensure 4 fingers can be inserted under the secured restraint. The nurse should ensure 2 fingers can be inserted under the restraints to prevent the restraint from being too loose. If the nurse is unable to insert 2 fingers under the restraint, it could cause impaired circulation to the extremities. 4. Remove the restraint every 3 hr. The nurse should remove the restraint at least every 2 hr and at that time check the client's skin, change the client position, toilet, or exercise the client.

A nurse is applying antiembolitic stockings for a client who has a history of DVT. Which of the following actions should the nurse take when applying the stockings?

1. Roll the stocking partially down if too long. The nurse should apply another size stocking if the stocking is too long. Rolling the stocking partially down can decrease venous return and cause skin irritation. 2. Remove the stocking once per day. The nurse should remove the stockings once every shift to inspect the skin and check circulation. 3. Bunch and pull the stocking half way up the calf. The nurse should slide the top of the stocking up over the client's calf all at once to lessen constrictive wrinkles that can decrease venous return. 4. Turn the stocking inside out up to the heel before applying. The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

1. Sanguineous exudate Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings. 2. Serous exudate Serous exudate drainage on the client's dressings indicates plasma from the blood and appears clear to light yellow, and is watery. 3. Serosanguineous exudate Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged and watery drainage. 4. Purulent exudate Purulent exudate drainage on the client's dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

1. Stand toward the client's stronger side. Safely transferring a client from a bed to a wheelchair requires the nurse to stand in front of the client toward the side that requires the most support. This technique will help maintain balance during the transfer. 2. Instruct the client to lean backward from the hips. Safely transferring a client from a bed to a wheelchair requires the nurse to instruct the client to lean forward from the hips. This technique positions the client in the proper direction of the movement. 3. Place the wheelchair at a 45° angle to the bed. Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required. 4. Assume a narrow stance with feet 15 cm (6 in) apart. Safely transferring a client from a bed to a wheelchair requires the nurse to assume a wide stance with one foot in front of the other. This technique protects the nurse from losing balance during the transfer.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

1. Start chest compressions. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation, which starts with chest compression, then opening the airway, and breathing for adults and pediatric clients because evidence indicates there is a great survival rate when chest compressions are started before a breath is initiated. 2. Provide breaths with a manual resuscitation bag. The nurse should provide breaths with a manual resusciation bag to oxygenate a client during cardiopulmonary resuscitation; however, there is another action the nurse should take first. 3. Administer oxygen. The nurse should administer oxygen to a client to ensure adequate oxygen is circulating during cardiopulmonary resuscitation; however, there is another action the nurse should take first. 4. Establish an airway. The nurse should establish an airway to perform ventilations and oxygenate the client during cardiopulmonary resuscitation; however, there is another action the nurse should take first.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?

1. The wound edges are well-approximated. Primary intention occurs when the closing of the wound using sutures or staples occurs at the time the incision is made and the suture line edges become well-approximated during healing. 2. The wound is closed at a later date. Tertiary intention includes using sutures to close an open wound at a later date after the wound drains and starts to heal. 3. A skin graft is placed over the wound bed. Tertiary intention can include the provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing. Skin grafting is required for deeper wounds, such as full-thickness burns, and is only rarely required for surgical wounds that do not heal. 4. Granulation tissue fills the wound during healing. The nurse should include in the teaching that a beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention that should occur within 5 to 21 days. Open wounds place the client at an increased risk for wound infection.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

1. Withdraw the specimen from the drainage bag. The nurse should use a fresh urine specimen obtained near the indwelling urinary catheter to prevent contamination. 2. Cleanse the collection port with soap and water. The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination. 3. Place the specimen in a clean specimen cup. The nurse should place the specimen in a sterile specimen cup to prevent contamination. 4. Clamp the tubing below the collection port. The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.