Fundamentals - Basic Physical Care

The nurse instructs a group of colleagues on actions to take to prevent back injuries when providing client care. Which statement by a colleague indicates that additional teaching is required? "A back belt prevents injuries." "It is safer to use an assistive device." "A lift team will help prevent back injuries." "An assistive device reduces the risk of client injury."

"A back belt prevents injuries."

Which statement indicates that a client understands the need for routine screening to detect colorectal cancer? "I need to have a colonoscopy at age 45 then every 10 years until age 75." "I will submit a stool sample for occult blood at age 50 and then yearly until age 75." "I will have a flexible sigmoidoscopy at age 45 and then every 10 years until age 70." "I need to have a stool DNA test at age 50 and repeat every 3 years."

"I need to have a colonoscopy at age 45 then every 10 years until age 75."

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse? "I will get the furosemide from the floor stock right now and give it to the client." "I will find you a computer that is not being used so you can enter the order into the computerized order entry system." "I will need to let the charge nurse know about the order so it can be entered in the computerized order entry system." "I will call the pharmacy and have them send the furosemide right away." "I will put the order in the computer order entry system and give the furosemide once it arrives from the pharmacy"

"I will find you a computer that is not being used so you can enter the order into the computerized order entry system."

When cleaning the skin around an incision and drain site, what should the nurse do? Clean the incision and drain site separately. Clean from the incision to the drain site. Clean from the drain site to the incision. Clean the incision and drain site simultaneously.

Clean the incision and drain site separately.

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client? Client has mild cognitive impairment. Client is being treated for a wound infection. Client needs minimal assistance to ambulate. Client is recovering from abdominal surgery.

Client is recovering from abdominal surgery.

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? Reposition the tube in the nares. Irrigate the tube with a cool solution. Apply a water-soluble lubricant to the nares. Have the client change position more frequently.

Apply a water-soluble lubricant to the nares.

A client had abdominal surgery 2 days ago and has copious drainage. The nurse uses Montgomery straps when changing the dressing. Which is the expected outcome of using these straps? Maintain pressure on the suture line. Prevent dehiscence. Avoid skin breakdown. Keep the client from touching the incision.

Avoid skin breakdown.

What should the nurse do to ensure safety for a hospitalized blind client? Require that the client has a sitter for each shift. Request that the client stays in bed until the nurse can assist. Orient the client to the room environment. Keep the side rails up when the client is alone.

Orient the client to the room environment.

A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? Perform frequent mouth care. Use normal saline nose drops daily. Sneeze and cough with mouth closed. Gargle every 4 hours with salt water.

Perform frequent mouth care.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure? The nurse should push fluid forcefully into the ear to remove the cerumen. The nurse should use cool water with the irrigation for client comfort. The nurse should irrigate as a last resort after trying to mechanically remove the cerumen. The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

The quality assurance nurse is reviewing orders on a client's chart. Which order transcribed by the nurse would require the quality assurance nurse to speak with the nurse manager? Marie L. Smith 2/28 1453 furosemide 20 mg oral twice a day Greg Davis, MD Lee F. Hardy 1/25 1500 warfarin 10 mg oral one time a day Missy Smith, APN Tamara M. Frank 3/15 0921 bumetanide 1 mg PO twice a day Scott Miller, APN Tom B. Smith 12/28 sertraline hydrochloride 25 mg oral twice Frank Bill, MD

Tom B. Smith 12/28 sertraline hydrochloride 25 mg oral twice Frank Bill, MD

The nurse has received a change-of-shift report. The nurse should assess which client first? a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 who has exhibited agitation, fearfulness, and sleeplessness over the last 36 hours a 36-year-old with chest tube due to spontaneous pneumothorax with current respiratory rate 18 breaths/min, oxygen saturation 95% on oxygen at 2 L per nasal cannula a 28-year-old who is 2 days post appendectomy with discharge prescriptions written and whose spouse is waiting to take the client home a 62-year-old admitted with a recent gastrointestinal (GI) bleeding whose hemoglobin is 13.8 g/dL (138 g/L)

a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 who has exhibited agitation, fearfulness, and sleeplessness over the last 36 hours

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advance directive. The client asks for an explanation of advance directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is: a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. a legal document, made by the client when the client is healthy, that directs others to follow the client's wishes if the client is incapacitated a legal document that is commonly referred to as a living will and recognized in North America. a legal document, also known as a health care proxy, where the client indicates a person to make health care decisions for the client if the client becomes incapacitated.

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status.

A nurse should question an order for a heating pad for a client who has active bleeding. a reddened abscess. tight back muscles. purulent wound drainage.

active bleeding.

When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate? administering fluids to the client having the client take nothing by mouth until the gag reflex has returned placing the client on bed rest assessing the client for the presence of any metal implants

administering fluids to the client

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort? assault battery negligence right to refuse care

assault

hen preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? at the top of the wound in the middle of the wound at the base of the wound over the total wound

at the base of the wound

The student nurse is admitting an elderly patient with congestive heart failure and sets up the room with standard precautions. Which is noted by the nursing instructor as the best action? wearing gloves for all client contact considering all body substances potentially infectious placing a body substance isolation sign on the client's door wearing a gown if the client is in respiratory isolation

considering all body substances potentially infectious

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order? incision and drainage culture debridement irrigation

debridement

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin restores the inflammatory response. enhances oxygen transport to tissues. reduces edema. enhances protein synthesis.

enhances protein synthesis.

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's lower foot. ankle. lower thigh. knee.

lower foot.

During an admission history a copy of the living will was provided by the client. The nurse's responsibility at this time is to: ensure that all the components of the living will are addressed within the document. thank the client for the information, read it thoroughly, and ask the client to place it in the top bedside drawer. record in the comment section of the admission history form key components of the client's living will. place the document on the client's chart and communicate the information to the health care team.

place the document on the client's chart and communicate the information to the health care team.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? assessing the client's temperature every 8 hours placing the client in respiratory isolation monitoring the client's fluid intake and output wearing gloves during all client contact

placing the client in respiratory isolation

A female client informs the nurse that her husband is concerned about her sexual response. The client reports that during stimulation, her husband has noticed her clitoris disappears, and he wonders if she is enjoying the experience despite her positive responses to his stimulation. The nurse explains that building excitement and retraction of the clitoris are normal characteristics of which stage of the sexual response cycle? plateau phase excitement phase orgasm resolution phase

plateau phase

A nurse is teaching a group of women health promotion strategies. Which activities are primary prevention strategies? Select all that apply. proper use of sunscreen weight-bearing exercises breast self-examinations importance of Papanicolaou (Pap) smear increased intake of vegetables and whole grains

proper use of sunscreen weight-bearing exercises increased intake of vegetables and whole grains

Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? rolling the client onto the side sliding the client to move up in bed lifting the client when moving the client up in bed having the client help lift off the bed using a trapeze

sliding the client to move up in bed

A scrub nurse is assigned to the operating room for an appendectomy case. Which action by the scrub nurse violates the standards of sterility during the operation? touching the corners of the sterile field removing a blood sponge from the body cavity tying the back of another nurse's gown passing a sterile gauze pad to the surgeon

tying the back of another nurse's gown

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is fluid intake and output. urine specific gravity. vital signs. weight.

weight