Fundamental week 4

a nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicated an understanding of the teaching

" a nurse will show me how to care for my wound"

a nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologies for the smell. Which of the following responses should the nurse make?

"it must be difficult to care for someone who is confined to bed"

a nurse is providing teaching on an older adult who has constipation. Which f the following statements should the nurse include in the teaching?

"sit on the toilet 10 min after a meal"

a nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. the nurse should suspect an injury to which the following parts of the brain

brainstem

a nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

explain the procedure to the client

during the insertion of the urinary catheter for a client, the tip of the catheter brushed against the nurse's arm. Which of the following actions should the nurse take?

obtain a new catheter and reattempt insertion

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

oil retention

a nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following action should the nurse take when collecting the specimen?

place the stool collection contain in a biohazard bag

a nurse is preparing to irrigate a clients wound. Whch of the following actions should the nurse take?

warm the irrigating solution to 37 degrees Celsius (96.6 degrees Fahrenheit)

a nurse is assisting a client's incision and observing the drainage to blood-tinged. Which of the following terms should the nurse use to document this finding?

sanguineous

a nurse is providing teaching about the proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water

a nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the clients indicates an understanding of the teaching

Gelatin

a nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions

Hemolytic

a nurse is changing the dressing of a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation

Montgomery straps

a nurse is planning care for a client who has a prescription for the collection of a specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

collect the specimen when the client rises in the morning

A nurse is planning to insert a female external urinary catheter for a client. Which of the following actions should the nurse plan take?

connect the catheter to continuous wall suction

a newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?

consult the medication reference book available on the unit

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

cover the incision with a moist sterile dressing

a nurse is asses a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

grimacing

a nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates need further teaching

i will be certain to take enteric-coated medication

a nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on the factors contributing to this postoperative complication.

impaired peristalsis of the intestines

a nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500mg/day for severe joint pain. The nurse should instruct the client that large dose of acetaminophen could cause which of the following adverse effect?

liver damage

a nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

provide an intake of 1.5g/kg of body weight per day

an assistive personnel (Ap) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further testing?

the AP hangs the collection bag at the level of the bladder

a nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify which of the following findings is an indication of infiltration?

edema at the infusion site

a nurse is instructing a client about collecting a 24-hour urine specimen for creatine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?

"Ill make sure to keep the collection bottle in the container of ice they gave me "

a nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

cold extremities