Hygiene, Mobility, and Safety

A nurse uses the get up and go test to assess a client for weakness, poor balance, and decreased flexibility. Place the following actions in the order in which they should be implemented when employing the get up and go test.

Ask the client to sit in a chair Ask the client to stand Ask the client to close the eyes Ask the client to open the eyes Ask the client to walk 10 feet and then return to the chair

A nurse must be at the feet of a client with diabetes. What should the nurse do before bathing this clients feet?

Assess for additional risk factors that may contribute to localized problems

A nurse is providing for the hygiene and grooming needs of an obese client who easily become short of breath when moving about. Which nursing intervention is important? Select all that apply.

Assessing the clients response to the activity Bathing areas that the client cannot reach

Which should the nurse do to best prevent a client from falling?

Assist the client with ambulation

A cognitively impaired client is incontinent of loose stools. Which action should the nurse implement to help the client prevent skin breakdown?

Bathe immediately after a bowel movement

A nurse is responsible for providing hair care for a client. What should the nurse do to distribute oil evenly along hair shafts?

Brush the hair from the scalp toward the hair ends

A client has dysphasia. Which nursing action takes priority when feeding this client?

Checking the mouth for emptying between every bite

I Nurs change the sheets and pillowcases of the bed while the client sits in a chair. Of the options presented, which is the most important nursing action when changing bed linens?

Checking the soiled bed linens for personal items

A client with a history of thrombophlebitis should not have pressure exerted on the popliteal space. In which position should the nurse avoid placing this client?

Contour

A nurse is giving a client a bed bath. Which nursing action is most important?

Ensure that the bathwater is at least 110°F

A nurse place is a client in the orthopneic position. Which is the primary reason for the use of this position?

Facilitates breathing

A nurse concludes that the client has the potential for impaired mobility. Which of the following reflect risk factors that support this conclusion? Select all that apply

Joint pain, limited range of motion

Profuse smoke is coming out of the heating unit in a clients room. Which should the nurse do first?

Move the client out of the room

A nurse places a client with a sacral pressure ulcer in the left Sims position. How should the nurse position the clients right arm? Select all that apply

On a pillow

A school nurse is teaching children about fire safety procedures. Which is the first thing they should be taught to do if their clothes catch on fire?

Roll on the ground

The client with a prescription for bed rest has diaphoresis. What should the nurse use to best limit the negative affects of perspiration on dependent skin services of this client?

Sheepskin

An unconscious client begins vomiting. In which position should the nurse place the client?

Side-lying

When giving a client a bed bath, a nurse washes the clients extremities from distal to proximal. Which is the rationale for this nursing action?

Stimulates venous return

Which should the nurse implement when caring for a client who wears eyeglasses? Select all that apply.

Store eyeglasses in a safe place when not being worn Use warm water to clean the lenses of eyeglasses at least once a day

A school nurse teaches an adolescent who has dry skin and acne about skin care. Which statement by the adolescent indicates that the information is understood? Select all that apply.

" I will use my also to gently cleanse my face thoroughly twice a day."

Which is an appropriately worded goal for a client who is at risk for falling? Select all that apply.

" The client will be able to walk from a bed to a chair safely while hospitalized." " The client will be free from trauma."

Which statement made by an older adult indicates to the nurse that additional teaching about skin care is necessary? Select all that apply.

"I use a bubble bath product when I take a bath." " I love to relax and a hot bath before going to bed."

A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurses actions in order of priority using the RACE model.

1. Pull the fire alarm 2. Shut the door to the utility room. 3. Close unit doors and windows. 4. Provide emotional support to agitated clients.

A toaster is on fire in the pantry of a hospital unit. Which should the nurse do first?

Activate the fire alarm

A primary healthcare provider prescribes a standard walker for a client who has left-sided weakness and requires some assistance with balance but can bear weight on both legs. Which should the nurse teach the client about how to use the walker safely? Select all that apply

Advance the strong leg last by itself Advanced the walker and the weak leg ahead together first

The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in this program?

Advanced age of clients

A nurse is placing a client in the left lateral position. Which of the following should the nurse implement when positioning this client? Select all that apply

Align the shoulders with the hips, protract the left shoulder

A nurse plans to use a trochanter roll when repositioning a client. Where should the nurse place the trochanter roll?

Along side the ileum to mid thigh

A client has had a nasogastric tube to decompress the stomach for three days and is scheduled for an intestinal surgery in the morning. Which of the following is the client at the highest risk?

Altered oral mucous membranes

A client with limited mobility has a prescription to be out of bed to a chair for one hour daily. The nurse plans to transfer the client using a mechanical lift. Which of the following should the nurse implement? Select all that apply

Apply gentle pressure against the clients knees when lowering the client into the chair Hook the longer straps on the end of the sling closest to the clients feet

A nurse is caring for a client with Parkinson's disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphagia should the nurse assess the client?

Aspiration

A nurse is to transfer a client from a bed to a chair. After washing their hands, providing privacy, and explaining the transfer to the client, the nurse ensures that the wheels on the bed or locked and move the bed to the lowest position. Place the following steps in order in which they should be implemented.

Assess the clients vital signs and strength while in the supine position Elevate the head of the bed to the high Fowlers position and put footwear on the clients feet Assist the client to a sitting position on the side of the bed, with the feet on the floor. Verify if the client feels dizzy Support the client sitting on the side of the bed for several minutes before transferring to a chair

A nurse plans to meet the hygiene needs of a hospitalized client who is experiencing him a paresis because of a brain attack (cerebrovascular accident). Which is an appropriate nursing intervention?

Assisting the client to bathe as needed

A nurse is planning to shampoo the hair of a client who has a prescription for bedrest. Which should the nurse do first?

Brush the hair to remove tangles

A nurse is assessing a client risk for thrombus formation associated with impaired mobility. Which of the following constitute for Virchow's triad? Select all that apply

Compression of small vessels in the legs, coagulation activation, venous stasis

A home care nurse is assigned to care for an older adult living at home. Which is the first action the home care nurse should employ to prevent falls by this older adult?

Conduct a comprehensive risk assessment

A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury?

Confused middle-aged man

A client has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility that may be associated with this client is a concern for the nurse?

Contractures

A client brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. Which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?

Controls stray electrical currents

A nurse covers the client with a cotton blanket during a bath. which of the following mechanisms of heat loss is prevented by the nurses action?

Convection

A client is diagnosed with stage IV pressure ulcer with eschar. Which medical treatment should the nurse anticipate the primary health care provider will prescribe for this client?

Debridement of the wound

Which clinical manifestation indicates that a further nursing assessment is necessary to determine if the client is having difficulty swallowing? Select all that apply

Debris in the buccal cavity, coughing episodes, noisy breathing, slurred speech, drooling

A nurse in a community center is conversing with a group of older adults who voiced fears about falling. Which is the most common consequence associated with older adults fear of falling that the nurse should discuss with them?

Decreased physical conditioning

Which systemic response in immobilized clients should nurses monitor for? Select all that apply

Dependent Adema, hypostatic pneumonia, increased cardiac workload

A nurse is transferring a client from a bed to a wheelchair. Which should the nurse due to quickly assess the clients tolerance to this activity?

Determine if the client feels dizzy

A nurse is implementing the action demonstrated in the illustration what is the nurse doing?

Dislodging an object from a clients airway

A nurse is performing passive range of motion exercises for a client who is in the supine position. Which motion occurs when the nurse been to the clients and cool so that the toes are pointed toward the ceiling?

Dorsal flexion

And adult client consistently tries to pull out a nasogastric tube. As a last resort to maintain integrity of the tube and client safety, the nurse obtained a prescription for a restraint. Which type of restraint is appropriate in this situation? Select all that apply.

Elbow restraint, wrist restraint, mitt restraint

The nurse must make and unoccupied bed. Which nursing action is essential? Select all that apply.

Ensure that the bottom sheet is free of wrinkles. Ensure that there is a tow plate at the foot of the bed

A nurse plans to shave a male clients facial hair with a safety razor. Which of the following should the nurse implement? Select all that apply

Ensure that the client is not receiving an anticoagulant.

A three-year-old child is admitted to the pediatric unit. What should the nurse do to maintain the safety of this preschool age child?

Ensure the child is under continuous supervision

A male client is admitted to ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the client, obtains the clients vital signs, and reviews the primary healthcare providers prescriptions. Which to the nurse do first?

Ensure the clients allergy band includes the clients identified allergies

A nurse is transferring a client from the bed to the wheelchair using a mechanical lift. Which is a basic nursing intervention associated with this procedure?

Ensure the clients feet are guarded when sitting on the mechanical lift.

A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important?

Ensuring that the bed wheels are locked

A nurse is making an occupied bed. Which nursing action is most important?

Ensuring that the clients head is supported and is in functional alignment

The nurse plans to assist a client who has impaired vision with a bed bath. Which is the most appropriate nursing intervention to facilitate bathing for this client?

Ensuring the client can locate bathing supplies placed on the over-bed table

A nurse is planning care for a client with a wrist restraint. How often should restraint be removed, the area massaged, and the joints move through their full range?

Every two hours

Nurse plans to provide the client with a partial that. Place the following steps in the order in which the nurse should proceed.

Face, axilla, both hands, change water, back, genital area

A nurse in the nursing education department of a community hospital is planning an inservice education class about injury prevention. Which factor that most commonly causes physical injuries in hospitalized clients should be included in the teaching plan?

Falls

A nurse raises a clients arm forward and upward over the head during range of motion exercises. Which word should the nurse use when documenting exactly what was done during this range of motion exercise?

Flexion

Which condition identified by the nurse places is a client at the highest risk for impaired self-care when toileting?

Fractured hip

A client who has a fever experienced significant diaphoresis during the night the client states, "I am so tired and I just want to sleep this morning". Which should the nurse do regarding bathing the client?

Give a bed bath with complete assistance

Which nursing action is common to both a bed bath and a tub bath? Select all that apply.

Helping the client wash body parts that cannot be reached Providing for privacy throughout the bath

A nurse plans to teach a client with hemiparesis to use a cane. What should the nurse teach the client to do? Select all that apply

Hold the cane in the strong hand when walking

Which is the priority nursing intervention to prevent client problems associated with latex allergies?

Identify persons at risk

The nurse is preparing a client for a physical examination. Which is most important for the nurse to do in the situation?

Identify the positions contraindicated for the client during the examination

A nurse must make the decision to give a client a full or partial bed bath. Which criterion is most important for the basis of this decision?

Immediate need of the client

A client is incontinent of urine and stool for which client response should the nurse be most concerned?

Impaired skin integrity

Which human response, identified by the nurse, best supports the concern that a client has a reduced capacity to provide for activities of daily living?

Inability to wash body parts

A nurse is bathing a client who has a fever. Why should the nurse use tepid bath water for this procedure?

Increases heat loss

A nurse must apply a hospital gown that does not have snaps on the shoulders to a client receiving an IV infusion in the forearm. Which should the nurse do?

Insert the clients IV bag and tubing through the sleeve from inside of the gown first

A nurse turns her clients ankle so that the soul of the foot moves immediately towards the midline. Which word should the nurse use when documenting exactly what was done during range of motion exercises?

Inversion

A nurse is caring for a male client who is at risk for a pressure ulcer. After reviewing the clients clinical record, which area of the body should the nurse identify is most at risk for a pressure ulcer?

Ischial tuberosities

A client sits for excessive length of time in a wheelchair. Which site should the nurse assess for skin breakdown in this client? Select all that apply.

Ischial tuberosities, bilateral scapula, sacrum

Which action employed by the nurse indicates acceptable body mechanics to avoid self injury? Select all that apply

Keep back neck pelvis and feet aligned Position oneself close to the client Keep knees and hips slightly flexed Arrange for adequate help

A client has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the client active range of motion exercises. Which client action indicates that further teaching is necessary?

Keeps 90° elbow flexion after the procedure

Which human response to illness alerts the nurse that a client is at risk for aspiration during meals? Select all that apply.

Lethargic, stomatitis, dysphasia

which nursing action should be implemented when assisting a client to move from the bed to a wheelchair?

Letting the client help as much as possible when transferring to the wheelchair

Which is the last step in making an occupied bed that the nurse should teach a nursing assistant?

Lowering the height of the bed toward the floor

A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling?

Maintain close supervision

And immobilize bedbound client is placed on a two hour turning in positioning program. Which should the nurse explain to the client is the primary reason for why this program is important?

Maintain skin integrity

Which common problem with the hair should the nurse anticipate when clients are on complete bed rest?

Matted hair

Nurse plans to give a client a back rub. Which product should the nurse use for this intervention?

Moisturizing lotion

A nurse is teaching a class to nursing assistance about how to care for clients who are immobile. Which should the nurse include about why immobilized people develop contractures?

Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles

A nurse is caring for a client with dementia. Which time of day is most concern for the nurse when trying to protect this client from injury?

Night

Which is the earliest nursing assessment that indicates damage to tissue because of compression of soft tissue between a bony prominence and a mattress?

Non-blanchable erythema

A nurse is orienting a newly admitted client to the hospital. Which is most important for the nurse to teach the client how to do?

Notify the nurse when help is needed

A nurse is caring for a client who has a prescription for a mitt restraint. Where with the mitt restraint strap be secured with a quick release knot?

On the bedframe

A nurse is caring for a client with impaired mobility. Which position contributes most to the formation of a hip flexion contracture?

Orthopneic

A primary health-care provider prescribes a vest restraint for a client. Which should the nurse do first when applying the restraint?

Perform an inspection of the client's skin where the restraint is to be placed.

A nurse is making an occupied bed. Which is the easiest way for the nurse to prevent plantar flexion?

Place a toe pleat in the top linens over the feet.

I Nurs plans to administer a footbath to a client who is sitting in a chair and has no contraindications for this intervention. Place the following steps in order in which they should be implemented.

Position a waterproof pad on the floor on which to place a basin half filled with warm water (105°F to 110°F). Don clean gloves and assist the client to position 1 foot in the water, verifying with the clients at the water temperature is comfortable. Soak each foot individually for 5 to 20 minutes, subject to the clients tolerance, condition of skin, and absence of a history of diabetes or peripheral vascular disease. Watch each foot with rinse-free soap and clean under the nails with an orange stick Try each foot gently, especially between the toes. Apply lotion to each foot, avoiding between the toes.

When providing morning care for a client, the nurse identifies crusty debris around the clients eyes. Which of the following should the nurse implement when cleaning the clients eyes? Select all that apply

Position client client on the same side as the eye to be cleaned Wash the eyes with cotton balls from the inner to outer canthus Use a separate cotton ball for each stroke when washing the eyes

Which intervention should the nurse implement when assisting a client to use a bedpan? Select all that apply.

Position the rounded room of the bed pan under the clients buttocks Encourage the client to help as much as possible when using the bedpan Raise the head of the bed to the semi Fowler's position once the client is placed on the bedpan

A nurse is caring for a client with a nasogastric tube for gastric decompression. Which nursing action takes priority?

Positioning the client in the semi-Fowler position

A nurse is evaluating and ambulating clients balance. Which factor about the client is most important for the nurse to assess?

Posture

A nurse turns the palm of her clients hand downward when performing range of motion exercises. Which word should the nurse use when documenting exactly what was done?

Pronation

Which should be the nurses first intervention after removing a bedpan from under a debilitated client who has just had a bowel movement?

Provide perineal care

Which nursing intervention most requires the nurse to consider the concept of intimate space?

Providing a bed bath

Which nursing intervention enhances in older adults sensory perception and thereby helps prevent injury when walking from the bed to the bathroom?

Providing adequate lighting

Which of the following should the nurse implement when providing fingernail care during a clients bath? Select all that apply

Push cuticles back with a section of a soft washcloth, file nails straight across rounding in corners slightly, apply and moisturizing lotion around cuticles, clean under nails with an orange stick, soak hands in warm water first

Which action is important when the nurse uses a stretcher? Select all that apply.

Pushing the stretcher from the end with the clients head

A nurse is helping a client who has right hemiparesis to get dressed. Which actions should the nurse implement?

Put the gown's right sleeve on first

A nurse is caring for a client with a moderate problem with balance. Which cane is most appropriate for this client?

Quad cane

A nurse is caring for a variety of clients, each experiencing one of the following problems. Which health problem place is a client at the highest risk for complications associated with immobility?

Quadriplegia

A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? Select all that apply.

Reasons for use of restraints must be clearly documented. Laws permit the use of restraints when specific guidelines are followed.

A client asks the nurse, " why do I have to use mouthwash if I brush my teeth?" Which rationale about the use of all mouthwashes should the nurse include when responding to this question?

Reduces offensive mouth odors

A nurse gives a bedbound client a bed bath. Which is the primary reason why the nurse provides hygiene care to this client?

Removes excess oil, perspiration, and bacteria by mechanical cleansing

A nurse enters the room of the client in the photograph. The client has right sided weakness and is attempting to transfer out of bed without the nurses knowledge. What should the nurse do first?

Reposition the client back to the semi Fowler's position

Which nursing action is most effective in relation to the concept: immobility can lead to occlusion of blood vessels in areas where bony prominences rest on a mattress?

Repositioning the client every two hours

Which do nurses sometimes do that increases the risk for injury when moving clients?

Rotate their backs when moving clients

An emaciated client is at risk for developing a pressure ulcer. And which position should the nurse avoid placing the client?

Side lying position

A client just had peroneal surgery. Which type of bath should the nurse expect to be prescribed for this client?

Sitz bath

During oral care of the nurse identifies a patch of dried food and debris adhered to the hard palate of the clients mouth. Which word should the nurse use when documenting this condition?

Sordes

The nurse identifies that a client pressure also has just partial thickness skin loss involving the epidermis and dermis. Which stage to pressure ulcer should the nurse document based on this assessment?

Stage II

Which stage pressure ulcer requires the nurse to measure the extent of undermining?

Stage III

Which word is most closely associated with nursing care strategies to maintain functional alignment my clients are bedbound?

Support

A family member brings an electric radio to a client in a long-term care facility. The client tells the nurse that an electric shock was felt while turning on the radio. Which should the nurse do first?

Take the client's apical pulse

A client with impaired mobility is to be discharged from the hospital within a week. Which is an example of a discharge code for this client?

The client will transfer independently to a chair by discharge

A nurse is observing a nursing assistant in a home care setting administering a bed bath. Which issue apparent in the photograph indicates that the nursing assistant has violated the standards of care for a bed bath? Select all that apply.

The nursing assistance uniform is in contact with the clients linens. The clients left leg should be covered with a bath blanket. The nursing assistant is not wearing clean gloves.

A nurse is caring for a client who is newly admitted to rehabilitation facility. After reviewing the clients clinical record, the nurse chooses which of the following bathing positions to meet the clients hygiene needs?

Towel bath with total assistance

A nurse is teaching a client about how many times a day it is necessary to brush the teeth to achieve effective dental hygiene. According to the American dental Association, how many times a day should the nurse teach the client to brush the teeth?

Two

A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury?

Two recent falls that occurred at hone

A nurse is planning to help move a client up in bed. Which of the following to the nurse implement to reduce the risk of self strain when performing this action? Select all that apply

Use the force of gravity to facilitate the move, keep the upper and lower body in alignment, use the large muscles of the legs, keep the knee slightly bent, raise the bed to waist level.

A nurse teaches a client effective oral hygiene practices. Which of the following indicates that the teaching about preventing and removing dental plaque was understood by the client? Select all that apply.

Uses a non-abrasive toothpaste, brushes the teeth with a toothbrush, gargles with antiplaque mouthwash, flosses the teeth with unwaxed floss, has teeth cleaned regularly by a dental hygienist

A nurse is providing hygiene to a client with peripheral neuropathy. Which action should the nurse implement?

Wash the feet with Luke warm water and dry well

A nurse is providing perineal care to a male client. Which should the nurse do? Select all that apply

Wash the penis with one hand while holding it firmly with the other hand. Wash the glans with a circular motion, starting at the tip and then proceeding down the shaft.

A nurse is caring for a client with an excessively dry mouth. Which nursing action is important when providing mouth care for this client? Select all that apply.

Wearing clean gloves, providing oral care every two hours

A primary healthcare provider prescribes crutches for a person who has left lower leg injury. The nurse is teaching the person how to move from standing to sitting position in a chair. Place the following steps in the order in which they should be implemented

While standing, back up so that the unaffected leg is against the edge of the center of the chair seat. Hold the handlebars of both crutches with the left hand Grasp the arm of the chair with the right hand Lean forward slightly and flex the knees and hips Lower the body slowly into the chair