Basic Care and Comfort

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? Select one: a. Avoid inadvertently advancing the catheter into the bladder. b. Examine condition of catheter and drainage tubing. c. Assess for perineal pain or discomfort. d. Assess the client's knowledge of importance of perineal hygiene.

a. Avoid inadvertently advancing the catheter into the bladder.

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? Select one: a. Awareness of body structures and sensations is normal and expected b. This is a possible infection or irritation in the genital area c. This is an early emergence of sexual expression that should be discouraged d. Your child is probably imitating behaviors that she has observed

a. Awareness of body structures and sensations is normal and expected

A nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client? Select one: a. Cooked spinach and celery b. Fresh strawberries and carrots c. Lettuce and alfalfa sprouts d. Raw cauliflower or broccoli

a. Cooked spinach and celery

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation? Select one: a. When the client has the urge to defecate. b. Immediately before meals. c. Every hour while awake. d. When the client feels abdominal cramping.

a. When the client has the urge to defecate.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "I can give him a tub bath in two days." c. "I will clean his penis with each diaper change." d. "The circumcision will heal completely within a couple of weeks."

b. "I can give him a tub bath in two days."

A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good understanding of how to use a bulb syringe to suction excess mucous from the infant's airway? Select one: a. "The bulb syringe should reach to the back of my baby's throat." b. "I should suction my baby's mouth before the nose." c. "I should compress the bulb syringe after I place it in my baby's mouth." d. "The bulb syringe should be sterilized after each use."

b. "I should suction my baby's mouth before the nose."

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration? Select one: a. Assisting the client into a supine position in preparation for the feeding. b. Assessing gastric residual volume immediately before administering the feeding c. Instructing the client to cough forcefully as the feeding is started. d. Performing nasotracheal suctioning before initiation of the feeding.

b. Assessing gastric residual volume immediately before administering the feeding

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? Select one: a. Positioning the client standing or supine. b. Cleansing the peristomal skin with alcohol. c. Measuring and assessing the stoma. d. Changing the pouch before a meal.

b. Cleansing the peristomal skin with alcohol.

A nurse is changing a dressing on a preschool-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child? Select one: a. Assisting the child to take deep breaths and focus on relaxing. b. Encouraging the child to watch a favorite cartoon on television. c. Promising the child a special treat in exchange for cooperation. d. Teaching the child how to go 'to a different place' using their imagination.

b. Encouraging the child to watch a favorite cartoon on television.

A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery? Select one: a. Cream cheese b. Fresh vegetables c. Strained fruit juices d. Lean meats

b. Fresh vegetables

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? Select one: a. Broiled liver and white rice. b. Pork chop and brown rice. c. Grilled salmon and cooked apricots. d. Roast chicken and cooked spinach.

b. Pork chop and brown rice.

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "When did your contractions begin?" b. "What happens to your contractions when you move about?" c. "Have you noticed any bloody show or fluid coming from your vagina?" d. "Have you felt fetal movement over the last 24 hours?"

c. "Have you noticed any bloody show or fluid coming from your vagina?"

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? Select one: a. "I should increase my fluid intake to 8-10 glasses of water a day." b. "I should increase my consumption of protein." c. "I should limit my sodium intake to 4 grams per day." d. "I should consume a diet low in carbohydrates."

c. "I should limit my sodium intake to 4 grams per day."

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "I will avoid standing for prolonged periods of time." b. "I will tighten my pelvic muscles when coughing." c. "I will increase my fiber intake to stay regular." d. "I will increase my daily fluid intake."

c. "I will increase my fiber intake to stay regular."

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? Select one: a. "We increase her protein intake when she's playing sports." b. "She eats a large breakfast every morning." c. "We allow her to pick out a treat at the grocery store for good behavior." d. "She enjoys helping to prepare her snacks in the kitchen."

c. "We allow her to pick out a treat at the grocery store for good behavior."

For which of the following clients would benefit most from use of a walker? Select one: a. A 32-year-old female client who fractured her left tibia. b. A 43-year-old avid jogger one week status post right knee replacement. c. An 82-year-old female client post right hip replacement that has had two falls in the past week. d. A 67-year-old male client post cerebrovascular accident with minimal right sided weakness.

c. An 82-year-old female client post right hip replacement that has had two falls in the past week.

A nurse needs to determine a client's strength before ambulating. Which of the following should the nurse do? Select one: a. Assess pedal pulses and feet for edema. b. Ask the client if they have been up before. c. Ask the client to plantar flex the feet against resistance. d. Assess how strong the client feels today.

c. Ask the client to plantar flex the feet against resistance.

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? Select one: a. Baked potato b. Wheat bread c. Broccoli with cheese sauce d. Chicken breast

c. Broccoli with cheese sauce

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education? Select one: a. Small sweet potato b. Wheat bread c. Cheddar cheese d. Small amounts of kiwi

c. Cheddar cheese

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period? Select one: a. Teach the client how to care for a urinary catheter and leg bag. b. Suggest methods for reducing urinary incontinence, such as Kegel exercises. c. Encourage use of patient-controlled analgesia (PCA) as needed. d. Administer a stool softener to prevent constipation.

c. Encourage use of patient-controlled analgesia (PCA) as needed.

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching? Select one: a. Vegetarian wrap with chips b. French onion soup and salad c. Grilled chicken salad with fresh salsa d. Chicken bouillon and crackers

c. Grilled chicken salad with fresh salsa

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? Select one: a. Finish a project they set out to do. b. Gratify their oral fixation. c. Increase their independence. d. Develop their sense of trust.

c. Increase their independence.

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate? Select one: a. Place quad cane in right hand, extend left lower extremity, and then right hand with quad cane and left lower extremity. b. Place quad cane in right hand, extend right hand with quad cane and left lower extremity. c. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. d. Place quad cane in left hand, extend left hand with quad cane, and then left leg followed by right leg.

c. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg.

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? Select one: a. Spinach b. Eggs c. Rabbit d. Tuna

c. Rabbit

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? Select one: a. The baby develops a localized or generalized rash b. The baby has an axillary temperature of 100.4o F. (38o C) c. The baby is crying inconsolably for more than three hours d. The baby develops swelling or redness at the injection site

c. The baby is crying inconsolably for more than three hours

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary? Select one: a. "I drink some hot milk and take a bath before going to bed." b. "I go to bed and get up at the same time each day." c. "I don't take naps during the day." d. "I watch television until I fall asleep."

d. "I watch television until I fall asleep."

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner should leave an empty space at the tip." b. "I can use spermicidal gels or creams to increase effectiveness." c. "My partner will put the condom on while his penis is erect." d. "I will remove the condom 30 minutes after intercourse."

d. "I will remove the condom 30 minutes after intercourse."

A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? Sipped 8 oz. clear broth. 100 mL ice chips. Voided 450 mL. IV push pain medication 50 mL. Drank 4 oz. juice and 6 oz. hot tea. Vomited 120 mL and voided 600 mL. Jackson Pratt drain emptied 40 mL. Select one: a. 680 mL b. 1068 mL c. 590 mL d. 1210 mL

d. 1210 mL

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? Select one: a. Mild diarrhea b. Abdominal distension c. Difficulty evacuating bowels d. Decreased urine output

d. Decreased urine output

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client? Select one: a. The infant is unable to sit with support b. The infant is unable to point to objects c. The infant demonstrates stranger anxiety d. The infant does not raise his head when placed on his abdomen

d. The infant does not raise his head when placed on his abdomen