Adaptive Quizzing Basic Care and Comfort

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs?

Correct4 High in protein and vitamin C

The mother of a 5-year-old child recovering from varicella (chickenpox) calls the nurse in the pediatric clinic, asking how the child's itching can be relieved. What is the best response by the nurse?

Correct4 Pat the lesions while applying the prescribed calamine lotion

Non-weight bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, what is the most important activity the nurse should teach the client?

Exercise the triceps, finger flexors, and elbow extensors

Which is the priority nursing intervention in order to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination?

Explaining the procedure and maintaining eye contact while touching the client gently

A nurse is developing a plan of care for an infant with nonorganic failure to thrive. What is the most important aspect of care to be incorporated into the plan?

Following a structured routine throughout the day

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first?

Gather more data from the night nurse about the technique used

A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention should the nurse emphasize?

Giving small amounts of clear liquids frequently to prevent dehydration

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care?

Head of the bed remains elevated after the feeding.

During her first prenatal visit the client reports that her last menstrual period began on April 15. According to Nägele rule, what is the expected date of delivery (EDD)?

Jan 22 To determine EDD with the use of Nägele rule, subtract 3 months from the date of the last menstrual period and add 7 days. January 8 is 2 weeks too early according to this formula. February 8 is too late. February 22 would be 1 month past the true EDD.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation?

Leaving a dim light on in the client's room at night

Which functional level of trauma center is involved in providing a full continuum of trauma services?

Level I

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of what?

Nerve endings in the limb that are still intact and react to stimuli

A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying?

Offer a pacifier

Which statement is true about the sleep pattern of preschoolers?

On average, a preschooler sleeps about 12 hours a night.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be?

Perform a complete pain assessment.

A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication?

Place the pill under the tongue and let it dissolve.

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI?

Prevent the development of clots in the bladder.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?

Previous experience and cultural values

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions?

Provide high-calorie foods between meals.

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse's priority intervention be?

Provide the client with comfort measures used for women in labor.

A nurse is caring for a client who underwent surgery for laryngeal cancer. Which nursing action may help to communicate effectively with the client? Select all that apply.

Providing the client with praise and encouragement Collaborating with a speech and language pathologist Asking the client to make noise when immediate attention is required

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

The stockings should be applied before getting out of bed.

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions?

This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.

The nurse provides moist heat to a client with cartilage degeneration. What is the rationale for this nursing intervention?

To increase blood flow to the area

While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention?

To prevent further edema

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?

Use lemon juice to season meat.

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant?

Weak, rapid pulse

A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child's history reveals a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child's edema?

Weighing daily

A nurse is preparing a 10-year-old child for a tonsillectomy and adenoidectomy to be performed later in the day. What information should the nurse share with the child?

What the child will experience before and after the procedure

A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid?

Wheat and oat products

Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item?

apple

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend?

apple doesn't irritate stomach

A nurse needs to perform a postural drainage of both lung apices in a 4-year old child. In what position should the nurse place the child?

sitting up on nurses lap

A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent?

swimming

Discharge teaching for a client with hypercholesterolemia includes nutritional instructions for a diet low in saturated fat. Which items included by the client on a list of foods to avoid support the nurse's conclusion that teaching is effective?

whole milk an cheese Milk and milk products are high in fat and should be limited to reduce cholesterol levels. High-fiber foods are beneficial and should be encouraged. Canned vegetables have very little fat. Citrus fruits have no fat and should be encouraged.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

penne pasta, spinach, banana, and decaffeinated iced tea

A nurse educates a group of parents about how to teach their children to safely cross roads and walk in parking lots. Which age group of the children is the nurse referring to?

preshcoolers

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

provide perineal care

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis?

salad, sliced chicken

An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip?

sing modified techniques for feeding

Which food should the nurse recommend for a toddler-age client who is at risk for developing rickets?

yogurt

primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with what

Correct4 Doppler ultrasound at 10 to 12 weeks

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?

pain

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective?

"Before I start the procedure, I will measure the residual volume."

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching?

"Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."

A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase?

"The client will maintain present muscle strength.

An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. What is the best response by the nurse?

"The energy that would have been expended on suckling is conserved."

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan about prevention of thrombophlebitis?

Correct4 Put on compression stockings before arising

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position?

1 to 2 hours

An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room?

Correct4 Say the child's name and touch the child's arm before starting care.

A nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. What is the volume of solution the nurse should prepare?

250 to 350 mL

A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest?

Correct4 Taking a hot tub bath or shower in the morning

A low-residue diet is recommended for a client. Which food should the nurse encourage the client to select from a menu?

Creamed potatoes

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare?

500 to 750 mL

What is the recommended size of the urinary catheter that can be used in a 3-year-old child?

8 to 10 Fr The recommended size of a urinary catheter that can be used in a 3-year-old child is 8 to 10 Fr. A urinary catheter of 5 to 6 Fr is generally used in infants. A length of 14 to 16 Fr is recommended for most adult clients. A length of 16 to 18 Fr is commonly used in adult mal

The parents of a child with acute poststreptococcal glomerulonephritis ask a nurse why their child is being weighed every morning. What is the best response by the nurse?

Correct

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow?

Correct1 Add extra salt to food

An older adult client who is confused and often does not recognize family members is admitted to a nursing home. The client appears slovenly, often soiling clothing with feces and urine. How can the nurse best manage this problem?

Correct1 Toileting the client every 2 hours

How should a nurse prepare a client for cranial surgery?

Correct2 Obtain the client's consent to shave the head

A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child?

Abduction of the hip

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure?

All metal, such as jewelry and hair ornaments, has been removed.

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome?

Allows excess tissue fluid to be excreted

A nurse is assessing a client with a diagnosis of primary open-angle glaucoma. Which ocular symptom should the nurse expect the client to report?

Correct3 Decreased peripheral vision

What is the optimal nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs

A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition?

Asking the parents to visit at mealtime

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress?

Bland foods

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention?

Check the compatibility of the medication and the continuous IV solution.

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis?

Comfort

A 10-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage?

Corn on the cob, baked chicken, rice, apple, and milk

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan?

Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

A client with severe chronic rheumatoid arthritis reports that pain lasts for 2 to 3 hours after exercising. What should the nurse should teach the client to do?

Decrease the total time and number of repetitions of the exercise

A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?

Deep breathing exercises

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia?

Deficiency of thiamine

The nurse is providing postoperative care to a client who had surgery in which a hip prosthesis was inserted. An abductor splint is in place. When should the nurse remove the splint?

During the client's skin care and physical therapy

A nurse is caring for a client who will have a below-the-knee amputation with an immediate postoperative prosthesis. The client asks the nurse the advantage of having an immediate prosthesis. What should the nurse explain is the advantage?

Encourages a normal walking pattern

A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include?

Encouraging continuation of breastfeeding

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges?

Put an ice pack on the affected area."

After abdominal surgery, a 5-year-old child is experiencing pain, and an opioid analgesic is prescribed. What should the nurse consider about children in pain and their response to opioid analgesics when an opioid analgesic is prescribed?

Even though children do not like taking medicines, analgesics will make them more comfortable.

A nurse performing a newborn assessment elicits the Babinski reflex. What does the nurse conclude that this finding indicates?

Immaturity of the central nervous system (CNS)

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve?

Reduce colonic irritation

A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures aimed to do what?

Relieve the client's discomfort

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?

Returning the aspirate and subtracting the amount of the aspirate from the feeding

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?

Rise of formula in the tube

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day.

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant?

Supine, with the head elevated about 45 degrees

A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program?

The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

primary consideration for a patient with rheumatoid arthritis

comfort

A nurse is performing range-of-motion exercises with a client who had a cerebrovascular accident (CVA). The nurse places the client's hand in the position exhibited in the picture. What is the term for this position?

extension

A client with severe breathing problems is brought to the emergency ward. Which level of Maslow's hierarchy of needs does the nurse need to follow?

first level

A nurse teaches the mother of a 2-year-old child who has celiac disease which foods to avoid. Which foods identified by the mother indicate that she understands the teaching?

maccaroni and cheese