NRS 200- Ch.35 PrepU

The nurse is caring for a client on their first postoperative day and the nurse is providing assistance transferring to the bathroom. What action will the nurse prioritize when performing this intervention? A. Protect the client's privacy B. Assess the client's pain C. Assess and protect the client's safety D. Allow sufficient time

C. Assess and protect the client's safety -rationale: Toileting often is associated with falls; the nurse must ensure the client's safety. While allowing time, privacy and assessing pain are important, safety is paramount.

A nurse assisting a client with contact lens removal finds that the hard contact is not over the cornea. What would be the appropriate intervention in this situation? A. Do not attempt to remove the contact because this will cause damage to the cornea. B. Remove the contact from the area it is located using gloved fingers. C. Gently slide the hard lens over the cornea and remove it with gloved fingers. D. Remove the contact with a contact remover.

C. Gently slide the hard lens over the cornea and remove it with gloved fingers.

The health care environment can be very stressful for a client. During an orientation session of nursing students, the nursing instructor teaches students how to minimize a stressful environment. Which statement from the students indicates the teaching was effective? Select all that apply. 1. "When I place soiled items in the client's trash, I will remove the bag from the room when I leave." 2. "We should discuss the client's condition outside of the room in order not to violate HIPAA." 3. "It is important to keep the room at a comfortable temperature for the client." 4."Spray the room daily with Lysol to reduce the spread of germs and maintain a sterile smell to assure the client it's clean." 5. "Always ask the client if anything is needed before you leave the room."

- "When I place soiled items in the client's trash, I will remove the bag from the room when I leave." - "It is important to keep the room at a comfortable temperature for the client." - "Always ask the client if anything is needed before you leave the room."

An older adult client has right-sided weakness. The nurse is preparing to assist the client with showering. Which action(s) will the nurse take to ensure safety when assisting the client? Select all that apply. 1. Place a bath rug at the base of the shower for the client to step onto when exiting the shower. 2. Ensure the grab bar is accessible to the client on the left side of the shower. 3. Check the temperature of the shower water prior to assisting the client to enter. 4. Use a firm rubbing motion to help the client dry off areas of the body the client cannot reach. 5. Assist the client to stand up in the shower by standing next to and supporting under the weak arm.

- Ensure the grab bar is accessible to the client on the left side of the shower. - Check the temperature of the shower water prior to assisting the client to enter.

A nurse caring for the skin of clients of different age groups should consider which accurately described condition? A. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions. B. An infant's skin and mucous membranes are protected from infection by a natural immunity. C. Secretions from skin glands are at their maximum from age 3 months on. D. The skin becomes thicker and more leathery with aging and is prone to wrinkles and dryness.

A. An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct? A. Heat the entire package in the microwave, following the manufacturer's recommendation. B. Place the washcloths in warm water, one at a time, in the order that they will be used. C. Fill the sink with hot water, place the unopened package in the water, and let it soak for at least 10 minutes. D. Twenty minutes before beginning the bath, place the unopened package underneath the small of the client's back.

A. Heat the entire package in the microwave, following the manufacturer's recommendation. -rationale: The nurse should warm the unopened package in the microwave, according to the manufacturer's directions. The other methods are not as effective or efficient.

The nurse is caring for a client who has been diagnosed with pediculosis (lice). What intervention will the nurse provide? A. Launder gowns, linens, and towels separate from other clients' items. B. Apply cortisone to this reddened rash. C. There would be no intervention, as this chronic skin disorder is noninfectious. D. Lesions should be squeezed gently to release pus.

A. Launder gowns, linens, and towels separate from other clients' items.

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her prosthetic eye. What actions by the nurse are most appropriate to accomplish the task? A. Pull up the upper lid and place your index finger under the glass edge. B. Pull down on the lower lid and exert slight pressure below the lid. C. Apply pressure over the eye with your index finger and thumb under the eye. D. Pull the inner canthus toward the bridge of the nose and lift under the glass.

B. Pull down on the lower lid and exert slight pressure below the lid. -rationale: To remove an artificial eye, pull down on the lower eyelid and exert slight pressure below the eyelid; this will overcome the suction holding the eye in place. None of the other listed actions will safely and gently remove the eye.

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention? A. Do not use over-the-counter products on unknown rashes. B. Use a tepid bath to relieve inflammation and itching. C. Use a moisturizing lotion on a wet rash to prevent itching. D. Avoid washing the area because cleansing agents will only make the rash worse.

B. Use a tepid bath to relieve inflammation and itching. -rationale: Tepid baths will most likely help relieve inflammation and itching. The area should be washed thoroughly with a mild cleansing agent and rinsed well. Over-the-counter products can be used on unknown rashes if approved by the health care provider. A moisturizing lotion is recommended to use on a dry rash, and a drying agent on a wet rash, to prevent itching and promote healing.

The nurse is caring for a client who has had multiple dental caries. Which food will the nurse encourage the client to avoid that is on the dietary tray? A. coffee with sugar substitute B. jelly to go on the toast C. vegetable soup with cheese D. salad with full-fat dressing

B. jelly to go on the toast -rationale: The nurse will remove toast, which is a carbohydrate, and jelly, which is a sugar, from the client's tray. Other food items are acceptable for the client to eat.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? A. The client should be placed in the lithotomy position. B. The client should be placed in a position of comfort. C. The client should be placed in a side-lying position to prevent aspiration. D. The client should remain in an upright position to avoid the tongue blocking the airway.

C. The client should be placed in a side-lying position to prevent aspiration. -rationale: Clients who are not alert are at risk for aspirating liquid into their lungs. Aspirated fluids predispose a client to pneumonia. The nurse should use special precautions to avoid getting fluid into the client's airways and lungs. Position the client on the side with the head slightly lowered. An upright position will not protect the airway from fluids entering. The lithotomy position is used for vaginal and anal exams and will not protect the airway from fluids and aspiration.

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention? A. Do not use over-the-counter products on unknown rashes. B. Use a moisturizing lotion on a wet rash to prevent itching. C. Use a tepid bath to relieve inflammation and itching. D. Avoid washing the area because cleansing agents will only make the rash worse.

C. Use a tepid bath to relieve inflammation and itching. -rationale: Tepid baths will most likely help relieve inflammation and itching. The area should be washed thoroughly with a mild cleansing agent and rinsed well. Over-the-counter products can be used on unknown rashes if approved by the health care provider. A moisturizing lotion is recommended to use on a dry rash, and a drying agent on a wet rash, to prevent itching and promote healing.

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? A. "I clean my ear mold on my hearing aid daily before use." B. "I use a washcloth to clean the auricles and cerumen when needed." C. "I never use bobby pins or other sharp objects when cleaning cerumen." D. "I use cotton-tipped applicators daily to remove cerumen."

D. "I use cotton-tipped applicators daily to remove cerumen."

A sitz bath would be most appropriate for which client? A. 41-year-old with intractable migraines B. 69-year-old with impaired circulation to the lower extremities C. 57-year-old who has just had surgery to repair a hernia D. 33-year-old who is one day postpartum

D. 33-year-old who is one day postpartum -rationale: A sitz bath includes the immersion of the buttocks and perineum in a small basin of continuously circulating water. This removes blood, serum, stool, or urine. The client who has given birth would benefit from this type of cleansing treatment. The other clients do not benefit as much, or at all, from the sitz bath.

A nurse is washing a client's hair using a shampoo cap. Which step should the nurse use? A. Place a towel around the client's shoulders after placing the cap on his or her head. B. Leave the cap in place for 5 minutes before beginning to massage the scalp. C. Use the storage warmer to warm cap; do not put the cap in a microwave oven. D. Remove and discard the cap after one use and dry the client's hair with a towel.

D. Remove and discard the cap after one use and dry the client's hair with a towel. -rationale: Remove and discard the shampoo cap after a single use and dry the client's hair with a towel. Caps may be safely warmed in a microwave oven. A towel should be placed around the client's shoulders before placing the cap on his or her head. There is no need to wait 5 minutes before massaging the client's scalp.

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? A. Shaving the face of a resident who has worn a beard for several years B. Providing a tub bath to a resident who is unable to mobilize independently C. Providing oral care to a client who has cognitive deficits and a decreased level of consciousness D. Using a tool to remove a contact lens that has adhered to the resident's eye

D. Using a tool to remove a contact lens that has adhered to the resident's eye -rationale: A contact lens that presents a challenging removal should be addressed by the nurse rather than delegated to UAP. This is due to the potential for injury to the resident's eye. All of the other listed tasks can be safely delegated to UAP.

In which situation would it be appropriate to shave the beard of an unconscious client without his permission? A. To facilitate skin care B. When the beard becomes tangled C. To facilitate use of a nebulizer D. When inserting an endotracheal tube

D. When inserting an endotracheal tube -rationale: If the client is brought to the hospital with a full beard, do not shave his beard without consent unless it is an emergency situation, such as insertion of an endotracheal tube. For this procedure, shave only the area needed and leave the rest of the beard. A nebulizer can be used effectively with a beard in place and a tangled beard can usually be untangled.