FUNDAMENTALS TEST 1 PREPU

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The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply. Communicate with the family regarding the need for restraints. Continue using the restraints until discharge. Offer opportunities for toileting frequently and regularly. Obtain a physician order 2 hours after restraints are applied. Check circulation and skin condition frequently and regularly.

Communicate with the family regarding the need for restraints. Check circulation and skin condition frequently and regularly. Offer opportunities for toileting frequently and regularly. Explanation: An order for restraints from the licensed health care provider must be obtained within 1 hour after the restraint is initiated. The nurse must provide frequent and regular nursing assessments of the restrained client's vital signs; circulation; skin condition or signs of injury; psychological status and comfort; and readiness for discontinuing restraint. In addition, the nurse must offer regular toileting, nutrition, hydration, and range of motion opportunities while the client is restrained. The nurse promptly communicates with the client's family regarding the need for restraints. When the assessment findings indicate that the client has improved, the nurse must legally and ethically remove the restraints. Restraints are not continued until discharge.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: play-related injuries. automobile accidents. falls from beds. falls from staircases.

automobile accidents. Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers.

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? move the client to edge of the bed opposite the side that client will be turning pull the client to the edge of the bed to which the patient will be turning push the client to the opposite side of the bed push the client to the edge of the bed to which the client will be turning

move the client to edge of the bed opposite the side that client will be turning Explanation: When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? transfer belt roller sheet transfer boards mechanical lift

transfer belt Explanation: A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse? Perform a vision test with Snellen chart Arrange for a skilled home care assessment Arrange an audiology consult to evaluate hearing Assess the client for signs and symptoms of osteoporosis

Arrange for a skilled home care assessment Explanation: The client's home should be evaluated for potential hazards and risks. There is no indication of vision or hearing issues. It is uncommon for falls to be directly attributable to osteoporosis.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: bioterrorism. chemical terrorism. mass trauma terrorism. nuclear terrorism.

mass trauma terrorism. Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death.

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed. near the client's hip, with legs together

near the client's hip, with legs shoulder width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age? "Always provide close supervision for young children when they are in or around pools and bathtubs." "Never smoke in the bed in the house when young children are present." "Store medications in a locked area to prevent children from getting into them." "Never keep firearms in the home with young children."

"Always provide close supervision for young children when they are in or around pools and bathtubs." Explanation: The leading cause of injury and death in children 1 to 4 years of age is drowning. Therefore, providing close supervision when children are in or around tubs and pools will help decrease and/or prevent this injury.

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her? "Car seats are only recommended until children are 3 years old." "At the age of 6 your child should be using a booster seat." "Car seats are recommended until children are at least 10 years old." "Your child will be safe in the car using the provided shoulder harness and lap belts."

"At the age of 6 your child should be using a booster seat." Explanation: When children outgrow standard car seats, parents and caregivers should use booster seats, preferably those that use combination shoulder and lap belts, until the car seat belt fits appropriately (typically when they have reached 4 ft, 9 in [1.43 m] in height and are between 8 and 12 years of age).

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her? "Car seats are recommended until children are at least 10 years old." "At the age of 6 your child should be using a booster seat." "Your child will be safe in the car using the provided shoulder harness and lap belts." "Car seats are only recommended until children are 3 years old."

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: "I should be able to fit two fingers between my chin and the chin strap." "The helmet should rest 1 in (2.5 cm) above the eyebrows." "My child should wear a helmet every time he rides a bike." "My child needs a helmet if in a secured passenger bike seat."

"I should be able to fit two fingers between my chin and the chin strap." Explanation: The nurse should determine that additional information is needed when the participant states that the chin strap should fit two fingers underneath the chin. The chin strap needs to be snug, and the ability to fit two fingers between the strap and the chin indicates it is not snug enough. The helmet should rest 1 in (2.5 cm) above the eyebrows. Children should wear a helmet every time they ride a bike or are strapped into a bike seat as a passenger.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states: "The helmet should rest 1 in (2.5 cm) above the eyebrows." "I should be able to fit two fingers between my chin and the chin strap." "My child should wear a helmet every time he rides a bike." "My child needs a helmet if in a secured passenger bike seat."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? "I will rescue clients from harm before doing anything else." "I will sound the alarm before I start moving a patient from a room." "I will leave all doors open after rescuing patients." "I know that nurses are the only ones who can extinguish a fire."

"I will rescue clients from harm before doing anything else." Explanation: The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue patients first.

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary? "I need to remove the hand roll often to exercise my hand muscles." "The hand rolls help keep my thumb positioned away from my hand." "I can use a rolled-up washcloth if I don't have a hand roll." "The hand rolls help me develop strength in my grip."

"The hand rolls help me develop strength in my grip." Explanation: Hand rolls prevent contractures (permanently shortened muscles that resist stretching) of the fingers. They keep the thumb positioned slightly away from the hand and at a moderate angle to the fingers. The fingers are kept in a slightly neutral position rather than a tight fist. A rolled-up washcloth or a ball can be used as an alternative to commercial hand rolls. Hand rolls are removed regularly to facilitate movement and exercise. Hand rolls are not used to strengthen the grip.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? "I will rescue clients from harm before doing anything else." "After clients are evacuated from the room with the fire, the alarm can be sounded." "I will close the door to the room where the fire is after clients have been removed." "Only certain members of the health care team can extinguish a fire."

"Only certain members of the health care team can extinguish a fire." Explanation: All members of the health care team are educated about how to extinguish a fire. Therefore, the UAP's statement about certain members being taught how to use the fire extinguisher requires correction. The other statements are appropriate.

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? "Picture yourself with good posture standing; that is how good lying posture works." "Keep knees and legs very straight." "Your feet should be at 45-degree angles from the legs." "Sleep with your head tilted to one side to take pressure off your neck."

"Picture yourself with good posture standing; that is how good lying posture works." Explanation: The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse? "Adolescents are generally difficult children. Sometimes punishment is necessary to make them change their attitudes." "Let's admit your child to an acute care facility so that we can run more tests." "These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." "This is typical adolescent behavior. Ignore it and it will improve."

"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial." Explanation: Some signs of substance use in adolescents include mood swings, withdrawal from the family, and failing school grades. The other statements are inappropriate generalizations and do not address the problem. There is not enough evidence to suggest a need for hospital admission.

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To preserve the client's functional ability to grasp and pick up objects." "To prevent foot drop." "To help client to turn independently." "To prevent the legs from rotating outward."

"To preserve the client's functional ability to grasp and pick up objects." Explanation: Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To preserve your functional ability to grasp and pick up objects." "To avoid contractures." "To prevent foot drop." "To prevent your legs from rotating outward."

"To prevent your legs from rotating outward." Explanation: Trochanter rolls prevent the client's legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? "I can only allow you to transfer without assistance with a physician's order, so I will help you now." "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

"You are free to move onto the stretcher without assistance, but I will supervise for your safety." Explanation: If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A physician order is not necessary for a transfer from a stretcher to a bed. The client can move independently and therefore does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "We'll have the nursing assistant watch you while you walk around the unit the first time." "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." "Your elbows will be slightly bent when you are using your crutches." "When your crutches fit right, most of your body weight will be supported by your armpits."

"Your elbows will be slightly bent when you are using your crutches." Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? A client who has leg strength and can cooperate with the movement A client who has an abdominal incision A client with a thoracic incision A client who is confined to bed rest

A client who has leg strength and can cooperate with the movement Explanation: The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bed rest.

Which nurse would be at the highest risk of causing a hazardous situation? A nurse who has worked 32 hours of overtime this week A nurse who has placed a client in the bed with three side rails up A nurse who is transferred to another unit to assist with care A nurse who is administering medications to four clients

A nurse who has worked 32 hours of overtime this week Explanation: Health care staff who suffer sleep deprivation due to extended work hours and variable shift assignments are more likely to commit errors and be a factor in adverse events. The remaining three scenarios are within the normal realm of practice. A nurse transferring to another unit is able to provide care to clients within the scope of practice; this does not present a hazardous situation. Placing three side rails up assists with prevention of falls and is not classified as a restraint. Administering medications to four clients is an acceptable number of patients to be assigned to administer medications for most clinical settings.

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason? Primarily protects the nurse from injury Acts to prevent injury to the client and/or nurse Primarily protects the client from injury Acts as a safeguard against legal action by the client

Acts to prevent injury to the client and/or nurse Explanation: When nurses use their bodies to perform therapies, to assist clients with movement, or to move equipment, they benefit from the effective use of body mechanics to prevent injury to themselves and clients. The actions do not safeguard against legal action by the client but rather are in place to prevent injury.

The nurse is assessing a client's mental health competence and decision-making ability. Which activity will best provide the needed information to the nurse? Ask the client to review his medical health history to assess for the level of organization of his thought processes. Discuss with the client's family any concerns about his mental stability. Ask the client "what if" questions to determine level of thought organization. Ask the client to read and discuss a passage from a pamphlet.

Ask the client "what if" questions to determine level of thought organization. Explanation: When reviewing mental health and level of decision-making ability, the best method is to ask the client "what if" type of questions. Assessing the client's reading ability and understanding of passages read will not provide the needed information. Asking the client to discuss his medical history will provide some information but will not provide information on his ability to reason and make clear decisions. Questioning the family provides only a secondary source of information and will not be as effective.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate? Assess for the need to urinate. Administer a prescribed dose of lorazepam. Raise the side rails. Contact the health care provider for a prescription to apply a waist restraint.

Assess for the need to urinate. Explanation: Client needs should be assessed before considering physical or pharmacologic restraint.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Arrange furniture so that the client has something to hold on to. Put the client's bedside rails up. Assess the need for assistance with ambulation. Apply socks to the client's feet.

Assess the need for assistance with ambulation. Explanation: The diverse physiologic and psychologic capabilities of people and encounters with various safety hazards across the lifespan put various age groups at risk for different safety concerns and potential injuries. Older adult clients are at a higher risk for falling. Thus, the nurse should assess the client's ability to ambulate independently before allowing the client to go to the restroom and to provide assistance, if needed. The nurse would lower, not raise, the bedside rails before having the client exit the bed. The nurse would put nonskid footwear like slippers, not socks, on the client to help prevent falls. Furniture should be arranged so that the client has a clear and easy path to the restroom.

The nurse is preparing to apply compression stockings for a client that is at risk for the development of deep vein thrombosis. What action(s) by the nurse demonstrate to the client the appropriate way to apply the stockings? Select all that apply. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. Estimate the size of the client's legs, and obtain the stockings. Massage the client's legs before applying. Apply the stockings in the evening. Assess the skin and neurovascular status of the legs and feet before applying.

Assess the skin and neurovascular status of the legs and feet before applying. Have the client lie down with legs and feet elevated for at least 15 minutes before applying. Explanation: The nurse needs to measure the client's legs to determine the proper size of stocking. Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be ordered to ensure correct fitting on each leg. The size should not be estimated. The nurse will apply the stockings in the morning before the client is out of bed and while the client is supine. If the client is sitting or has been up and about, the nurse will have the client lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. The nurse will not massage the client's legs before applying the stockings. If a clot is present, massaging the leg may break it away from the vessel wall and it can circulate in the bloodstream.

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? Assessment of head circumference Assessment of vital signs and respiratory status Evaluation of all of his cranial nerves Initiation of a peripheral intravenous (IV) line for fluid administration

Assessment of vital signs and respiratory status Explanation: Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than 2 years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment. Assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined.

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client? Assessment of vital signs and respiratory status Initiation of a peripheral intravenous (IV) line for fluid administration Assessment of head circumference Evaluation of all of his cranial nerves

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. Client-centered care Teamwork and collaboration Establishment of clinical career ladders Revamping the licensing requirements for foreign-educated nurses Quality improvement (QI)

Client-centered care Teamwork and collaboration Quality improvement (QI) Explanation: The Quality and Safety Education for Nurses (QSEN) project has been designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses. The six competencies include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Requirements for foreign-educated nurses and the establishment of clinical career ladders are not explicit focuses of the QSEN competencies.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first? Request a sedative from health care provider Conceal IV tubing with gauze wrap Ask visiting family member to stay Assure bed alarms are activated

Conceal IV tubing with gauze wrap Explanation: Wrapping the IV line provides protection for the site. Medications used to control behavior can be considered a chemical restraint that is an intervention of last resort. The presence of a family member may assure client safety and alleviate client anxiety, but would not necessarily protect the IV site. As well, it is inappropriate to delegate client safety observation to family members. Bed alarms alert the nurse to the client leaving his or her bed, but not interference with the IV site.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply. Drowsiness Increased thirst Headache Fever Vomiting

Drowsiness Headache Vomiting Explanation: Concussions are a frequently seen sports injury in school-age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? Use a quick-release knot to tie the restraint to the side rail. Remove the restraint at least every 4 hours, or according to facility policy. Ensure that two fingers can be inserted between the restraint and the client's extremity. Apply restraints to the hands or wrists, never to the ankles.

Ensure that two fingers can be inserted between the restraint and the client's extremity. Explanation: Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager? A small dolly is used to transport heavy items. Work is being carried out under sources of non-glare lighting. Chairs have firm back support and allow the feet to touch the floor. Equipment is positioned to the side, 50 degrees away.

Equipment is positioned to the side, 50 degrees away. Explanation: Proper ergonomics promote comfort, performance, and health in the workplace. All findings support proper ergonomics, with the exception of equipment positioning. Equipment should be positioned 20 to 30 degrees away, in front, not off to the side, to avoid turning or twisting of the head, neck, and shoulders.

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply. Hyperextension of fingers Abduction of fingers Extension of fingers Flexion of fingers Adduction of fingers

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers Explanation: The standard range-of-motion exercises for the fingers of the left hand that will assist the client are extension, flexion, adduction, and abduction of the fingers. Hyperextension of the fingers is not appropriate and may cause injury to the client.

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death? Fifth Tenth First Eighth

Fifth Explanation: Unintentional injuries are the fifth leading cause of deaths behind heart disease, cancer, stroke, and chronic obstructive lung disease. Listed are the top 3 leading causes of death in the US: Heart disease, cancer, and chronic lower respiratory diseases.

The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. Semi-Fowler Supine Fowler Modified supine Upright

Fowler Semi-Fowler Upright Explanation: The Fowler position is a sitting position, also known as upright, that raises the client's head 80 to 90 degrees and benefits the client by preventing aspiration, promoting ventilation, facilitating eating, and improving cardiac output. The semi-Fowler position is a 45-degree angle, which also allows for ventilation without aspiration. The supine and modified supine (pillow under knees) would not be appropriate for facilitation ventilation and preventing aspiration.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? Sims' Fowler's supine prone

Fowler's Explanation: Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. The other position choices do not promote oxygenation.

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? You may switch hands with your cane if you become tired. Hold the cane 6 in (15 cm) in front of you. Hold your cane on the right side. Lean into the cane as it supports you.

Hold your cane on the right side. Explanation: Because this client is using the cane due to weakness, it should be placed on the "strong" side, in this case the right side. The client should stand tall and not lean into the cane. The cane should be 4 in (10 cm) outside the stronger foot. This client should not switch hands with the cane.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? Apply the stockings at night when the client is going to bed. Apply the stockings after the client has been sitting up for an hour. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Avoid the use of powders on the legs before applying stockings.

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Explanation: Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Apply the stockings at night when the client is going to bed. Avoid the use of powders on the legs before applying stockings. Apply the stockings after the client has been sitting up for an hour.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Contact the physician for a restraint order. Put up all four side rails on the bed. Administer the client's sedative as ordered. Initiate use of a bed alarm.

Initiate use of a bed alarm. Explanation: To prevent a fall, the nurse should attempt to prevent the confused client from getting out of bed by himself by using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all four side rails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming himself or others. Contacting the physician for a restraint order or sedative is appropriate if the least restrictive measures do not work.

x An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action? Place the client in a prone position to apply the restraint. Remove the client's upper body clothing and reapply it over the restraint. Insert a fist between the restraint and the client to ensure that her breathing is not constricted. Assess the client at least every 2 hours or according to facility policy, as required.

Insert a fist between the restraint and the client to ensure that her breathing is not constricted. Explanation: The client should be in a sitting position. Apply the restraint over the clothing and insert a fist between the restraint and the client to ensure that breathing is not constricted. Assessments should be made every hour to ensure respirations are not obstructed.

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? Involve family members in the client's care. Allow the client to use the bathroom independently. Keep the client sedated with tranquilizers. Maintain a high bed position so the client will not attempt to get out unassisted.

Involve family members in the client's care. Explanation: Family members are an invaluable resource in assessing a client's risk for a fall because they can provide information regarding periods of weakness, confusion/disorientation, and a history of unreported falls. Allowing the client to ambulate independently may further increase the risk of a fall. Sedating a client is a form of chemical restraint, and may cause the client to have an unsteady gait when ambulating. If the client attempts to get out of bed a high bed position would cause more injury to the client if a fall occurs.

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply. Make sure the client's weaker leg is nearest to the chair. Provide the client with nonskid slippers to put on prior to standing up. Ensure that the client's bedrails are up prior to transfer. Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide step-by-step instructions to the client before the transfer begins.

Lower the bed to the lowest position allowing the client's soles to contact the floor. Provide the client with nonskid slippers to put on prior to standing up. Provide step-by-step instructions to the client before the transfer begins. Explanation: Lowering the bed to the point where the client is able to touch the ground allows the client to be as stable as possible prior to standing up. Having the client wear nonskid slippers prevents the client from slipping and falling during the transfer. Providing step-by-step instructions to the client allows the nurse to solicit the client's help as much as possible. This action informs the client, encourages self-help, and reduces the workload/burden on the nurse. The nurse should ensure the bedrails are down prior to starting the transfer. Having these up will obstruct movement and make the transfer more difficult. Since the client is not lying in bed, the bedrails do not need to be up for client safety. The client's strongest leg should be positioned closest to the chair to provide stability and prevent a fall as the client moves to lower oneself into the chair.

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies? New systems are introduced to increase communication between nurses and the members of other health disciplines. New partnerships are established between the hospital and local schools of nursing. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees. Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost.

New systems are introduced to increase communication between nurses and the members of other health disciplines. Explanation: Teamwork and collaboration is one of the core QSEN competencies, and is exemplified by increasing communication between different disciplines. The six QSEN competencies do not explicitly address financial costs of care, higher levels of education for nurses, or increased partnership between hospitals and educational institutions.

A hospital is introducing a program that has the goal of aligning practices more closely with the Quality and Safety Education for Nurses (QSEN) project. What initiative best exemplifies QSEN competencies? Systems are reviewed with the goal of achieving the best client outcomes at the lowest cost. New systems are introduced to increase communication between nurses and the members of other health disciplines. New partnerships are established between the hospital and local schools of nursing. Hiring practices are reviewed to maximize the proportion of nurses who possess baccalaureate or graduate degrees.

The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion? Notify the National Abuse Hotline. Because the nurse is not sure, observation of the parents behavior will be done. Inform the parent that abuse is suspected. Call the police.

Notify the National Abuse Hotline. Explanation: All 50 states have laws that require health care personnel to report suspected child abuse. Nurses can report abuse, by contacting The National Child Abuse Hotline. The nurse should not delay reporting, because the safety of the child is of utmost importance. The parent should not be confronted, because the child may be removed from the facility. Calling the police is not the appropriate action at this time.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide? Allow emergency personnel to apply oxygen. Wait inside until emergency personnel arrive. Open doors and windows. Recommend that carbon monoxide detectors be installed in the home.

Open doors and windows. Explanation: Carbon monoxide (CO) is extremely lethal because it is colorless, odorless, and tasteless. The nurse recognizes symptoms of bright cherry red skin color, nausea, headache, and inability to move. The initial direction will be for the caller to open doors and windows to reduce the level of toxic gas and provide adequate ventilation. If, while waiting for emergency personnel to arrive, the family members gain the ability to move, they can evacuate outdoors. After having the caller open doors and windows, the nurse can then provide instructions about emergency personnel and further discuss CO detectors.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? Supervise your child on the changing table. Place all household cleaners out of reach. Peer pressure causes children of this age to take risks. Buy protective sporting equipment.

Peer pressure causes children of this age to take risks. Explanation: Adolescents tend to be impulsive and take risks as a result of peer pressure, so this is important for the nurse to teach the adolescent. Buying protective sporting equipment, placing household cleaners out of reach, and supervising the child on the changing table are not age-appropriate teachings to include.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client? Placing the client in a bed with a bed alarm Providing a bed that is elevated from the floor Raising all the side rails of the bed Using restraints on the client to prevent a fall

Placing the client in a bed with a bed alarm Explanation: Raising all side rails on the bed would be a restraint, and may increase the client's risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client? Providing a bed that is elevated from the floor Placing the client in a bed with a bed alarm Raising all the side rails of the bed Using restraints on the client to prevent a fall

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls? Accompany the client to the bathroom every 4 hours around the clock. Limit the client's fluid intake during the evening. Obtain an order for insertion of an indwelling urinary catheter. Provide a bedside commode and ensure adequate lighting.

Provide a bedside commode and ensure adequate lighting. Explanation: The use of a commode can often reduce the risk of falls that is associated with ambulating to the bathroom. Falls reduction is not considered a justifiable rationale for catheter insertion. Toileting every 4 hours may or may not be adequate for the client's needs. Fluid intake should never be reduced for the sole purpose of reducing urine output.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas. Check the batteries in all smoke detectors. Store prescription medications on the counter. Remove extension cords from open spaces.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas. Explanation: Nursing assessment includes identifying individuals at risk and recognizing unsafe situations in the environment. Assessment includes an awareness of risk factors in the home. The nurse would advise the client to remove extension cords from open spaces, check the batteries in smoke detectors, remove throw rugs, and ensure appropriate lighting in hallways and entrances to the home. The nurse would not advise the client to place prescription medications on the counter as anyone could access these. It is recommended that medication be kept in a place that is easy for the client to access, but still should be kept out of the reach of children or others who may take them.

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident? Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality. Report this sentinel event to the Joint Commission and to relevant state agencies Inform the public that the incident occurred, while protecting the confidentiality of the clients. File an incident report with the American Nurses Association describing plans for preventing similar events in the future.

Report this sentinel event to the Joint Commission and to relevant state agencies Explanation: At issue here is that the nurse directly exposed a client via direct bloodline to a client infected with HCV. The uninfected client could become infected and require lengthy treatment. Sentinel events must be reported to the Joint Commission and to relevant state agencies. Sentinel events are not normally publicized, and incident reports are not provided to the ANA. Matters related to financial compensation would likely involve the courts, not the Joint Commission or health agencies.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Evacuate clients and staff. Activate the fire alarm on the unit. Rescue anyone who is in immediate danger. Attempt to extinguish the fire.

Rescue anyone who is in immediate danger. Explanation: The acronym "RACE" can be used as a guide to the immediate response to fire. This involves rescuing anyone in immediate danger (R); pulling the alarm, calling "code red," and alerting appropriate personnel (A); confining the fire by closing doors and windows (C); evacuating clients and other people to a safe area (E). Extinguishing the fire is not part of the immediate response.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care? Impaired Bed Mobility Related to Muscle Wasting Noncompliance Related to Medication Regimen Risk for Injury Related to Agitation Chronic Confusion Related to Long-Standing Alcohol Use

Risk for Injury Related to Agitation Explanation: The client's risk of self-injury or injury to others is the justification for restraint use. Restraints are not normally used to address noncompliance or chronic confusion unless there is a consequent safety risk. Impaired bed mobility is not a justification for restraints.

A father asks the nurse who is caring for his 13-year-old daughter why his daughter could be performing poorly in school lately, and why she is distancing herself from friends and family. Which of these possibilities would the nurse consider as the priority risk? She may be beginning her menses. She has lost interest in academics because she has a boyfriend now. She may be the victim of cyber-bullying. She may be developing nutritional deficiencies from poor dietary habits.

She may be the victim of cyber-bullying. Explanation: Symptoms of cyber-bullying include faltering school achievement, absenteeism, health concerns, isolating oneself from peers/friends, and increased anxiety and depression symptoms. Adolescents may neglect academics when involved in personal relationships, but that is a common milestone of the age group. Achieving menarche may alter mood, but it is not a risk concern. Nutritional deficits can be seen in adolescence and may need to be investigated with this client, but it is not the priority at this time. Reference:

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? The wrist is classified as an irregular bone. Short bones contribute to movement. Flat bones are found in the spinal column. Long bones are relatively thin and contribute to shape.

Short bones contribute to movement. Explanation: Short bones contribute to movement and are located in the wrist and ankle. The wrist is classified as a short bone. Long bones, such as the femur and humerus, are located in the upper and lower extremities and contribute to height and length. The flat bones are relatively thin and contribute to shape. The flat bones are found in the ribs and several of the skull bones and contribute to shape (structural contour).

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? prone Fowler's Sims' supine

Sims' Explanation: Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include? Keep medications out of reach. Supervise your child on the changing table. Buy protective sporting equipment. Peer pressure causes children of this age to take risks.

Supervise your child on the changing table. Explanation: Infants should be supervised on a changing table. Therefore, it is appropriate to tell the caregiver to supervise the child on the changing table. The other options are not appropriate for infants, but are more appropriate for older children.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? The alternative measures attempted before applying the restraints A verbal prescription for the restraints, renewed every 48 hours A detailed description of the restraint application process The type of personal protective equipment used by the nurse during restraint application

The alternative measures attempted before applying the restraints Explanation: Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply. The IV is not infusing at the correct rate. The client's television is turned off. There is spilled water on the floor. The client is wearing the oxygen around the neck. The skin is a bluish-color.

The client is wearing the oxygen around the neck. There is spilled water on the floor. The IV is not infusing at the correct rate. The skin is a bluish-color. Explanation: The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate coldness or lack of perfusion.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? The hospital must bear any costs incurred for treating the client's injury. The hospital will be fined by CMS because the client developed a pressure injury. CMS will bear the hospital's costs if the client chooses to sue the hospital. CMS may choose to divert clients to other health care facilities in the future.

The hospital must bear any costs incurred for treating the client's injury. Explanation: If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital. Fines are not levied against the hospital, however, and CMS does not actively divert clients to other facilities. CMS does not pay damages on behalf of hospitals.

A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? The nurse should rock his or her pelvis out on the opposite side of the client. The nurse should place his or her feet close together with one foot in front of the other. The nurse should grasp the gait belt and pull the client's body backward away from his or her body. The nurse should gently slide the client down his or her body to the floor.

The nurse should gently slide the client down his or her body to the floor. Explanation: The nurse should place feet wide apart, with one foot in front, and rock the pelvis out on the side nearest the client. The nurse should grasp the gait belt and support the client by pulling his or her weight backward against his or her body and then gently slide the client down his or her body to the floor, protecting the client's head.

A nurse is using the QSEN competency of evidence-based practice when caring for clients. What is an example of this competency? The nurse manager holds an in-service for staff to teach them the safe operation of a new piece of equipment. The nurse works with other health care team members to provide care for a client diagnosed with Alzheimer's disease. The nurse researches best current practices for prevention of the spread of infection in physician offices. The nurse uses computer-generated care plans for client care.

The nurse researches best current practices for prevention of the spread of infection in physician offices. Explanation: The QSEN model specifies the integration of best current evidence with clinical expertise, along with client and family preferences and values, for delivery of optimal health care. Researching current practices for prevention of the spread of infection demonstrates this competency. Working with others to provide care demonstrates collaboration of care. The nurse manager holding an in-service demonstrates education of the staff. Use of computer-generated plans for client care demonstrates the use of nursing informatics.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? The nurse should notify the primary care physician about the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises. The nurse should request permission from the client to photograph the bruises.

The nurse should question the client about the source of the bruises. Explanation: The initial action by the nurse would be to determine the source of the bruises. If suspicion remains, the nurse should question the client. If the nurse feels there is potential abuse the nurse is obligated to report it.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should include a note on the client's chart that mentions the report. The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should await results of the x-ray before filing the report. The nurse should make a copy of the safety event report and place it in the client's medical record.

The nurse should record the incident in the client's medical record and fill out a safety event report separately. Explanation: The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should include a note on the client's chart that mentions the report. The nurse should await results of the x-ray before filing the report. The nurse should make a copy of the safety event report and place it in the client's medical record.

Using proper body mechanics, which motions would the nurse make to move an object? The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity.

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Explanation: Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate? The report becomes a confidential part of the client's health record once it is reviewed by hospital administration. The incident report is reviewed by state agencies and the Occupational Safety and Health Administration rather than by hospital administration. The report provides a detailed and objective account of the circumstances before, during, and after the event. The client and the client's family will be required to sign the report, acknowledging that they read it before it was filed.

The report provides a detailed and objective account of the circumstances before, during, and after the event. Explanation: Incident reports are used for internal review and improvements to systems. They include detailed descriptions of the event in question. They do not become part of the client's health record. They are often provided to outside agencies, but they do not bypass the institution where the event occurred. Clients and their families do not sign incident reports.

Which factor is related to the highest proportion of falls in long-term care settings? Polypharmacy Agitation Impaired sleep patterns Toileting

Toileting Explanation: More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep.

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply. Hold diuretic medications. Keep all bed rails up at night. Keep the client's slippers at the bedside for easy reach. Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up

Use a chair alarm when the client is out of the bed. Use a bed alarm to signal when the client gets up Explanation: Interventions for decreasing fall rates and decreasing the severity of injury if a fall occurs have become a focus to ensure safe client care. By identifying clients at greatest risk, the nurse can increase and individualize surveillance and preventive interventions. Some fall prevention strategies for all clients include orientating the client to the environment and keeping a call light and personal belongings within reach. If the assessment determines that the client is at high risk for falling, the nurse should individualize the plan based on the specific risk factors. One thing to consider is using a bed or chair alarm for confused clients.

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply. Keep the client's slippers at the bedside for easy reach. Hold diuretic medications. Use a chair alarm when the client is out of the bed. Keep all bed rails up at night. Use a bed alarm to signal when the client gets up

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? Logrolling can be performed by one experienced nurse. Logrolling will maintain straight alignment when the client is sitting in a chair. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. It is acceptable to twist the client's head, but not the hips, while logrolling.

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Explanation: Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. Twist or bend electric cords to make sure the cords are not dragging on the floor. Use equipment only for the use for which it was intended. Clean all equipment with soap and water after use. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible. Explanation: Nurses work with mechanical and electrical equipment on a daily basis. Proper care to avoid injury and damage to these items includes using them only for the specific purpose, using three-pronged plugs, and having working knowledge of the correct procedures for safety. Bending cords can cause internal wire damage. Many types of sensitive technical equipment can be damaged if cleaned with soap and water.

A nurse is teaching parents about Internet safety for children. Which action(s) is a recommended guideline for Internet use? Select all that apply. Emphasize that everything read online is usually true. Keep identifying information posted on the web sites. Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures. Explanation: Parents should keep identifying information private (e.g., full name, address, telephone number) and investigate filtering software or methods of blocking out objectionable information. They should warn their children to avoid public chat rooms and forums and emphasize that everything said or anything read online may not be true. They should also be alert for downloaded files with suffixes that indicate images or pictures (e.g., .jpg, .gif, .bmp, .tif, .pcx) and consider keeping the computer in a central location in the house, rather than in a child's bedroom (USAA Educational Foundation, 2009).

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include? correct placement of booster seats for the car the use of skid-proof mats for the bath tub Use of blankets, pillows, and stuffed animals in the crib safety of guns in the home

Use of blankets, pillows, and stuffed animals in the crib Explanation: Infant safety education should include use of approved car seats and not booster seats. Booster seats are used for the pre-school child with recommended height and weight. The use of skid-proof mats in the bathtub are topics more suited to the parents of preschool children. Infants are not likely to be physically able to access guns in the home. Infants should not have pillows, stuffed animals, or blankets in the bed due to the risk of suffocation.

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include? safety of guns in the home correct placement of booster seats for the car Use of blankets, pillows, and stuffed animals in the crib the use of skid-proof mats for the bath tub

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group? Do not text while driving. Use protective sporting equipment. Be cautious of electrical outlets. Use caution when descending stairs.

Use protective sporting equipment. Explanation: School-age children in the 7th grade are physically active, which makes them prone to play-related injuries. Therefore, protective sporting equipment should be used. Information about not texting while driving is more appropriate for teenagers and adults who drive. Using caution around electrical outlets and stairs is more appropriate for parents of toddlers.

A group of children is preparing for a camping trip in the woods with camp counselors. The children are learning about health promotion activities to use on their upcoming camping trip. Which principle is most important for the nurse to teach to promote a safe camping experience? Avoiding poison ivy Using the buddy system during the trip Running on smooth surfaces Wearing sturdy shoes for hiking

Using the buddy system during the trip Explanation: The buddy system, a prearranged agreement between two or more people to provide mutual companionship and to monitor each other's whereabouts and well-being during certain high-risk activities, is an important outdoor and water safety strategy and the most important principle for the nurse to teach to ensure a safe camping experience. Wearing sturdy shoes for hiking, avoiding poison ivy and running on smooth surfaces are strategies to stay safe, but the buddy system is the most important to ensuring an overall safe camping experience.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? When I lift an object, I will get close to the object being lifted. When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. When lifting an object, I will keep my feet shoulder width apart. When lifting an object, I will bend at the knees instead of the waist.

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. Explanation: The nurse teaching a group of UAPs about proper body mechanics recognizes the need for additional education when a class participant states that, when lifting and carrying a heavy box of supplies, the UAP will keep it at an arm's length from body. This motion will result in injury and the UAP should be instructed to keep items close to the body. The UAPs should lift an object with feet shoulder width apart by bending at the knees instead of the waist and getting close to the object being lifted. These actions reflect the correct understanding of proper body mechanics.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client? an 84-year-old male with four recent driving violations a 12-year-old male who sprained his wrist skateboarding a 42-year-old female who is a single mom with a sick child home from school a 16-year-old pregnant female who has morning sickness

an 84-year-old male with four recent driving violations Explanation: An older adult with multiple driving infractions may be having difficulty with sensory-perceptual alterations due to aging changes such as glaucoma, cataracts, presbyopia, presbycusis, cognition, or response time impairments. The 12-year-old should not experience sensory issues with a sprain of the wrist. The 42-year-old may be stressed but is not experiencing illness. The 16-year-old is experiencing illness, but it is not a sensory-perceptual alteration.

Which type of mobility aid would be most appropriate for a client who has poor balance? axillary crutches a single-ended cane with a half-circle handle a cane with four prongs on the end (quad cane) a single-ended cane with a straight handle

a cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply. adjust the height of the work area use a wide stance and lift with the large leg muscles hold his breath only when lifting heavy objects face in the direction of the activity he is performing

adjust the height of the work area face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles Explanation: Breath holding is a sign of muscle strain and an inefficient use of body mechanics.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety? admitting the client to the health care facility transferring the client from one location in the hospital to another electronically reporting the results of diagnostic testing to the client's primary care provider administering medications to the client

administering medications to the client Explanation: A large proportion of adverse events in hospital settings involves medication administration. It is generally accepted that medication administration is more risky than communication of testing results, client transfers, or client admissions.

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? alongside the bed at the same height alongside the bed 2 in (5 cm) higher alongside the bed 2 in (5 cm) lower alongside the bed 1 in (2.5 cm) either lower or higher

alongside the bed at the same height Explanation: By placing the bed and the stretcher at the exact same height, it makes for easier transfer and decreases risk of potential injury. If the stretcher were lower or higher, it would not make for a smoother transfer and the client could be injured during transfer.

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? lying flat sitting up lying flat with feet raised slightly lying prone

lying flat Explanation: The nurse would position the bed so that the client is lying flat on the back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed. If the client was prone, the client will need to be moved to the client's back. Sitting up is another position a client can be moved into.

What is a benefit of regular exercise over time? increased risk for blood clots increased work of breathing decreased venous return decreased heart rate

decreased heart rate Explanation: Regular physical activity over time results in cardiovascular conditioning and therefore decreased heart rate. Regular exercise increases circulating fibrinolysin that serves to break up small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? is demonstrating a common gait for the older adult. requires crutches for mobility. requires a better walking shoe. should have an orthopedic consultation.

is demonstrating a common gait for the older adult. Explanation: Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise? isometric anaerobic isotonic aerobic

isometric Explanation: Isometric exercise isolates a specific muscle or muscle group and exercises it by holding the muscle steady and maintaining tension.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? keeping medications in clearly labeled containers alternatives to chemical-based cleaning supplies hidden sources of lead in the household environment avoiding the use of alternative and complementary therapies

keeping medications in clearly labeled containers Explanation: Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors. Cleaning supplies and lead are more significant sources of poisoning in infants and children. Alternative and complementary therapies carry risks, but it would be unnecessary to recommend complete avoidance of all such therapies.

When logrolling a client, the nurse should use supportive devices in turning the client in order to: maximize the client's participation. allow the client's leg to rest on the bed. maintain the natural alignment of the client's body. prevent the blood stasis that can lead to skin breakdown.

maintain the natural alignment of the client's body. Explanation: Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine. It maintains spinal alignment, thus preventing injury. It is not performed for the purpose of maximizing the client's participation or preventing blood stasis.

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? pull the client to the edge of the bed to which the patient will be turning move the client to edge of the bed opposite the side that client will be turning push the client to the opposite side of the bed push the client to the edge of the bed to which the client will be turning

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed. near the client's hip, with legs together to the dominant side of the client, with legs together and one foot near the head of the bed

Which level of health care provider may make the decision to apply physical restraints to a client? nurse practitioner LPN team leader RN nurse manager senior personal care assistant

nurse practitioner Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician assistant.

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client? deep vein thrombosis orthostatic hypotension hypertension circulatory alterations

orthostatic hypotension Explanation: The nurse would stand in front of the client and assess for any balance problems or reports of dizziness upon standing due to orthostatic hypotension. Orthostatic hypotension occurs when the blood pressure drops when standing from the sitting or lying position. Standing in front of the client prevents falls or injuries. Hypertension or high blood pressure is a condition in which the force of the blood against the artery walls is too high. Hypertension needs to be treated with medications to lower the blood pressure. Deep vein thrombosis is a thrombosis or blood clot in a vein lying deep below the skin, especially in the legs. Treatment is by medications, compression stockings, and filters. There are other circulatory alterations, like peripheral artery disease, which is caused by narrowed blood vessels that reduce blood flow to the limbs.

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? place a trochanter roll under the arms place a small pillow under each arm elevate the head of the bed instruct the client to place arms on the side rails

place a small pillow under each arm Explanation: A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (Fowler) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? positioning the client on the stomach contacting the primary care physician administering a muscle relaxer placing a small towel under the neck

placing a small towel under the neck Explanation: Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the physician is unnecessary.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? standing at the top of the bed and having a colleague stand at the bottom of the bed positioning a friction-reducing sheet under the client to facilitate movement placing the bed in its lowest position to reduce the client's risk for falls using back muscles to gently and gradually pull the client to the side

positioning a friction-reducing sheet under the client to facilitate movement Explanation: After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in circulating fibrinolysin predisposition to renal calculi increase in the movement of secretions in the respiratory tract increased metabolic rate

predisposition to renal calculi Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should: provide the client with an overhead trapeze. manually roll the client to the side of the bed. teach the client to pull up with the headboard. use a pull sheet whenever moving the client.

provide the client with an overhead trapeze. Explanation: Overhead trapezes may provide handholds for clients to assist with transfers and repositioning. The headboard should not normally be used for this purpose. A pull sheet may be unnecessary if the client can partially assist.

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? provides slippers for ambulation clears a path from bed to bathroom has client sit in bed for a few moments before standing places bed at lowest setting

provides slippers for ambulation Explanation: Older adults often wear slippers to accommodate swollen feet. Although slippers are more comfortable, less expensive, and less tiring to put on than shoes, they do not offer much support or traction. The nurse should intervene to remind the UAP that better footwear should be utilized. Placing the bed at the lowest setting, clearing a path from the bed to the bathroom, and having the client sit in bed before standing increase safety while minimizing risk for falls.

A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group? providing drug, alcohol, and sexuality education teaching stress reduction techniques selecting toys for the developmental level providing close supervision to prevent injuries

providing drug, alcohol, and sexuality education Explanation: The school-age child should be taught drug, alcohol, and sexuality education. Selecting toys for the developmental level applies to infants. Teaching stress reduction techniques applies to adults. Providing close supervision to prevent injuries applies to toddlers.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. removing clutter from the floor installing hardwood floors placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor Explanation: Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? increased need for calcium and vitamin D scoliosis kyphosis shifted center of gravity

scoliosis Explanation: Numerous factors, including growth and development, influence a person's posture, movement, and daily activity level. The adolescent should be assessed for scoliosis (curvature of the spine). Kyphosis is increased convexity in the thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (in the adult) because of the developing fetus. Older adults have an increased need for calcium and vitamin D related to the risk for osteoporosis.

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? joint stiffness after sitting for an hour walking with a slow and uncoordinated movement shortness of breath after walking up five stairs a change in pulse from 80 to 84 after walking up 20 stairs

shortness of breath after walking up five stairs Explanation: Activity Intolerance may result from any condition that interferes with the transport of oxygenated blood to tissue. The altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing diagnosis. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 points is not excessive. Joint stiffness is a defining characteristic of the nursing diagnosis Impaired Physical Mobility. Walking with a slow and uncoordinated movement is another defining characteristic of Impaired Physical Mobility.

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? supine prone slight Trendelenburg Sims'

slight Trendelenburg Explanation: Placing a client in slight Trendelenburg position may help keep the client from sliding down toward the foot of the bed. Placement into the other position choices does not accomplish the same purpose.

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as: disequilibrium. hemiparesis. ataxia. spasticity.

spasticity. Explanation: Spasticity refers to stiff or awkward muscle movements. Hemiparesis refers to weakness on one side of the body. Ataxia refers to impaired muscle coordination. Disequilibrium would lead to balance problems.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: leans over the walker when walking. places the walker far in front when walking. steps into the walker when walking. uses the sides of the walker to rise from a chair.

steps into the walker when walking. Explanation: A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: steps into the walker when walking. uses the sides of the walker to rise from a chair. places the walker far in front when walking. leans over the walker when walking.

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? Sims' prone supine lateral

supine Explanation: Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are inappropriate for placing an infant to sleep.

The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep? Sims' prone supine lateral

supine Explanation: Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are incorrect.

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? under the client's feet under the client's head in front of the client's abdomen supporting the client's back

supporting the client's back Explanation: The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered? temporary application of devices that reduce the client's ability to move arms administration of an antipsychotic agent to alter the client's behavior delegating to the unlicensed assistive personnel (UAP) to sit with the client providing a sleep agent to help the client rest instead of pulling IV lines and the catheter

temporary application of devices that reduce the client's ability to move arms Explanation: If diversion behaviors and chemical (drug) restraints have failed, the nurse anticipates that the provider may order temporary application of devices to reduce the client's ability to move arms, which will prevent the behavior. The other actions are not appropriate, so the nurse would not anticipate them.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? the 24-month-old child who is unable to walk unassisted the 3-month-old child who is unable to raise the head when prone the 6-month-old child who is unable to roll over the 18-month-old child who is unable to stack blocks

the 24-month-old child who is unable to walk unassisted Explanation: At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early. Reference:

When assessing the physical activity of clients, the nurse would be most concerned about which client? the Native American who hunts the older adult client who goes to the mall 3 times a week the young mother of a 2-year-old and 4-year-old the middle-aged computer programmer

the middle-aged computer programmer Explanation: Although further assessments should be done to avoid making assumptions and imposing stereotypes, there are many variables that may contribute to a sedentary lifestyle, such as occupations. A computer programmer has a job that is inactive. The nurse would be concerned about this client and would need to do further assessments to determine activity, frequency, and intensity that occur outside of work. The mother of small children would be involved in housecleaning and chasing after the children. Walking is a commonly prescribed exercise, and going to the mall provides a safe environment where walking would be possible. A Native American who hunts is engaging in culturally related physical activity.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? skeletal contractures pooling of secretions thrombus formation oliguria

thrombus formation Explanation: Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? roller sheets trochanter rolls foot splints foot boards

trochanter rolls Explanation: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the heads of the femurs, near the hip. Placing positioning devices at the trochanters helps prevent the legs from rotating outward. Other devices are inappropriate for this client.

A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce their risk for injuries incurred while working with clients. Which action(s) would contribute to this risk? Select all that apply. using assistive devices using uncoordinated lifts standing for long periods lifting when tired engaging in repetitive movements

using uncoordinated lifts lifting when tired engaging in repetitive movements standing for long periods Explanation: Variables that can lead to back injuries or back pain for health care workers include performing uncoordinated lifts, manual lifting and transfer of clients without assistive devices, lifting when fatigued, repetitive movements, and standing for long periods.

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