Custom basic care and comfort

A nurse is providing hygiene care for a client who is immobilized. Which of the following actions should the nurse

[A] check the bed linens when removing them for personal items. [c] keep the bath water temperature between 43.3 (110 F) and 46.1 (115). [D] shave the client hair in the direction of the hair growth.

A nurse is collecting data from a client who has had paraplegia for several years. Which Of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

[] muscle atrophy [] venous pooling [] urinary stasis

A nurse is assisting a client with range-of-motion exercises Of the neck. Which Of the following terms should the nurse use when documenting the client bending her head backward as far as it will go?

hyperextension

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?

i have a set of my brothers crutches in my basement that i can also use.

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV solution, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

1720

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumed 1 cup Of coffee, 4 oz Of orange juice, 3 oz Of water, 1 cup Of flavored gelatin, 1 cup Of tea, 5 oz Of broth, and 3 oz of water. The nurse should record how many mL Of intake on the client's record? (Round the answer to the nearest whole number.)

1170

A nurse is calculating the fluid intake for an infant at the end of an 8-hr shift. For oral intake, the infant had 10 mL of medication, 3 oz of formula, and 2 oz of juice. In addition, the infant had IV fluid infusing at 20 mL/hr via an IV pump. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole

320

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

4.0

A nurse is calculating the total fluid intake for a client during an 8-hr period. The client had an IV bolus of 150 mL and consumed 4 oz of juice, 6 oz of hot tea, 100 mL of water, and 8 oz of clear broth. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)

790

A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Bruxism

A client is about to undergo a closed reduction Of a fracture. In addition to analgesia, the nurse that the client listen to an audiotape Of music. Which Of the following nonpharmacologic interventions for pain management is the nurse using?

Distraction

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

[]offer the client a back rub []remind the client to use incisional splinting []identify the client pain level []change the clients postion

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

a redden area over the sacrum

A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client spreading her fingers far apart?

abduction

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

abduction

A nurse is explaining different types Of complementary and alternative healing modalities to a client who has chronic pain. Which Of the following healing modalities should the nurse describe as the use Of needles to stimulate specific points on the body to relieve discomfort, promote health, and cure disease?

accupuncture

A nurse is assisting a client with range-of-motion exercises Of the hands and wrists. Which Of the following terms should the nurse use when documenting the client bringing her fingers together, closing the spaces between them?

adduction

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client reaching across her body toward the opposite side of the bed?

adduction

A nurse is planning care for a client who has anorexia and has manifestations of malnutrition. When reviewing the client's laboratory values, which of the following test results should the nurse expect to be low?

albumin

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?

auscultate breath sounds at least every 2 hrs.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

check that the client lifts the walker and then places it down in front of her

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

check to see if the suction equipment is working.

While collecting data from an older adult client, the nurse learns that the client has had difficulty sleeping at night for several months. When evaluating the client's sleep disturbances, the nurse should factor in which of the following principles that can affect older adults and sleep?

chronic pain and illness interfere with the sleep patterns of older adults.

A nurse is assisting a client with range-of-motion exercises of the hip. Which of the following terms should the nurse use when documenting the client moving her leg so that she is tracing circles with her foot?

circumduction

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

clean under the nails with an orange stick

A nurse is administering a cleansing enema for a client who has constipation. Which of the following actions should the nurse take?

hold the container of solution 30 cm (12 inch) above the anus

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

close the curtain around the clients bed

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

cranberry Juice

A nurse is caring for a client who requests pain medication. Which of the following actions should the nurse first?

determine the location of the pain.

A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

determining the client's mobility

A nurse is caring for a client who is receiving enteral tube feedings of a diluted formula. Which of the following complications of enteral tube feeding should the nurse identify as a reason to administer diluted feedings to clients?

diarrhea

A client who has metastatic bone cancer tells the nurse, "l want to go home to die." The client's family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?

discuss a referral to home health and hospice care with the client and family

A nurse is assisting a client with range-of-motion exercises of the feet and ankles. Which of the following terms should the nurse use when documenting the client extending her leg and bending her foot and toes upward toward the ceiling?

dorsiflexion

A nurse is caring for an Older adult client who reports constipation. Which Of the following recommendations should the nurse make?

eat raw vegetables

A nurse is assisting a client with range-of-motion exercises of the feet and ankles. Which of the following terms should the nurse use when documenting the client turning the sole of her foot outward away from the body's midline?

eversion

A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

explain to the client that she will feel temporary discomfort

A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client bending her wrist upward in the direction of the outer surface of the forearm?

extension

A nurse is assisting a client with range-of-motion exercises Of the shoulders. Which Of the following terms should the nurse use when documenting the client reaching over her opposite shoulder to scratch her upper back?

external rotation

A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client making a fist with her hand?

flexion

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

flexion

A nurse is caring for a client who is postoperative following knee surgery. In addition to analgesia, the nurse suggests that the client imagine herself relaxing on a beach and enjoying the tropical breezes. Which Of the following nonpharmacologic interventions for pain management is the nurse using?

guided imagery

When providing care for a client who has facial fractures, the nurse notices a strong mouth odor. Which of the following terms should the nurse use to document this finding?

halitosis

Which of the following instruction should a nurse provide to promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injury of the left lower extremity?

hold the cane on the right side

A nurse is reinforcing teaching for with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

i watch television until i fall asleep at night

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

i will position the head of the bed 45 degrees during the feeding

A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

increased calcium excretion

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client reaching to scratch the same side of her lower back?

internal rotation

A nurse is assisting a client with range-of-motion exercises of the feet and ankles. Which of the following terms should the nurse use when documenting the client turning the sole of her foot inward and aligning it with the body's midline?

inversion

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "l am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following actions should the nurse take?

keep a night light on in the clients room.

A nurse is assisting a client with range-of-motion exercises Of the neck. Which Of the following terms should the nurse use when documenting the client tilting her head sideways and downward toward one shoulder and then the other shoulder?

lateral flexion

A nurse is assisting a client who has generalized weakness out Of bed to a wheelchair. Which Of the following actions should the nurse take?

lock the wheels of the bed and wheelchair

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?

move your head form the upright position back as far as you can.

A nurse is assisting a client with range-of-motion exercises of the fæt and ankles. Which of the following terms should the nurse use when documenting the client extending her leg and hnding her foot and toes downward toward the floor?

plantar flexion

A nurse is caring for a client whose hand movement is limited. Which Of the following actions should the nurse take to assist the client with feeding?

provide an adaptive feeding device from the client

A nurse is caring for an Older adult client who is at risk for skin breakdown. Which Of the following interventions should the nurse use to help maintain the client's skin integrity?

provide the client with a diet high in protein

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe abduction of the shoulder joint?

raise your arm from your side forward and upward to beside your head.

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client turning her head laterally from one side to the other?

rotation

A nurse is caring for a client who is postoperative and has a prescription for a full liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

scramble eggs

A nurse is administering a cold application to a client. Which of the following manifestations indicates the need to discontinue the application due to a systemic response by the client?

shivering

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. Which of the following foods should the nurse select as a component of the client's meals?

steamed vegetables

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

stop the treatment if the clients skin becomes red

A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an finding for which of the following types of incontinence?

stress incontinence

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should monitor the client for which of the following expected outcomes after catheter removal?

temporary urine retention

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

test the PH of gastric aspirate

A nurse provides a fracture bedpan for a client Who has a femur fracture and needs to defecate. When the client asks why the nurse chose that type of bedpan, which of the following responses should the nurse make?

this kind of bedpan is easier to place under you.

A nurse in an urgent care center is reinforcing teaching with a client whose injury requires that he bear weight on only one foot. Which of the following crutch gaits should the nurse remind the client to use?

three point gait

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

to identify delayed gastric emptying

A nurse caring for a client who has a chest tube to water-seal drainage plans to straighten the client's bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for this client?

to modify the client perception of pain

A nurse is collecting data about a client's range Of motion. Which Of the following instructions should the nurse give to the client to observe the elbow rotate for supination?

turn each of your hands and forearms so your palm is facing up

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

turn the client on his side before starting oral care.

A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. Which of the following strategies should the nurse include in the plan?

use of auditory or tactile materials.

A nurse is caring for a client who is postoperative and has a prescription for a clear liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

vanilla pudding

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

vitamin C

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

when the client moves he should move the cane forward first