Basic Care & Comfort

​A nurse is caring for a postoperative client. Which of the following comfort measures should the nurse recognize as appropriate to include in the care? (Select all that apply.)

Keep bed linens smooth -One simple way to promote comfort is by removing or preventing painful stimuli. This is especially important for clients who are immobilized postoperatively. The nurse should monitor the client more frequently and change linens as needed if the client is diaphoretic, has draining wounds, or is incontinent. The linens should remain clean, dry, and free of wrinkles. Monitor transcutaneous electrical nerve stimulation (TENS) therapy -This is effective for controlling postsurgical and procedural pain. This therapy requires a prescription from the provider. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. A mild electrical current is passed through the electrodes and stimulates the skin. The client controls the device. The client should feel a buzzing or tingling sensation. The client will adjust the intensity and quality of skin stimulation until pain relief occurs. Give a back massage. -Massage is effective for producing physical and mental relaxation, reducing pain, and enhancing the effectiveness of pain medication. This will promote sleep and comfort. Teach relaxation techniques, such as guided imagery -Relaxation techniques, such as meditation, yoga, guided imagery, and deep breathing, alter cognitive pain perception. Relaxation techniques promote a sense of well-being and diminish stress. This in turn can help the client develop confidence to manage the challenges of pain.

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

"I only need to catheterize myself twice a day." -The client who has spina bifida has paralysis from the level of the defect down. In the majority of cases, this affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent emptying of the bladder can result in stasis and urinary tract infections.

A nurse is caring for a client undergoing a lumbar puncture. The appropriate nursing action to maintain privacy for the client is to

pull the curtains around the client's bed. -Pulling the curtains around the client's bed assures privacy for the client should someone open the door or enter the room.

​A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

"Skeletal traction is more appropriate than skin traction for reducing a fracture. " ​-Skeletal traction allows for reduction and alignment of a fracture. Skin traction decreases muscle spasms commonly associated with a fracture.

A nurse provides teaching to a client who is being fitted for a prosthetic leg. Which of the following statements indicate to the nurse a need for further instruction?

"The prosthesis fitting will occur at the time the staples are removed." -This is a false or untrue statement and indicates a need for further instruction. The staples are removed before the shrinking and shaping of the residual leg is complete. The prosthesis would not fit once this process is complete.

A nurse is providing oral care for an immobilized client. Which of the following interventions should the nurse take?

Position the client on one side before starting oral care. -This is the appropriate action. Placing the client on one side encourages fluids to run out of the client's mouth, lessening the risk of aspiration and choking.

A nurse is teaching a parent of an infant about bottle-feeding. Which of the following statements by the parent indicates a need for further teaching?

"Each feeding should last about 15 minutes." -Infants will suck vigorously for the first 5 minutes of a feeding. However, infants should be allowed to continue to suck for at least 20 minutes.

A nurse is planning care for an older adult client who is at high risk for developing pressure ulcers. Which of the following is an appropriate measure for the nurse to include?

Use a draw sheet to move the client up in bed. -Using a draw sheet or a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

​A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. Which of the following statements indicates the client understands the teaching?

​"Liver must be eliminated from my diet." ​-The nurse should encourage the client who has gout to avoid organ meats, such as liver due to high levels of purine. -Patients who have gout should include fruit servings as part of a healthy diet

​A nurse is caring for a group of clients. Which of the following clients should the nurse know has an increased risk of aspiration while eating? (Select all that apply.)

​A client who has a new diagnosis of gastroesophageal reflux disease is incorrect. -There is no increase in the risk of aspiration while eating for a client who has GERD. Reflux of gastric contents occurs most often at night during sleep. The client should be instructed to raise the head of the bed 6 to 12 inches during sleep and to try to sleep on the right side. These activities can help decrease reflux of gastric contents. Aspiration pneumonia is a complication of GERD. This client also should elevate the head of the bed immediately after eating as well. A client who was admitted with a diagnosis of cerebrovascular accident is correct. -Clients who have had a cerebrovascular accident are at risk of experiencing swallowing difficulties. These clients should be kept NPO until their swallowing ability has been thoroughly evaluated. Follow agency policy regarding this procedure. A swallowing scan can be prescribed, or the client may be evaluated by a speech-language pathologist. This client has an increased risk of aspiration. A client who is 4 hr postoperative following a leg amputation with general anesthesia is correct. -The client who is recovering from sedation and has been intubated is at increased risk of aspiration. Both the medications and intubation can decrease the ability to swallow postoperatively. This client should be observed carefully during the first meal to monitor for potential aspiration. A client who is 8 hr following traumatic laryngeal nerve damage is correct. -Laryngeal nerve damage can result in paralysis of one or both vocal cords. It also may result in open or closed vocal cord paralysis. If closed, this results in an impaired airway in which stridor is the major manifestation. If the vocal cords are open, manifestations include hoarseness, a "breathy" weak voice, and aspiration of food. This client is at risk of aspiration. A client who has a prior shift admission with a recent prolonged coughing episode is correct. -Coughing episodes can increase the risk of coughing during food intake. A recent coughing episode can weaken the swallow reflex. In clients who have respiratory disorders, such as pneumonia, aspiration has a significant impact on outcomes. The ability of the lungs to evacuate additional food or fluid is compromised, and the presence of aspirate can interfere with adequate oxygenation. Even if a client has been eating successfully, the coughing episode increases the risk of choking. This client is at risk of aspiration.

​A nurse is caring for a client whose right leg is placed in Buck's traction. Which of the following should the nurse implement to promote mobility?

​Active range of motion to the left leg ​-Active range of motion is the best way for a client to maintain joint function and mobility while on bed rest. Active range of motion requires the client's strength to move a joint. This would be possible in the left leg. The goals of active range of motion include prevention of contractures, prevention of thrombus, and maintenance of some muscle mass and strength. Buck's traction is a form of skin traction. The primary purpose of skin traction is to decrease painful muscle spasms. Active range of motion in the right leg would be contraindicated.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client. -Slipper-socks are soft, short socks with a non-skid bottom that are dispensed to hospital clients to help provide warmth and increase the client's level of comfort.

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

Soy milk -Soy milk is the best choice for this client because soy milk is lactose-free.

​A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions is appropriate to include in the plan of care?

​Decrease the client's fluid intake. -​The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

bottle feeding

-Feeding an infant on alternate sides offers different stimuli and should be encouraged. -Holding an infant close during feedings will help to ensure emotional closeness and should be encouraged. -Infants need at least 2 hr of sucking each day to provide for oral gratification.

​A nurse provides a back massage as palliative care to an unconscious client who is grimacing and restless. Which of the following indicates a therapeutic response? (Select all that apply.)

​The shoulders droop is correct. The facial muscles relax is correct. The respiratory rate increases is incorrect. The pulse is within normal range is correct. The legs are drawn up to a fetal position is incorrect. -A back rub promotes relaxation, relieves muscular tension, and decreases perception of pain. The relaxation or drooping of the shoulders would be a positive response to the backrub.

​A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?

​Vitamin A -​The nurse should instruct the client that fat-soluble vitamins include vitamins A, D, E, and K.

A nurse is caring for a client whose immobility is impaired. Which of the following support devices should the nurse plan to use to keep the client from developing plantar flexion contractures?

Foot board -Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. Placing the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, keeps them dorsiflexed and prevents this deformity.

​A nurse should reinforce teaching on how to use a three-point gait for which of the following clients requiring crutches?

​A client who has a right femur fracture prescribed no weight bearing of affected leg ​-A three-point gait is appropriate for this client. A three-point gait requires the client to bear all of the weight on one foot. In a three-point gait, the client bears weight on both crutches and then on the uninvolved leg, repeating the sequence. The affected leg does not touch the ground.

​A nurse is providing palliative care to a hospice client who is unconscious. Which of the following prescriptions should the nurse expect? (Select all that apply.)

Suction PRN is correct. -Suctioning assists in maintaining the client's airway and promotes a more comfortable/peaceful death. Palliative care is identified as the level of care that is designed to relieve or reduce intensity of uncomfortable symptoms but not to produce a cure. Palliative care relies on comfort measures and use of alternative therapies to help individuals become more at peace during the end of life. Hospice care uses an interdisciplinary approach to recognize and address the holistic needs of clients and families to facilitate quality of life and a peaceful death and care that neither hastens nor postpones death but provides relief of symptoms. Place on a Posey bed is incorrect. -A Posey bed is a soft-sided, self-contained enclosed bed that is much less restrictive than chemical or physical restraints. It allows for freedom of movement and thus reduces the side effects, such as pressure ulcers and loss of dignity, caused by physical restraints. An unconscious client would not need to be restrained. Obtain vital signs every 2 hr is incorrect. -Monitoring vital signs every 2 hr will not help relieve uncomfortable symptoms or provide for a more peaceful death. Vital signs are taken usually once a shift for hospice clients in order to give health care personnel data regarding the client's current state of health. Frequent monitoring of vital signs is indicated to recognize changes that could cause or lead to a decline in health or death in order to intervene to reverse the condition. Death is expected for the unconscious hospice client receiving palliative care, and interventions to delay death are not part of care. Perform mouth care every hour is correct. -Oral care is needed to offset a decrease in salivary secretions and enhance the comfort level of the client. Dry mucous membranes often crack and lead to pathogens entering the system. Oral care promotes client comfort and facilitates client well-being. When performing mouth care, the nurse should not use any product that could further dry the mucous membranes (e.g., mouthwashes containing alcohol or lemon glycerin swabs). Chlorhexidine rinse 0.12% is recommended and has been found to reduce the risk for ventilator-associated pneumonia in intubated clients. Administer oxygen 2 L/min per nasal cannula is correct. -Immobility negatively affects the respiratory system. Symptoms include dyspnea, crackles, wheezes, and hypoventilation. Hypoventilation occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide. Anxiety and restlessness are signs of inadequate oxygen supply. Providing low-flow oxygen per nasal cannula facilitates the comfort level of the client.

​A nurse is preparing to remove an NG tube from a client. Which of the following should be the nurse's priority action?

Verify provider order to discontinue the tube. -​Discontinuing a NG tube requires a provider order. Therefore, confirmation of an order would be a priority before removal of the tube. Nasogastric tubes can be used to provide enteral nutrition, to administer medication, and to provide gastric decompression.

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low cholesterol diet?

"I eat two eggs for breakfast each morning." -Clients should avoid eating eggs which are high in cholesterol.

A nurse working in an orthopedic unit is caring for four clients. Which of the following clients is at greatest risk for skin breakdown?

An older adult client who has a hip fracture and is in Buck's traction. -Due to the aging process (decreased muscle mass, thin and fragile skin), and the limitation of movement of this client, this client is at the greatest risk for skin breakdown.

​A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the skin. ​-Skin that is left in contact with urine for prolonged periods of time is at risk for maceration and breakdown. Cleansing the skin and removing items that are wet (e.g., incontinence pads, sheets, undergarments) is a priority to prevent breakdown. Moisture-barrier ointments and creams also are useful to prevent the urine from coming in contact with the skin. Moisture barriers should be applied to the client's skin after cleansing, keeping the epidermis lubricated but not oversaturated.

​A nurse is caring for a client who has thickened skin, hyperpigmentation, and parasthesia in the lower extremities. Which of the following actions should the nurse implement?

Apply elastic stockings. ​-This client is exhibiting signs and symptoms of venous insufficiency. Venous insufficiency occurs as a result of prolonged venous hypertension, which stretches the veins and damages the valves. Signs and symptoms of venous insufficiency include itching and tingling, dull aching sensations, cramping and heaviness in legs, thickened skin, hyperpigmentation, discomfort when standing, painless ulcerations, and leg edema. Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic stockings should be worn during the day and evening, and applied before getting out of bed. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart.

​A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following should the nurse recommend to the client as an appropriate sweetener?

Nonnutritive sugar substitute -​Clients who have type 1 diabetes mellitus should limit carbohydrate intake. Nonnutritive sugar substitutes allow the client to sweeten the taste of foods without increasing carbohydrate intake.

​A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

​"Eating yogurt can help decrease the amount of gas that I have." -​The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following is an appropriate nursing intervention?

Apply the bag for 30 min at a time. -The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no unexpected effects. -Wait 1 hr after removing the ice to reapply

​A nurse is caring for a client following a left hip arthroplasty. Which of the following should the nurse implement to prevent dislocation?

Maintain foam wedge between legs. -​Because the muscle surrounding the hip joint has been cut to expose and replace the diseased joint, clients are at risk for hip dislocation. Proper body alignment after total hip arthroplasty includes keeping the affected leg slightly abducted. A major complication of total hip arthroplasty is subluxation (partial dislocation) or total dislocation. In some facilities, abduction devices such as foam wedges and pillows are placed between legs. Adduction of the hip should be avoided to prevent dislocation.

​A nurse auscultates a client's bowel sounds. Which of the following actions by the nurse would require intervention by a charge nurse?

​Palpates the abdomen prior to performing auscultation. ​-Bowel sounds should be auscultated prior to palpation because manipulation of the abdomen can alter the frequency and intensity of bowel sounds. Bowel sounds should be auscultated in all four quadrants with the warm diaphragm of a stethoscope. -​If an NG tube is present, it should be clamped during auscultation to prevent the sound of suction being mistaken for bowel sounds. -Bowel sounds are best auscultated between meals

​A nurse is caring for an older adult client who has left-sided weakness. Which of the following information regarding the use of a cane is appropriate?

​Place cane on right side, and advance left foot forward. -​The cane should be placed on the stronger side of the body (held with the right hand). The weaker leg (left leg) should be advanced toward the cane. The stronger leg (right leg) is then advanced forward past the cane.

​A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to immediately intervene?

​The nurse allows the client to sleep in supine position during feeding. -The head of the bed should be positioned at a minimum of 30⁰ elevation to prevent aspiration from reflux during feedings. The greatest risk to a client receiving enteral feedings is injury from aspiration. Therefore, the priority nursing action before initiating an enteral feeding is to determine proper placement of the tube and maintain the client in semi-Fowler's position during the feeding. -If aspiration of formula is suspected, the first action the nurse should take is to stop the feeding. Other actions should include the following: • Turn the client to the side. • Suction the airway. • Provide oxygen if indicated. • Monitor the client's vital signs for elevated temperature. • Auscultate breath sounds for increased congestion. • Notify the provider. • Obtain a chest x-ray.

​A nurse is preparing a teaching plan for a client who has hemorrhoids. Which of the following should the nurse plan to include in the teaching?

​The client should follow a high-fiber diet to establish bowel regularity. ​-The client who has hemorrhoids should be encouraged to follow a high-fiber diet to help promote regular, soft stools. High-fiber food choices include bran and complex carbohydrates.

​A nurse is caring for a client who has a halo traction device. Which of the following actions should the nurse include when providing care?

​Monitor for elevated temperature. ​-Clients who have cervical fractures may be placed in a halo fixation device. The device is secured with four screws inserted directly into the client's skull. This promotes cervical alignment. The metal halo ring may be attached to a vest when the spine is stable. This allows for increased mobility. Common complications include loose pins, local infection, and scarring. More serious complications include osteomyelitis, subdural abscess, and instability. The nurse should monitor vital signs for signs of infection (fever, purulent drainage from pin sites). An elevated temperature would indicate an infectious process. The nurse should notify the provider should this occur.

​A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to help promote sleep?

​Provide home bedtime rituals -​Toddlers are very ritualistic. Establishing a bedtime routine is important. Reading a familiar book or providing a favorite stuffed toy or blanket will help decrease the child's insecurity and fears. Parents should stay with the child because separation from parents is stressful. Toddlers' main areas for rituals include eating, sleeping, bathing, toileting, and playing. When the routines are disrupted, difficulties can occur in any or all of these areas. The principal reaction to such change is regression.

What are the steps in administering intermittent NG tube feedings using a large barrel syringe or feeding bag?

Intermittent feeding may be done by using a large barrel syringe or feeding bag. The steps in administering intermittent NG tube feedings include the following: • Have the formula and a 60-mL syringe prepared. • Remove the plunger from the syringe. • Hold the tubing above the instillation site. • Open the stopcock on the tubing, and insert the barrel of the syringe with the end up. • Fill the syringe with 40 to 50 mL of formula. • If using a feeding bag, fill the bag with the total amount of formula prescribed for one feeding, and hang it to drain via gravity until empty (about 30 min). • If using a syringe, hold it high enough for the formula to empty gradually via gravity. • Continue to refill the syringe until the amount prescribed for the feeding is instilled. • Flush with tap water after infusion is complete. Clamp the NG tube once the feeding and flushing are complete.

A nurse provides teaching to a client on proper hearing aid use. Which of the following statements indicates a need for further instruction?

"I will clean the hearing aid with alcohol wipes." -Alcohol use can break down the mechanism of the hearing aid. The client should follow the manufacturer's instructions. Hearing aids are usually cleaned with a soft cloth. The hearing aid should never be submersed in water.

​A nurse is caring for a client with Crohn's disease who is receiving parenteral nutrition. The fluid in the present infusion should be complete by 8:00 AM. At 7:00 AM the nurse observes that the infusion is complete and additional solution is not yet available on the unit. Which of the following actions is appropriate?

Administer an intravenous infusion of dextrose 10% in water. ​-Dextrose 10% in water is an appropriate temporary substitution for parenteral nutrition until more solution is available and will help prevent hypoglycemia.

A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid?

Fresh apples -Clients with dumping syndrome following a hemi-colectomy should avoid fresh fruits and choose canned or well-cooked fruits instead. -Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods.

​A nurse is caring for a client who has been on strict bed rest for 1 week. Which of the following findings indicates client readiness to ambulate?

Performs active range of motion exercise to all extremities ​-During periods of immobility, it is important to have the client perform range of motion (ROM) exercise to reduce the hazards of immobility (e.g., contractures, loss of muscle mass, and thrombosis). A client who is weak may be able to perform only passive ROM exercises, during which the nurse assists the client by supporting the extremities during movement. During active ROM, the client is doing the movement with little to no assistance. The client may be able to actively move some extremities and joints and require assistance with others. This is a collaborative effort with physical therapy to safely ensure that the client restores mobility.

​A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler. Which of the following statements by the parents indicates understanding of the teaching?

​"The quality of food I provide him is more important than the quantity." ​-Toddlers are very picky eaters and usually eat only one or two adequate meals each day. Therefore, it is essential that the meals are balanced with essential nutrients. The nutritious quality of the food is much more important than the quantity. Toddlers generally prefer finger foods because of increasing autonomy. Eating habits established in the first 2 to 3 years of life tend to have lasting effects on subsequent years.

​A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following would be the best meal choice?

​Beans​ ​-An increase in protein is needed to aid in the promotion of tissue healing postinjury. Vegan diets may be lower in protein. Nuts and legumes will increase the amount of protein in the diet, which will aid in tissue repair.

​A nurse is implementing a bladder training program. Which of the following actions by the assistive personnel (AP) who is assisting in the client's care indicates a need for further instruction?

​Instructs the client to void whenever the urge occurs. -​The goal of bladder training is to increase bladder control. The primary objective is to have the client resist the urge to urinate so that time between voidings can be increased, as well as increasing the total volume of urine in the bladder. The nurse should instruct the AP to encourage the client to take deep breaths when the urge to void occurs. The nurse should provide further instruction to the assistive personnel to delay voiding. Although clients with frequent urinary infections should be taught to void when the urge occurs, in bladder training, the client needs to ignore urges and work to increase time between voidings.

​A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following are appropriate nursing actions? (Select all that apply.)

Add the amount of bladder irrigation to the total output is incorrect. -The irrigation solution that should be used is sterile normal saline, unless otherwise directed by the surgeon. The amount of bladder irrigation solution should be subtracted from the total urine output amount. For example, if the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, subtract 1,000 from 2,500 and record 1,500 mL as the total urine output. Use sterile technique when preparing the irrigation solution is correct. -Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. These clients should also be observed closely for manifestations of infection, such as fever and elevated WBC. Ensure the drainage tubing is patent and without obstruction is correct. -For continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter system. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury. Contact the surgeon if the client reports a continual need to void is incorrect. -The catheter used following a TURP is large and is pulled taut and secured to the client's leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client probably will experience a continual need to void. The nurse should inform the client that the urge to void is expected. However, the client should not attempt to void around the catheter because this can cause bladder spasms, which can be painful and initiate bleeding. Notify the surgeon if the urine is bright red in appearance or has large clots is correct. -It is important to record the type and amount of irrigation solution used and the character of the drainage. It is normal to see a few small blood clots, but urine that is bright red, ketchup-like, or has large clots is an indication of bleeding and should be reported to the surgeon. The client's Hgb and Hct should be monitored as well to help determine the degree of blood loss.

​A nurse is caring for a client who has a chronic illness and is admitted due to anorexia and malnutrition. Which of the following findings should the nurse expect?

Decreased mental status -​This client is likely to have a decreased mental status. A nutritional deficit will result in decreased glucose. The brain requires glucose to function. When the body lacks adequate glucose, the body will metabolize tissue such as muscle and fat. The resulting metabolic acidosis also may decrease the client's mental status. Nutritional deficits of fluids will result in dehydration. Dehydration also may cause a decrease in mental status.

​A nurse is providing postmortem care to an adult client. Which of the following interventions should the nurse include? (Select all that apply.)

Place client in supine position is incorrect. -The nurse should provide dignified and sensitive care to the client and the family. The nurse should elevate the head of the bed as soon as possible after death to prevent discoloration of the face. Determine whether an autopsy has been ordered is correct. -It is important to determine whether an autopsy has been ordered because an autopsy or organ donation has specific requirements at the time of death. If an autopsy is ordered, tubes, equipment, and indwelling lines must remain in place until the coroner deems otherwise. Cover body with a sheet and place head on pillow is correct. -The nurse should cover the body with a clean sheet, place head on a pillow, and leave arms outside covers if possible. The nurse should close eyes by gently holding them shut, leave dentures in mouth to maintain facial shape, and cover any signs of body trauma. The client should be presentable for viewing by family and friends. Maintain cultural and religious rituals regarding death is correct. -There are cultural and religious rituals and mourning-specific practices that loved ones use to achieve inner peace and expression of grief. One's culture greatly influences what behaviors and rituals are expected at the time of death. Institutional guidelines and end-of-life care procedures for clients from all cultures provide standards based on compassion, maintaining privacy and dignity, and respect for clients' and family members' cultural beliefs and practices. Cleanse body, maintaining standards regarding body fluids is correct. -Cleanse body thoroughly while maintaining safety standards for body fluids and contamination. Maintain precautions implemented during the life of the client. For instance, if the client was on contact precautions, contact precautions should be maintained during postmortem care. Micro-organisms can be transmitted after the death of the client.

A client is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning? (Select all that apply.)

Remove pillows prior to repositioning is correct. -Pillows inhibit upward motion often causing the client's neck to be flexed or hyper extended according to the thickness of the pillow. Removing the client's pillows, sheets, and blankets will assist with unencumbered movement and provide a more accurate assessment to place the client in an alignment. Elevate the bed to waist height is correct. -Working at waist height promotes ergonomics and minimizes risk of injury to the individuals performing repositioning maneuvers and to the client being repositioned. Position the client towards the edge of bed with a foam wedge is incorrect. -This action places the client too close to the edge of bed, which places the client at risk for injury. The client should be positioned in the opposite direction of the turn, thereby providing ample space to maintain safety. Although a foam wedge provides support to the client, the additional force towards the edge of the bed increases the risk of fall injury. Stand with feet wide apart is correct. -A wide base of support when moving a client facilitates movement and minimizes risk of injury to individuals performing repositioning maneuvers. The body's center of gravity is the pelvis. The closer the center of gravity is to the base of support, the more stable the movement. This is achieved by standing with the feet wide apart. The nurse should avoid twisting the spine or bending at the waist to minimize risk for injury. Face the direction of movement when positioning the client is correct. -When positioning a client, the nurse should move the rear leg back to promote ergonomic stability. Facing the direction of movement will maintain alignment for both the client and the nurse. This prevents straining back muscles or bending at the waist. Sliding, rolling, and pushing in the same direction that the nurse faces require less energy and has less risk for injury.

​A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

​Bottled water is an appropriate choice to increase fluid intake. ​-Clients who have neutropenia are at risk for foodborne illness. Bottled water prevents client exposure to pathogens that may be found in other water sources. -​Clients who have neutropenia should avoid foods that are not fully cooked due to a higher risk of foodborne illness.

​A nurse is caring for a client who is to receive a mechanically altered diet. Which of the following client food choices necessitates intervention by the nurse?

​Piece of wheat toast -​Clients receiving a mechanically altered diet have limited chewing ability and should only receive pureed breads.

​A client has a first-degree ankle sprain. Which of the following interventions should the nurse reinforce immediately after the injury? (Select all that apply.)

​Immobilize ankle for 4 to 6 weeks is incorrect. -The client should rest the ankle, but immobilization is not necessary for a first-degree sprain. Initially, the client may need to avoid weight bearing. Immobilization is indicated for 4 to 6 weeks in third-degree sprains, or when severe ligament damage occurs. As a result of a third-degree sprain, arthroscopic surgery may be necessary. Because this client experienced a first-degree sprain, prolonged immobilization is not necessary. Elevate ankle above the level of the heart is correct. -In order to reduce inflammation as a result of the sprain, the client should elevate the ankle above the level of the heart to promote venous return and decrease edema. For example, the nurse should position the client on the bed with the client's foot propped up on one or two pillows to elevate the ankle above the heart. Apply heating pad to the ankle several times daily is incorrect. -A first-degree sprain requires rest, ice, compression, and elevation (RICE). Immediately after the injury, the nurse should reinforce to the client to rest, ice, compress, and elevate the ankle. Heat may be applied after 48 hr, but the client should not apply heat during the initial 48 hr of injury. Wrap ankle with an elasticized compression bandage is correct. -Application of an elasticized compression bandage for a few days following the injury is necessary to reduce swelling and provide joint support. Compression also can help with pain relief and is facilitated by wrapping an elasticized compression bandage around the injured extremity. If the client reports throbbing, discomfort, or the wrap is too tight, the nurse should remove and rewrap the bandage with less stretch. The nurse should begin from the distal point of the extremity (toes) and move toward the proximal point (up the leg) in order to promote venous return. Apply intermittent cold compress to the ankle for the first 24-48 hr is correct. -Cold is used for the first 24-48 hr. For a client who has a muscle sprain, an ice bag is an ideal nonpharmacological intervention to prevent edema formation as well as to anesthetize the body part. Cold provides short-term pain relief and also limits swelling by reducing blood flow to the injured area through vasoconstriction. The nurse should reinforce to the client not to apply ice directly to the skin or leave ice on the ankle for more than 20 min at a time. Longer exposure can damage the skin and even potentially result in frostbite.

A nurse is caring for a client who is prescribed an infusion of 5% dextrose in water. Which of the following is the amount of dextrose in this solution?

5 g/100 mL -A solution of 5% dextrose in water contains 5 grams of dextrose per 100 mL.

​A nurse is implementing a bladder training program. Which of the following actions by the assistive personnel (AP) who is assisting in the client's care are acceptable?

Assists the client to the bathroom every 2 hr. ​-During initial bladder training, clients are assisted to the toilet at regularly set intervals. During the first 24 hr of the program, it may be as often as every 30 min, gradually increasing the time between voidings in 15-min intervals, working up to a goal of 3 to 4 hr in between. By assisting the client to the toilet every 2 hr, a regular pattern of voiding is established, and the client learns to trust that the staff places value on bladder training needs and also learns a physical pattern that promotes bladder control. ​ Encourages oral fluid intake during waking hours. ​-Adequate fluid intake that does not include caffeine can be beneficial to a bladder training program. The fluid acts to both increase the flow to the bladder and ensures the bladder will expand while decreasing the likelihood of a urinary tract infection. The presence of infection can delay bladder training. The AP is helping the overall health of the client and improving the likelihood of successful bladder training. ​Offers the opportunity to void 15 min prior to bathing. ​-Relaxation of bladder muscles is a common response to bathing. In clients working to increase control of the bladder, it is beneficial to offer an opportunity to void before the bath. This action can help decrease loss of control during bathing. The AP is implementing an action that will help the client reach the goal of bladder control.

​A nurse is preparing to transfer a client who has limited mobility from the bed to a chair. The client weighs 113.6 kg (250 lb). Which of the following actions should the nurse take?

Use a mechanical lift, and transfer the client with the assistance of another nurse. -​This client should be considered fully dependent. The client has limited mobility and weighs 113.6 kg (250 lb). A caregiver would be required to lift more than 15.9 kg (35 lb) of the client's weight. A mechanical lift should be used. In addition, the client should be transferred with the assistance of a minimum of two caregivers. -If a client cannot move onto a stretcher independently and weighs less than 90.9 kg (200 lb), a friction-reducing device and/or a lateral transfer board should be used, and at least two caregivers should assist with the transfer. If the client cannot move independently and weighs more than 90.9 kg (200 lb), a ceiling lift with a supine sling, a mechanical lateral transfer device, or an air-assisted device should be used, and three caregivers should assist with the transfer.