PassPoint - Basic Physical Care

A client with newly diagnosed chronic obstructive pulmonary disease (COPD) presents to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful?

"I should avoid using powders."

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

"I will administer the enema while lying on my left side with my right knee flexed."

A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding?

"My child can't eat wheat, rye, oats, or barley."

The nurse has completed discharge teaching with new parents who will be bottle-feeding their term newborn. Which statement by the parents reflects the need for more teaching?

"We should weigh our baby daily to make sure they are gaining weight."

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply.

-Monitor distal pulses of the affected extremity. -Maintain the leg elevated above the level of the heart. -Administer anticoagulation per healthcare provider's order.

What should the nurse instruct a client who has cerumen buildup in the ear to do? Select all that apply.

-Wash the external ear with a washcloth. -Instill cerumenolytic drops in the ear canal. -Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.

A nurse is working with an unlicensed assistive personnel (UAP). Which client(s) should the nurse assign to the UAP? Select all that apply.

-older adult client who had hip replacement surgery and needs to walk in the hall with a walker -adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours

The nurse is planning care for a client on complete bed rest. To prevent venous thrombosis, what should the nurse include in the plan of care? Select all that apply.

-turning every 2 hours -passive and active range-of-motion exercises -use of thromboembolic disease support (TED) hose

The nurse would most likely expect to manage a percutaneous feeding tube as part of daily care for which client?

90-year-old client with dysphagia following a stroke

Which client is at increased risk for developing a wound infection?

A client with an albumin level of 2.4 g/dl

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation?

Ask for a private meeting to explore the charge nurse's concerns in detail.

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error?

Assess the patient for the medications' effects.

An adult admitted to the hospital with a hemoglobin of 6.5 g/dL (65 g/L) is experiencing cerebral tissue hypoxia. What should the nurse do next?

Assist the client in ambulating to the bathroom.

A client had abdominal surgery 2 days ago and has copious drainage. The nurse uses Montgomery straps when changing the dressing. Which is the expected outcome of using these straps?

Avoid skin breakdown.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care?

Bending and twisting while providing care may cause injury.

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client?

Client is recovering from abdominal surgery.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

Client's level of consciousness

The nurse is preparing to administer a continuous enteral feeding. Which action is most important for the nurse to include in the plan of care?

Elevate the head of the bed.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

Encourage a high-calorie, high-protein diet.

The nurse is caring for a client with a Jackson-Pratt drain. Which action by the nurse would be the most appropriate?

Ensure that the drainage receptacles are kept compressed to maintain suction.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure?

IV catheter insertion

The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse?

Measure client's thighs and calves to ensure the antiembolism stockings are the correct size.

A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy?

Monitor the appearance, size, and number of stools.

A client in a long-term care facility has signed a form stating that they do not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next?

Notify the physician that the client has no vital signs.

Which nursing assessment is recommended to confirm placement of the nasogastric (NG) tube into the stomach of a client?

Obtain a chest X-ray and measure the pH of stomach contents.

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately?

Obtain more information from the client about the nurse's findings.

The nurse is planning care for a hospitalized client who is blind. What should the nurse do to ensure safety for this client?

Orient the client to the room environment.

What should the nurse do to prevent pressure ulcers in an older adult?

Perform a systematic skin assessment at least once a day.

Bacterial conjunctivitis has affected several children at a local daycare center. A nurse should advise which measure to minimize the risk for infection?

Perform thorough handwashing before and after touching any child in the daycare center.

The home health nurse is conducting a safety assessment in an older adult's home. On the bathroom floor, the nurse finds a throw rug that the client refuses to remove. What is the appropriate recommendation by the nurse?

Place nonslip backing on the underside of the rug.

Which item must the nurse consider when positioning a client for tracheal suctioning?

Position in a semi-Fowler's position.

A client is admitted to the postanesthesia care unit following a left hip replacement. The initial nursing assessment is temperature 96.6°F (35.9°C); pulse 90 bpm; respiration rate 14 breaths/min; and blood pressure 128/80 mm Hg. The client only responds with moaning when spoken to. What should the nurse do first?

Position the client on the right side.

A nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 325 mg enteric coated aspirin to be given via the feeding tube once daily. How should the nurse give this medication?

Request an alternate formulation

The nurse is assessing a client who is receiving normal saline intravenously at 100 mL/hr through the right forearm. The nurse observes that the forearm is swollen, cold to the touch, and pale. What action would the nurse take?

Restart the infusion at a different site.

Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task?

Scheduling staff assignments for the next month

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

Shift your weight every 15 minutes.

A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which priority would be the most important?

Teach about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness.

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The catheter bag is placed on the client's lap for safe transport.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next?

The incident report will provide a basis for promoting quality care and risk management.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure?

The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

The urine output is more than 35 mL per hour.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should perform which action?

Use an alternating air pressure mattress.

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine?

albumin level

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort?

assault

Which option is an example of a primary preventive measure?

avoiding overexposure to the sun

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

care-based ethics

While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which type of precautions for this client?

contact precautions

A partner of a client diagnosed with Kaposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that the client "has just given up. I know with medication my partner will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving?

denial stage

A nurse-manager appropriately behaves as an autocrat in which situation?

directing staff activities if a client experiences a cardiac arrest

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care?

documenting the situation and providing support for the victim

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy

A client is admitted with peritonitis. Which is the priority of nursing care for this client?

fluid and electrolyte balance

A nurse is assessing a client for the risk of falls. The nurse should obtain

gait and balance information.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used?

handling of the dislodged radiation source.

Which strategy can help make the nurse a more effective teacher?

including the client in the discussion

A water-soluble biohazardous bag is placed in the room of a client in contact precautions. Which item should the nurse place into this bag?

linens

Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis?

sliding the client to move up in bed

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?

sodium

Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers?

systematic skin assessment at least once per shift

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with the most recent being temperature 98.6°F (37°C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16 breaths/min, and heart rate (HR) 78 bpm, but these signs are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?

temperature 101.8°F (38.8°C); BP 140/86 mm Hg; HR 94 bpm; RR 24 breaths/min

The nurse is caring for a client with knee high antiembolism stockings. Which assessment finding does the nurse prioritize as needing notification of the healthcare provider?

unilateral swelling

The nurse is planning care for an older adult with an indwelling catheter who is at risk for septic shock. Which nursing action will be most important for this client?

using aseptic technique when caring for the catheter

The mother of a client who has a radium implant asks why so many nurses are involved in their daughter's care. They state, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client?

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.