Exam 2 Review- NR 224

A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication? Group of answer choices

Elevates the head of the bed 60 degrees

Which of the following actions would the nurse recommend to provide a 12-month-old infant with nutrients for growth?

Offer the infant small amounts of meat and vegetables before offering milk.Exclude milk from the infant's diet until he or she begins to like other foods.

The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client?

Oxygen administration

The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. The nurse should place the client in which position to administer the feeding?

Semi-Fowler's

An unlicensed assistive personnel (UAP) is caring for a client who has an indwelling urinary catheter. Which direction should the registered nurse provide to the UAP regarding urinary catheter care?

Use soap and water to cleanse the perineal area.

The nurse manager is providing an educational session to the nursing staff on the safe use of physical restraints. Which are examples of safety guidelines when using physical restraints? Select all that apply. Group of answer choices

A primary health care provider's prescription is required. Restraints should be secured with a quick-release tie. Restraints are used when other measures have failed to prevent self-injury or injury to others.

Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply.

Advance the catheter 1 to 2 inches after urine appears in the tubing. Place the drainage bag lower than the bladder level. Use strict aseptic technique.

The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?

Advance the catheter 2.5 to 5 cm.

The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?

Balance, muscle strength, and confidence

The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings should indicate to the nurse that death is imminent? Select all that apply.

Cyanosis Irregular respiratory pattern Dyspnea Adventitious bubbling lung sounds