exam 2 lab

When placing the client on a bedpan, which position will the nurse place the client?

B) Semi-Fowler's

The nurse must remove soiled equipment from a client's isolation room. Place the steps in correct order of how the nurse will remove the equipment.

A) Place equipment in an isolation bag. B) Wash equipment with an antimicrobial agent. C) Perform hand hygiene and don gloves. D) Remove the isolation bag. Answer: C, B, A, D

The nurse plans to assist in the transfer of the client to a bedside commode. Place the procedure steps in the correct order

A) Place slippers on the client. B) Place commode at the foot of the bed. C) Raise the client's head of the bed and move client to the edge of the bed. D) Safely transfer the client to the commode. E) Cover client with bath blanket as needed for warmth. Answer: B, A, C, D, E

The nurse exits a client's room who is in isolation precautions. The nurse must remove both protective eyewear and a face mask. Place the steps in the correct order of removing the PPE.

A) Untie the upper strings of the mask. B) Dispose of the mask. C) Remove the protective eyewear. D) Untie the lower strings of the mask. Answer: C, D, A, B

The nurse is caring for an older adult client who has been diagnosed with a closed head injury. The healthcare provider decides to monitor the client's intracranial pressure (ICP) using an ICP transducer system. The nurse will place the client in which position to prevent compromise of the client's condition?

B) Supine, head midline, head of bed elevated 30 degrees

The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring. Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply

A) The nurse notes "Doll's eyes" when assessing the client's pupils. C) The nurse finds that all extremities are flaccid. E) The nurse documents that the client is in a comatose state

The nurse prepares to perform an indwelling urinary catheterization for a client who will undergo surgery. Place the steps of client positioning and sterile glove donning in the correct order.

A) Open the drainage package, maintaining sterility. B) Position the client. C) Remove and discard gloves; perform hand hygiene. D) Open the catheterization kit; apply sterile gloves. Answer: B, A, C, D

The nurse cares for a client with an AV fistula for hemodialysis. Which assessments will the nurse perform when assessing the AV fistula? Select all that apply.

A) Palpation B) Auscultation C) Inspection

The nurse teaches a client with a peritoneal dialysis catheter about the signs and symptoms of peritonitis. Which teaching statements will the nurse include? Select all that apply.

A) "Monitor your temperature and report any fever." C) "Report any nausea or vomiting you may have." D) "Monitor the insertion site and report any redness." E) "Report any abdominal pain you may have."

The nurse is caring for an older adult client who sustained a closed head injury approximately 4 hours ago. At the time of the injury, the client denied any pain or other symptoms. Which statement by the client would cause the MOST concern to the nurse?

A) "Who are you? Why do you keep asking me my name?"

Calculate the flow rate of the following intravenous therapy prescription: 3 liters 09.% normal saline over 24 hours.

A) 125 mL/hr

The nurse prepares to administer a medication through the client's central line. Per hospital policy, the nurse must use heparin to keep the line patent. Place the steps in the correct order for administering medication through the central line.

A) Administer the medication. B) Flush the catheter with 5-mL saline. C) Flush the catheter with heparin. D) Flush the catheter with 10-mL saline. Answer: D, A, B, C

The home care nurse prepares to drain the fluid of a client with continuous ambulatory peritoneal dialysis (CAPD). Place the steps in correct order of the procedure to drain the fluid.

A) Attach the sterile bag and transfer set to the catheter. B) Place the bag on a low stool or table below the client's abdomen. C) Unclamp the tubing and allow fluid to drain. D) Reclamp the tubing. E) Don gloves and uncap the catheter. Answer: E, A, B, C, D

The nurse is instructing a UAP in the technique of assisting a client to stay in the proper position for a lumbar puncture. The nurse will know that the UAP is doing it correctly if the UAP holds which parts of the client's body immediately before the procedure begins?

A) Behind the client's neck and knees

When auscultating a client's AV fistula, the nurse notes a whooshing sound. What term is used to describe this finding?

A) Bruit

Place in correct order the steps for obtaining capillary blood glucose sampling

A) Cleanse the side of the client's finger. B) Apply the blood to the test strip. C) Pierce the skin with a lancet. D) Calibrate the blood glucose meter. E) Apply clean gloves. F) Wipe away the first drop of blood. Answer: D, A, E, C, F, B

The nurse cares for an older adult and recognizes the client is at increased risk for developing infection. Which condition poses the greatest risk of infection in the client?

A) Diabetes mellitus

The nurse prepares to obtain a urine sample from a client's closed drainage system. Place the procedure steps in the correct order

A) Disinfect the needle insertion site. B) Insert the needle at a 30-to 40-degree angle. C) Unclamp the catheter. D) Transfer the urine to the specimen container. E) Withdraw the required amount of urine. F) Clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes. Answer: F, A, B, E, C, D

After removing a client's intravenous catheter from the upper extremity, the nurse notes the client has persistent bleeding despite applying firm pressure. Which action will the nurse take?

A) Hold the client's arm above the level of the heart.

The charge nurse is discussing the endocrine system and the new nurse correctly identifies which organ as the one that influences the release of hormones into the portal circulation?

A) Hypothalamus

The nurse is caring for a client who is receiving intravenous therapy with an infusion pump. An occlusion alarm sounds. Which things will the nurse check? Select all that apply.

A) IV site B) Pinched tubing C) Closed clamp D) Client positioning

The nurse cares for a client with an intravenous infusion of D5NS. Which complications will the nurse closely monitor the client for? Select all that apply.

A) Increased serum sodium C) Fluid overload E) Increased serum chloride

The nurse cares for a client with traumatic injuries due to a motor vehicle accident. The nurse wants to increase the intravenous flow rate of intravenous fluids infusing. Which actions will the nurse take? Select all that apply

A) Insert a large bore IV catheter. B) Warm the IV fluid prior to infusing E) Use a macrodrip IV tubing set.

The nurse prepares to enter the room of a child who requires isolation precautions. Which actions will the nurse take to ease the child's fears? Select all that apply.

A) Introduce self before donning a mask, if possible. B) Encourage the child to play with the equipment. C) Visit the client frequently.

The nurse administers intravenous fluid therapy using a Dial-A-Flo device. What is a disadvantage of this device that the nurse recognizes?

A) It does not control the size of the drops delivered.

The nurse in the clinic receives a call from a client diagnosed with diabetes mellitus who states his blood sugar is 275 mg/dl and he doesn't feel well. Which is the first thing the nurse should tell the client to do?

A) Obtain a urine specimen and check it for ketones.

The nurse cares for a client who is sedated, intubated, mechanically ventilated, and has a central line. While repositioning the client, the central line is disrupted. Place the steps in correct order in response to the clinical scenario.

A) Place the client in supine position. B) Clamp the affected lumen with a soft-tipped clamp. C) Place a strip of tape over the catheter. D) Notify the health care provider. Answer: A, C, B, D

The nurse is assisting the health care provider insert a central line for the client. During the procedure, the client reports sudden shortness of breath and the client's SpO2 falls to 88% on room air. Which actions will the nurse take? Select all that apply.

A) Place the client in the left side-lying position.

The nurse cares for a client who acquires a healthcare-associated infection while in an isolation environment. Which action will the infection control nurse take that best responds to the client's condition?

A) Plan staff education on isolation precautions and proper hand hygiene.

The nurse is caring for a client suspected of having tuberculosis. The nurse must don an N95 particulate mask. Place the steps in correct order for donning this mask.

A) Position the mask over the mouth and nose. B) Pull the strap over the head. C) Pull the shorter strap over the head, below the ears. D) Hold the mask in the hands with the nosepiece towards the fingertips. Answer: D, A, B, C

The nurse is removing gloves after performing client care activities. Place the steps in correct order for removing gloves

A) Pull off one glove by touching the outside of the glove at the cuff. B) Slip one finger of ungloved hand under glove cuff of other hand. C) Pull down and off so both gloves are removed as one. D) Roll up glove and place in gloved hand. Answer: A, D, B, C

The nurse is removing gloves after performing client care activities. Place the steps in correct order for removing gloves.

A) Pull off one glove by touching the outside of the glove at the cuff. B) Slip one finger of ungloved hand under glove cuff of other hand. C) Pull down and off so both gloves are removed as one. D) Roll up glove and place in gloved hand. Answer: A, D, B, C

The nurse needs to remove an isolation gown that slips over the head. How will the nurse remove the gown?

A) Pull the shoulders forward to loosen the Velcro at the neck

A nurse prepares to administer a warm water enema to a client. Place the steps of the procedure in correct order.

A) Raise the solution container. B) Open the clamp. C) Encourage the client to retain the solution. D) Lift the upper buttock, insert the tube slowly. E) Assist the client to the left lateral position with right leg flexed. F) Allow the solution to run through the tubing to remove air. Answer: F, E, D, A, B, C

The nurse is caring for a client in isolation. The nurse needs to remove the isolation gown and gloves after leaving the client's room. Place the steps in correct order for removing PPE.

A) Remove gloves. B) Use the nondominant hand to pull sleeve wristlet over the dominant hand. C) Grasp outside of gown through the sleeves at shoulders. D) Using the dominant hand and grasping the clean part of the wristlet, pull sleeve wristlet over the nondominant hand. E) Fold gown inside out and discard. F) Pull gown down over the arms. Answer: A, D, B, C, F, E

The nurse cares for a client with a PICC line that requires a dressing change. Place the procedure steps in the correct order the nurse will perform.

A) Remove old transparent dressing. B) Discard old dressing and gloves. C) Perform hand hygiene and don clean gloves. D) Assess the exit site. E) Perform hand hygiene and don sterile gloves. F) Clean the exit site and catheter with antimicrobial swabs; allow to dry. G) Place securement device and cover exit site with transparent dressing. Answer: C, A, D, B, E, F, G

The nurse prepares to change the client's central line dressing. Place the steps of the procedure in correct order.

A) Remove the old dressing. B) Remove and discard gloves; perform hand hygiene. C) Don a mask and have the client don a mask. D) Apply the new dressing. E) Cleanse the site. Answer: C, A, B, E, D

The nurse cares for a client with a triple lumen central line who develops a fever, which the nurse suspects is from the central line. Which nursing actions are appropriate? Select all that apply

A) Replace the infusing TPN with normal saline. B) Change the IV tubing. D) Change the IV dressing. E) Culture the insertion site using sterile technique.

An uncircumcised male client needs to provide a clean-catch urine sample. Which client teaching will the nurse provide the client regarding the procedure? Select all that apply.

A) Retract the foreskin slightly. C) Use a circular motion to clean the meatus. D) Use each towelette only once, then discard. E) Void a small amount prior to collecting the sample.

The nurse prepares to change a client's fecal ostomy pouch. Which assessments regarding the stoma are PRIORITY? Select all that apply.

A) Skin around the stoma. B) Location of the stoma. C) Appearance of the stoma.

The nurse notes that an elderly resident of a long-term care facility has fallen and the client is unable to say whether or not he hit his head. Which are the first signs that the nurse will note if this client has sustained a closed head injury? Select all that apply.

A) Spontaneous vomiting C) Vertigo D) Headache

The nurse reviews the various isolation environments to prevent the spread of disease. What basic preventive practices are implemented with all clients and others to ensure disease transmission does not happen?

A) Standard

The nurse prepares to change the client's central line dressing and replace the injection cap. Which position will the nurse place the client?

A) Supine

The intensive care unit nurse is preparing to assess the level of consciousness of a client who is intubated and has both hands restrained to prevent the client from pulling out the endotracheal tube. The client's injury occurred due to a stabbing incident that ultimately caused the client to fall and hit his head. Which item related to the client will cause the nurse to report an incomplete Glasgow Coma Score (GCS)?

A) The client is intubated.

The nurse caring for a client in an isolation environment decides to change the isolation mask. What is the most likely reason the nurse changes the mask?

A) The effectiveness of the mask decreased.

The home care nurse cares for a client who requires continuous ambulatory peritoneal dialysis (CAPD) at home. Place the steps in correct order for infusing the dialysate.

A) Warm the dialysate. B) Add medications to the dialysate as ordered. C) Connect tubing to dialysate bag. D) Perform hand hygiene and don gloves. E) Hang the dialysate bag above the client's shoulder and open the clamp. Answer: A, D, B, C, E

A novice nurse works with a nurse preceptor on a busy medical surgical unit. Which action by the novice nurse requires intervention by the nurse preceptor when observing the novice nurse performing hand hygiene?

A) Washing hands with warm soapy water for 15 seconds.

The nurse needs to obtain blood samples from the client's central line for blood analysis. Place the steps of the procedure in correct order.

A) Withdraw 10 mL of blood and discard. B) Flush with 5 mL normal saline. C) Inject 5mL heparin. D) Draw up the required blood and transfer to the appropriate containers. E) Clean the infusion access port according to policy for 10 seconds. F) Clean the infusion access port according to policy for 30 seconds. Answer: F, A, D, E, B, C

The client tells the nurse that he doesn't check his blood sugar as often as he should because his fingers are so sore from pricking them. How can the nurse assist this client to be more compliant with his blood sugar monitoring?

B) Hang the hand to be used below the waist for a minute to make sure the site that is chosen will have adequate blood supply for the test.

The nurse cares for a group of clients with infectious diseases or conditions. Which conditions can the nurse use a waterless antiseptic gel for hand hygiene? Select all that apply

B) Hepatitis B D) Staphylococcus aureus E) Escherichia coli

The nurse enters a client's room with a suspected head injury in preparation for completing a neurological assessment that includes a Glasgow Coma Score (GCS). Upon entering the room and turning on a light, the nurse notes that the client doesn't open his eyes immediately. Which is the nurse's next action?

B) Gently touch the client's arm to see if the client spontaneously awakens.

A staff nurse asks the charge nurse the difference between airborne and droplet precautions. How will the charge nurse respond?

B) "Airborne precautions require the use of an N95 mask, while droplet precautions do not."

The nurse is interviewing a client with a suspected endocrine disorder. Which question by the nurse would BEST obtain subjective data related to this client's possible diagnosis?

B) "Can you tell me more about the tingling you are experiencing in your feet?"

The nurse cares for a client who requires hemodialysis and has an arteriovenous fistula. Which statements will the nurse include when teaching the client safety precautions for the AV fistula? Select all that apply.

B) "Do not wear constrictive clothing or jewelry." C) "Avoid lifting heaving objects with the extremity that has the AV fistula." D) "Avoid lying on the extremity with the AV fistula." E) "Immediately report swelling or discoloration."

The nurse plans teaching for the client on methods of encouraging fluid intake. Which statements will the nurse include? Select all that apply.

B) "Limit your alcohol intake." C) "Avoid excess amounts of fluids high in salt." E) "Consume 6-8 glasses of water daily."

The nurse is caring for a client who just had 1,500 mL of fluid removed during a paracentesis. The client asks the nurse why his belly still feels so big even though that large amount of fluid was removed. Which is the nurse's BEST answer to this client?

B) "Only a certain amount of fluid can be removed from our abdomen at a time to prevent your body from going into shock."

The nurse instructs the UAP to hold the infant in a side-lying position in preparation for a lumbar puncture. The nurse shows the UAP how to flex the infant so that the spine is exposed and curved. Which explanation is the BEST to help the UAP understand why this position must be maintained?

B) "This position must be maintained because it gives the healthcare provider the best access to the infant's spinal column."

The nurse is caring for a client diagnosed with diabetic ketoacidosis and notes that the client's level of consciousness appears to be deteriorating. The nurse is aware that which assessments are a component of both the Glasgow Coma Score and the Full Outline of UnResponsiveness (FOUR Score) Coma Scale? Select all that apply.

B) Ability to follow verbal commands E) Types of motor responses

The nurse is caring for a client with a diagnosed head injury who has an ICP transducer system to monitor the client's intracranial pressure. Which sign on the ICP monitor indicates that the client's condition is worsening?

B) Appearance of plateau waveforms

The nurse attempts to secure and stabilize an IV catheter and dressing of an older adult client. Which nursing action is appropriate?

B) Apply skin protector solution prior to dressing the IV site.

A novice nurse performs care of a client's central line. Which action by the novice nurse requires intervention by the nurse preceptor?

B) Changing a clean transparent dressing that is 72 hours old

The registered nurse acts as preceptor to a novice nurse who is placing an indwelling urinary catheter for a client. Which action by the novice nurse requires intervention by the preceptor?

B) Cleansing the urethral meatus before removing the catheter from the protective sleeve.

The nurse is caring for a client with cancer who is neutropenic. Which guidelines will the nurse follow regarding neutropenic precautions? Select all that apply.

B) Do not allow the client to receive fresh flowers. C) Inspect the client's food trays to ensure no fresh vegetables are given. D) Keep the client's door closed

A client diagnosed with acromegaly is scheduled for a growth hormone test. When the client arrives for the test, the nurse notes that the client appears to have been crying. The nurse shares with the client this observation and the client begins to cry again and tells the nurse about some serious family problems. Which should the nurse do at this time in relation to the client's growth hormone test?

B) Explain to the client that the growth hormone test will not be accurate if performed when the client is emotionally upset, so the test needs to be rescheduled.

The nurse is planning care for a client who receives peritoneal dialysis. Which nursing diagnosis will the nurse determine is PRIORITY?

B) Risk for infection

The nurse is observing a client obtain a capillary blood specimen for glucose and notes that the client actively squeezes the finger after piercing it with a lancet and then places a drop of blood on the test strip. The meter shows the blood glucose as 126 mg/dl. How does the nurse interpret these results?

B) The blood sugar result may be incorrect. The milking of the finger caused the test to read lower than it should.

The nurse is conducting an initial assessment of a client diagnosed with an endocrine disorder and identifies which signs and symptoms as subjective, as opposed to objective symptoms? Select all that apply.

B) The client complains of feeling tired most of the time. C) The client states that he can't see as well as before. E) The client reports very dry skin.

The nurse working in the emergency department is preparing to determine the level of consciousness on a client who was involved in a motor vehicle accident with a possible head injury. Which client precondition would prevent the nurse from using the Glasgow Coma Score?

B) The client is deaf

Prior to beginning to assist a healthcare provider with a lumbar puncture on an adult client, the nurse asks another nurse to also assist in the procedure for what reason?

B) To encourage the client to lie as still as possible

The nurse cares for a client with a central venous catheter. Which action by the nurse is incorrect when maintaining the client's central line?

B) Using a 5-mL syringe to flush the catheter.

The nurse prepares to remove a client's indwelling urinary catheter. Which technique will the nurse use when performing this procedure? Select all that apply.

B) Withdraw all the fluid from the balloon. C) Detach the catheter from the client's skin. D) Use clean gloves instead of sterile gloves. E) Place a towel between the client's legs.

The client calls the clinic complaining of an unusual problem. Which client statement to the nurse is most suggestive of a subjective symptom related to an endocrine problem?

C) "All I want to eat are salty things and I'm adding salt to everything I eat."

The nurse is talking to parents of a 6-month-old infant who will have a lumbar puncture to rule out meningitis. The mother tells the nurse that she refuses to leave the baby and that no one will touch her child unless she is there. Which is the nurse's BEST response to this mother?

C) "I know this must be stressful with your child so sick. Would you like to help hold her in the correct position or would you just like to talk quietly to her during the procedure?"

The nurse is teaching a client on the importance of monitoring intake and output at home. Which statement will the nurse include in the client teaching?

C) "If you notice sticky mucus membranes, contact your health care provider."

The healthcare provider has ordered a radioactive iodine (RA) uptake exam for a client who has complained of constipation, fatigue, and weight gain. The client asks the nurse to explain again why this test has been ordered in relation to these symptoms. Which is the nurse's BEST response to this client?

C) "Your symptoms are suggestive of a thyroid problem. Iodine is taken up exclusively by the thyroid gland, so it is used to evaluate if this gland is responsible for your problems."

The charge nurse is preparing to assign a staff member to assist the healthcare provider planning to perform a lumbar puncture on a 9-month-old infant who is irritable and has an elevated temperature. Which staff member would be the best one to assist in this procedure?

C) A UAP with 2 years of experience on a pediatric unit

A nurse attempts to obtain a urine sample from a client's ileal conduit. After correct sterile catheterization, no urine output is noted. How should the nurse respond?

C) Ask the client to drink water.

The nurse is caring for a client who is experiencing both decreased appetite and shortness of breath related to ascites. A paracentesis has been scheduled for this client. Immediately prior to the procedure, the nurse accompanies the client to the bathroom so the client can void. Which would be the nurse's BEST action when the client reports an inability to void?

C) Ask the healthcare provider for a one-time order of an in-and-out catheterization.

A nurse attempts to flush the lumen of a triple lumen central catheter and notes severe resistance to flushing. Which diagnostic procedure does the nurse anticipate when assessing the correct placement of the central line?

C) Chest X-ray

The client diagnosed with diabetes mellitus calls the nurse to complain about dizziness that occurs upon standing. The nurse informs the client that this may be caused by which initial complication related to diabetes mellitus?

C) Diabetic autonomic neuropathy

The nurse is caring for an older adult client who is being observed after sustaining a minor head injury. The client's only complaints related to the head injury are headache and dizziness. Which interventions would be most helpful to this client in preventing a possible increase in intracranial pressure?

C) Dim the lights in the room and encourage the client to rest.

The nurse cares for a client with bacterial meningitis. Which isolation precaution will the nurse apply?

C) Droplet

The nurse prepares to insert an intravenous catheter in an older adult client. Which action should the nurse take?

C) Insert the catheter in a distal vein.

The nurse is caring for a client with a large abdomen. Which assessment technique would assist the nurse in determining whether the client is experiencing ascites or the large abdomen is related to obesity?

C) Measure the client's abdomen daily.

A nurse performs a sterile urine specimen collection from an ileal conduit. Which action by the nurse is incorrect and may lead to inaccurate results?

C) Obtaining the sample from the collection pouch.

The nurse is assisting with a lumbar puncture of an infant who is irritable and feverish. The manometer indicates increased intracranial pressure and the cerebral spinal fluid appears cloudy. The nurse will institute which interventions as a result of these findings?

C) Place the child in respiratory isolation because of possible meningitis.

The nurse prepares to obtain a urine specimen from a client's indwelling catheter. What is the nurse's understanding of the purpose of clamping the indwelling catheter prior to collection of urine?

C) Promotes sterile collection

While holding a 2-year-old child in a flexed position for a lumbar puncture, the nurse monitors which vital sign to detect any abnormality caused by the child's position?

C) Respirations

The nurse is completing a Glasgow Coma Scale reassessment of a client who fell down a flight of stairs 8 hours ago. On admission, the client displayed spontaneous eye opening. The nurse does not see this response at this time and knows to do which to know if the client responds at the next level of eye opening?

C) Tell the client to "open his eyes" or to look at the nurse

The nurse cares for a client with norovirus. Which action by the nurse regarding the isolation precautions should the nurse perform?

C) Using soap and water only when leaving the client's room.

The nurse teaches an older adult client on methods of infection control. Which statement, specific to this client population, will the nurse include in the teaching?

D) "Ensure adequate protein intake in order to maintain immune function."

A client calls the clinic and asks to speak to the nurse. The client states, "I don't understand why you keep telling me that my thyroid is overactive when my TSH level is so low." How does the nurse BEST explain this to the client?

D) "TSH stands for thyroid stimulating hormone, so if it is low it means that your thyroid is working hard and producing more hormone than it needs to."

The nurse is discussing glucose control with a client who reports consistently elevated capillary blood glucose levels. The client appears unconcerned and says, "I don't see why this is a problem. I feel fine." Which is the nurse's BEST response to this client?

D) "While you may feel good right now, complications usually appear after many years of poor glucose control."

The nurse is caring for a client who has just been diagnosed with diabetes mellitus. The client tells the nurse that she went to the doctor with symptoms of a urinary tract infection and ended up being admitted with diabetes mellitus. She then tells the nurse that her father had diabetes and he ended up dying with kidney failure. The client says, "It looks like that's what is going to happen to me. My kidneys are already messed up." Which is the nurse's BEST response to this client's statement?

D) "Your current infection was caused by the diabetes, but watching your blood sugar in the future will help prevent complications."

The nurse removes a client's intravenous catheter and notes the tip of the catheter is broken. The nurse palpates the client's arm and feels the broken piece. Which action should the nurse take?

D) Apply a tourniquet above the insertion site.

The nurse is discussing issues related to childbearing with a woman who has a low prolactin level and knows that this woman may experience difficulty related to which childbearing activity?

D) Breastfeeding

The nurse is setting up an intravenous infusion for a client and the nurse has set the IV pump according to the health care provider's orders. How will the nurse best verify that the drops/minute rate is correct?

D) Count the drops in the drip chamber for 15 seconds and multiply by 4.

When assessing the client's AV fistula, the nurse notes vibration at the fistula site. How should the nurse respond to this finding?

D) Document the finding.

The healthcare provider is preparing to perform a lumbar puncture on a 5-year-old child and requests that the child be placed in a sitting position. How will the nurse assist the child to maintain this position?

D) Request another nurse assist so that one nurse can hold the child's neck and head in the curved position and the other nurse can assist the child to hold the knees steady.

The charge nurse in a long-term care facility is called to assess an older adult client diagnosed with Alzheimer disease who has fallen and has a head laceration. The nurse is aware that the Glasgow Coma Scale is not an accurate tool to assess this client's level of consciousness because of which reason?

D) The client has been diagnosed with Alzheimer disease.