Saunders 3

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

1,2,4

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

1. Pedal pulses 2. Capillary refill 3. Color of the extremity 4. Temperature of the skin

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply

1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000/mm3

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action?

Activate the fire alarm

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

Aim @ the Base

The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates the balloon, the client complains of discomfort. Which is the appropriate nursing action?

Aspirate the fluid, advance the catheter further, and reinflate the balloon.

The nurse is preparing to administer medication through a nasogastric (NG) tube that is connected to suction. Which indicates the accurate procedure for medication administration?

Clamp the NG tube for 30 minutes after medication administration.

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Closes the roller clamp on the IV tubing

The nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which action should the nurse implement?

Contact the electrical maintenance department for assistance.

The nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, which should the nurse avoid to minimize the chance for further injury?

Delays in responding to call light

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

The nurse prepares to administer a prescribed dose of scopolamine (Transderm-Scōp). The nurse should monitor for which side effect of this medication?

Dry Mouth

The nurse is preparing to begin a continuous tube feeding on a client with a nasogastric tube. In which position should the nurse place the client for safe administration of the tube feeding?

Elevated 45*

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands?

Every 30 Mins

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

Every Hour

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescents knowledge of gun safety

The nurse is preparing to reposition a dependent client who weighs more than 250 pounds. Which intervention is best for the nurse to consider when moving this client?

Find Help

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200 mL. Which action should the nurse take?

Hold the feeding

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?

Logrolling

The registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which supply obtained by the LPN indicates a need for further teaching regarding this procedure?

Oil-Soluble Lubricant

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should avoid which action when performing this procedure?

Placing suction on the catheter while introducing the catheter into the tracheostomy tube

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semireclined, rear-facing position.

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which item is least appropriate to use and could cause harm to the client?

Restraints

The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of the tube, the nurse should assist the client to which position?

Right Side

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

Scissors

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. How should the nurse transfer the client from the stretcher to the bed?

Slider board and assistance of 4 people

The nurse obtains a prescription from the health care provider to restrain a client using a jacket (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the client tells the nurse that a space heater is used to heat the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn.

The nurse is performing an environmental assessment in the home of an older client. Which requires immediate attention?

Unsecured Scatter Rugs

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal, how should the nurse position the client?

Upright in a chair

The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which?

Using products with lemon or alcohol

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the health care provider?

Valerian

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse should explore with the mother which suggestion to decrease the children's sense of isolation and fear?

You should seek community after-school programs or activities for your children."

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with a fever. The LPN intervenes if the UAP obtains which unnecessary item(s)?

a bottle of alcohol

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statement?

"I drink hot chocolate before bedtime."

The emergency department nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

"We will be sure not to leave hot liquids unattended."

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.

2,4,5,6

The registered nurse (RN) tells a licensed practical nurse (LPN) that the health care provider has prescribed a hypotonic intravenous (IV) solution for a client. Which IV solution should the LPN obtain for administration to the client?

45% Saline

A client is being discharged to home following spinal fusion with insertion of rods. For which home environment situation should the nurse suggest a consultation with the continuing care nurse?

Bedroom and bath on 2nd floor

The nurse is preparing to change the neck ties on a tracheostomy tube. Which action should the nurse take?

sencnd health care member to assist