1. Basic Physical Care PrepU

Which statement indicates that the client who has undergone repair of the nasal septum has understood the discharge instructions?

"I will take stool softeners and modify my diet to prevent constipation."

The nurse is teaching a client with an ostomy about the care of the appliance to decrease the risk of skin irritation and potential skin breakdown. Which client statement indicate that learning has occurred? Select all that apply.

-"I will push the skin away from the seal of the bag instead of pulling the bag against the skin." -"I will apply skin protectant around the stoma after cleaning the site." -"I will clean the skin with mild soap and water and pat the skin dry."

A nurse is caring for a client who underwent surgical repair of a detached retina in the right eye. Which nursing interventions would the nurse perform postoperatively? Select all that apply.

-Administer a stool softener -Discourage client from bending down -Orient client to the environment -Approach client from the left side

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply.

-Administer diphenhydramine -Insert an IV -Have RT provide an albuterol treatment

The nurse is planning care for a client postoperatively to prevent pressure ulcers. Which interventions should the nurse include in the plan of care? Select all that apply.

-Turning every 2 hours -Keeping linens dry -Monitoring nutritional status

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 ROM exercises -Use of TED hose

A client suddenly loses consciousness. What should the nurse do first?

Assess for responsiveness

A nurse is working within the managed care delivery model. Which is true regarding managed care?

All systems reflect the values of efficiency and effectiveness

A physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by:

Checking and taping all connections

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day?

Complete regular admission procedures

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse?

Explore other ways to control symptoms and address the family's concerns more effectively

When bandaging a client's ankle, the nurse should use which technique?

Figure-eight

A client is admitted with peritonitis. The priority of nursing care for this client is:

Fluid and electrolyte balance

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Increasing fluid intake

A client reports occasional numbness in the fingers and lips. Which dietary choices should the nurse encourage the client eat?

Milk products

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response?

Notify the anesthesiologist

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate?

Offer the client frequent oral hygiene care

A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation above, which procedures would the nurse implement next?

Performing active ROM exercises of the legs

The 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 NS via IV at 100 mL/hr through the right forearm. The nurse observes that the forearm is swollen, cold, and pale. What action should the nurse take?

Restart the infusion at a different site

Which action by the client indicates that the client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy?

The client takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips

A nurse is caring for a male client of a different culture. Which nursing actions should the nurse include to provide culturally-appropriate care to this client? Select all that apply.

-Allowing the daughter to bring food from home appropriate to the client's dietary plan -Inquiring about a dining ritual that is often used at home -Including the religious leader when developing the plan of care per the client's wishes

The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply

-Wash hands with soap and water -Wear a protective gown when in the room

The nurse has just received morning change-of-shift report on four clients. In what order from first to last should the nurse perform the actions? All options must be used.

1. Notify the HCP about a client who has a serum potassium level of 6.2 mEq/L 2. Assess the client who has been vomiting according to the report from the night nurse 3. Discuss the plan for the day with the UAP, delegating duties as appropriate 4. Begin discharge paperwork for a client who is eager to go home

The nurse notices a fire in a wastebasket in a patient's room. In which order of priority from first to last should the nurse perform the actions?

1. Remove the patient from the room 2. Pull the fire alarm 3. Confine the fire by closing the door to the patient's room 4. Extinguish the fire

The client is wearing graduated compression stockings and begins to report leg pain in the right leg. Place the steps in order taken to accurately assess this client. All options much be used.

1. Remove the stockings. 2. Assess the skin for redness and the leg for swelling. 3. Assess for warmth discrepancies in both legs. 4. Measure the calves of both legs. 5. Notify the HCP.

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is:

A legal document initiated by the physician to give the client DNR status

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:

Assess for pain

The nurse instructs the unlicensed assistive personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which technique should the nurse ask the UAP to incorporate into the client's daily care?

Use a soft toothbrush to brush the client's teeth after each meal

When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first?

Gloves