NSG 212 Exam 1

What's the difference between endogenous and exogenous sources?

endo: comes from within the patient body. (skin, mucous membranes/tracts) exo: organisms that come from external sources. (surgical instruments, medical devices, surgical team members, air)

A nurse is caring for a client whose immobility is impaired. Which of the following support devices should the nurse plan to use to keep the client from developing plantar flexion contractures?

foot board

A nurse is assisting an older adult client to ambulate who sometimes loses her balance while walking. Which of the following devices should the nurse use in helping the client to ambulate?

gait belt

What is the best way to control the spread of pathogens?

hand washing

A trochanter roll keeps the clients...

hips in neutral position

_________ is a condition in which an inadequate amount of oxygen is available to cells. This results in difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis.

hypoxia

If there is decreased cardiac output, respiration rate will...

increase

A nurse is assessing a client's bowel sounds. The nurse understands that the bowel sounds should be auscultated ​after palpating the abdomen. ​prior to percussing the abdomen. ​after checking for kidney tenderness. ​prior to inspecting the abdomen.

prior to percussing the abdomen. ​Auscultation should be performed prior to percussing the abdomen to prevent altering the bowel sounds.

Briefly explain the immune response defense mechanism.

recognition of foreign material (antigen) by the body. The body then produces antibodies to fight the antigen, WBC destroy antigen cells. Poor immune response = inc. risk for infection!

There is some bacteria that peacefully lives in our body normally. These types of bacteria are referred to as...

resident flora ex: e.coli in intestines

A nurse is teaching a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching?

"I will need to wipe my perineal area from back to front after urination." ​Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) in the proper use of assistive devices while ambulating residents. Which of the following statements should the nurse use when instructing the AP regarding the use of a cane?

"When the client moves, the cane is moved forward first." When the client moves, the cane is moved forward first about 12 in. Then, the weak leg is moved even with the cane. Finally, the strong leg is brought forward and ahead of the cane and weak leg.

A nurse is caring for a client who has impaired renal function. The nurse should notify the provider if the client's hourly urine output falls below which of the following?

30 mL ​Output that is less than 30 ml/hr should be reported to the provider. This alerts the nurse to severe fluid imbalance and means the client has a decreased circulating fluid volume, and possibly inadequate renal perfusion.

A nurse is caring for a client and is to maintain I&O. What is the client's intake during an 8 hr period based on the following data? Breakfast -- 4 oz juice and 6 oz hot tea Voided 450 mL after breakfast. IV bolus of 150 mL at 0900 100 mL of ice chips before lunch Lunch -- 8 oz of clear broth Vomited 120 mL and voided 600 mL after lunch Jackson Pratt drain emptied of 40 mL bloody drainage at 1330 _____ mL

4 x 30 mL/oz + 6 x 30 mL/oz + 150 mL + 100 mL + 8 x 30 mL/oz = 790 mL

Potty-training is most commonly accomplished at what age? A. 3-4 years B. 6-12 months C. 15-18 months D. 5-6 years

A

A child who has leukemia is being admitted. Several rooms are available on the pediatric floor. Which of the following clients should the nurse place in the same room with this child?

A child who has nephrotic syndrome A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder, and therefore, poses no risk to the child with leukemia. - a child with a ruptured appendix, cystic fibrosis, and rheumatic fever may be infectious

The nurse is assisting a patient with conditioning exercises to prepare for ambulation. The nurse correctly instructs the patient to: A. Do full body push ups in bed 6-8x/day B. Breathe smoothly during quadriceps drills C. Dangle on the side of the bed for 30-60 minutes D. Allow the nurse to bathe the pt completely to prevent fatigue

B A- ridiculous C- we don't dangle on the bed that long D- bathing has nothing to do with fatigue

What color would a necrotic wound be? A. black B. white C. green D. red

A: black

Which type of exercise is characterized by muscle contraction with resistance? A. Isokinetic B. Isometric C. Isoaerobic D. Isotonic

A: isokinetic

Which of the following categories of health promotion is aimed at preventing illness? A. primary B. secondary C. tertiary D. restorative

A: primary. Primary prevention aims to prevent a disease/complications as a whole. This would include a healthy diet, exercise, and vaccinations/immunizations.

Which of the following statements should the nurse include in the teaching?

Advance the catheter 2 inches after urine begins to flow. The nurse should instruct the client to insert the catheter 2 inches more after urine flows to be sure the straight catheter is completely in the bladder.

What are the 3 fundamental characteristics of wound assessment?

Age Depth Color

A nurse working in an orthopedic unit is caring for four clients. Which of the following clients is at greatest risk for skin breakdown? A: An adolescent who has a cervical fracture and is in a halo brace. B: A young adult who has a femur fracture and is in skeletal balanced suspension tractions. C: A middle-age client who has a fractured radius and an arm cast. D: An older adult client who has a hip fracture and is in Buck's traction.

An older adult client who has a hip fracture and is in Buck's traction. Due to the aging process (decreased muscle mass, thin and fragile skin), and the limitation of movement of this client, this client is at the greatest risk for skin breakdown. - A:Even though this client is at risk for skin breakdown, she will be able to ambulate, which minimizes the risk for skin breakdown. - B: Even though this client is at risk for skin breakdown, he will be able to shift his weight while immobilized, which minimizes the risk for skin breakdown. - C: Even though this client is at risk for skin breakdown, he will be able to ambulate with an arm cast, which minimizes the risk for skin breakdown.

​A nurse is preparing to provide nail care for a client. Which of the following actions by the nurse is appropriate?

An orange stick is commonly used to push back the cuticle and clean under the nail. - nails should be filed straight across

There are two types of bacteria: aerobic and anaerobic. Which is harder to kill and why?

Anaerobic. Since they don't need oxygen, these bacteria usually lie deep within the brain or other hard to reach areas, therefore it makes them harder to kill.

If you read the nursing dx, Impaired urinary elimination related to maturational enuresis, you would recognize you pt is which of the following? A. >65 and IC B. >4 with involuntary urination C. 12 month old with involuntary urination D. A paraplegic with urinary IC

B

​A nurse is planning care for a client who is placed in transmission-based respiratory precautions (airborne precaution). Which of the following is an appropriate nurse precaution?

Apply an N95 respirator mask. ​The nurse should wear a specially-fitted N95 respirator mask to prevent exposure to the client's infectious particles. - should be in a negative air pressure room

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following is an appropriate nursing intervention?

Apply the bag for 30 min at a time. The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no unexpected effects. - after removing, nurse should apply one hour later - should place towel in between ice and skin - let air OUT of bag before placement

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following is an appropriate nursing action? ​Put on sterile gloves. ​Assist the client to the left Sims' position. ​Hang the enema container 24 inches above the anus. ​Insert the tubing about 6 inches into the anus.

Assist client into sims. - container should be maximum of 18 inches above the anus - don clean gloves to administer an enema - the max length of insertion into the anus is 4 inches

Which of the following best describes ileostomy drainage? A. Runny and odorous B. Solid and odorous C. Liquid with minimal odor D. Solid and controlled

C

A nurse is caring for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan of care?

Cleanse with saline solution. ​Isotonic saline solution, a nonionic agent, is used to prevent disruption of tissue healing.

The presence of specific signs and symptoms indicates what stage of illness: A. convalescent B. prodromal C. illness D. incubation

C: illness

Your patient has developed a low grade fever and states that she is tired. This phase of infection is known as the: A. incubation B. prodromal C. illness D. convalescent

C: illness

As the nurse prepares to assist her pt with her newly created ileostomy, she is aware that: A. A continuous appliance will not be required B. The size of the stoma stabilizes in 2 weeks C. Irrigation is necessary D. Fecal drainage will be liquid

D

Which action is believed to be most useful in preventing wound infections? A. Using sterile supplies B. Suggesting dietary supplements C. Applying Antibiotic ointment D. Careful hand hygiene

D: careful hand hygiene

Define dehiscence.

Dehiscence occurs when a surgical incision site starts to "open at the seams," usually occurs due to obesity.

A nurse is caring for an older adult client who reports constipation. Which of the following is an appropriate nursing recommendation?

Eat raw vegetables. ​The client should eat raw vegetables to help provide fiber in the diet to increase stool bulk and move the stool through the colon to prevent constipation. - client should also be consuming 1800 mL / day

What two age populations are at an increased risk for illness and injury?

Elderly and newborn babies

Define evisceration.

Evisceration occurs when contents of the body come out through a wound/surgical incision site.

How do we tell the difference between gram positive and gram negative bacteria on a stain?

Gram positive stains purple, has a thick wall, and don't decolorize. Gram negative have a complex wall and can be decolorized. Think positive = purple

A nurse is caring for a client who has been prescribed a clear liquid diet. Which of the following foods is appropriate to include in the client's diet? Hard candy ​Lemon sherbet ​Milkshake ​Vanilla ice cream

Hard candy ​Hard candy is an appropriate food choice to include on a clear liquid diet. the other 3 are appropriate for a full liquid diet, not clear.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client is on airborne precautions and is being treated with multidrug therapy. A chest x-ray is scheduled for the client. Which of the following precautions should the nurse take to safely transport the client to x-ray? Ask the x-ray technician to come to the client's room to perform a portable x-ray. Have the client wear a mask. Notify the x-ray department that the client is on airborne precautions. Wear a filtration mask and gloves for protection against the client's microorganisms.

Have the client wear a mask. When a client with a communicable disease is being transported to another department in the hospital, it is important to protect everyone with whom the client may come in contact. Having the client wear a mask protects others from the airborne particles should the client cough.

A nurse is teaching a client who has left hemiparesis how to properly use a cane. Which of the following should the nurse include in the teaching?

Hold the cane on the right side to provide support for the weaker extremity. The cane is commonly used to support and balance a client with decreased leg strength. Instruct the client to keep the cane on the unaffected side of the body, which is the right side in this case

A nurse is preparing to administer a cleansing enema for a client who has constipation. Which of the following is an appropriate action by the nurse?

Hold the container of solution 12 inches above the anus. ​The nurse holding the container of solution 12 to 18 inches above the anus is correct to allow a greater force of fluid flowing to properly cleanse the colon.

What is the difference between infection and inflammation?

Inflammation is the body's protective and reparative response to some type of illness or injury. Infection is the actual disease taking place in the body.

A nurse is caring for a client who is on bedrest. The client's plan of care states that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to hold a muscle tight for approximately 5 seconds, then relax. Isometrics is a form of exercise involving static (no movement) contraction of a muscle without any movement of the joint. Isometrics may help to prevent muscle atrophy in clients who are on complete bedrest.

A nurse is implementing a bladder training program. Which of the following actions by the assistive personnel (AP) who is assisting in the client's care indicates a need for further instruction?

Instructs the client to void whenever the urge occurs. ​The goal of bladder training is to increase bladder control. The primary objective is to have the client resist the urge to urinate so that time between voidings can be increased, as well as increasing the total volume of urine in the bladder. The nurse should instruct the AP to encourage the client to take deep breaths when the urge to void occurs. The nurse should provide further instruction to the assistive personnel to delay voiding. Although clients with frequent urinary infections should be taught to void when the urge occurs, in bladder training, the client needs to ignore urges and work to increase time between voidings. -assist to bathroom every 30min - 2hr - increase fluid intake, just not caffeine

Give some examples of direct transmission.

Kissing, touching, sexual contact

A nurse is assisting with transferring a client from a bed to a wheelchair. Which of the following actions should the nurse perform?

Lock the wheels of the bed and the wheelchair. To prevent them from moving, the wheels of the bed and wheelchair should always be in the locked position when transferring a client.

_________ is a term referring to tissue death.

Necrosis

What are nosocomial infections and what are the types?

Nosocomial infections are hospital-inquired infections. Exogenous source: hospital environment or personnel Endogenous source: from pathogens pt. harbors himself Iatrogenic source: as a result of treatment or procedure

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?

Nurses and other emergency medical personnel Nurses and other emergency personnel such as physicians, EMTs, and paramedics are responsible for performing triage duties.

A nurse is caring for an older adult client who has left-sided weakness. Which of the following information regarding the use of a cane is appropriate?

Place cane on right side, and advance left foot forward. ​The cane should be placed on the stronger side of the body (held with the right hand). The weaker leg (left leg) should be advanced toward the cane. The stronger leg (right leg) is then advanced forward past the cane

A night nurse is caring for a client who is confused and has pulled the peripheral IV catheter out three times. Which of the following should the nurse consider?

Place mitten restraints on the client's hands. The nurse may consider placing mitten restraints on the client's hands to prevent pulling the IV catheter out.

A nurse is providing oral care for an immobilized client. Which of the following interventions should the nurse take?

Position the client on one side before starting oral care. This is the appropriate action. Placing the client on one side encourages fluids to run out of the client's mouth, lessening the risk of aspiration and choking.

A nurse caring for a client who requires contact precautions has just finished a care procedure. Which of the following actions should the nurse perform first?

Remove his gloves. ​The gloves are the most contaminated item of personal protective equipment, so the nurse should remove them first. The greatest risk to safety is pathogen transmission. Failing to remove the most contaminated item first increases this risk.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume

A nurse is working at a health fair that is offering blood screenings for diabetes and high cholesterol. What level of health promotion is she helping to achieve?

Secondary prevention. This level of prevention aims for early detection of a disease that already exists. So you would already have the diabetes and not know it yet; a blood test would detect this early.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse recognizes that which of the following laboratory findings will impact wound healing? Serum albumin 3.2 g/dL Hemoglobin 16 g/dL WBC 8,000 uL aPTT 1.8

Serum albumin 3.2 g/dL A serum albumin level is a good indicator of the nutritional status of a client. A value below 3.5 g/dL is an indicator of poor nutrition and can delay wound healing and lead to infection. - all the rest of these answers are in normal range

A nurse is caring for a client who has HIV. Which of the following infection control precautions should the nurse use while caring for this client?

Standard precautions should be instituted for the care of all clients. Correct application of standard precautions prevents contact with pathogens transmitted by direct or indirect contact with infected blood or body fluids, and the transmission of HIV is easily preventable with proper use of standard precautions.

A nurse is preparing to assist a client who can partially bear weight and is cooperative from the bed to a chair. Which of the following actions by the nurse will be most safe for the client and the nurse? Enlist help of another staff member. ​Adjust bed to appropriate height. ​Use a powered standing-assist lift. ​Avoid movements that twist the spine.

Use a powered standing-assist lift. ​Using a powered standing-assist lift will best ensure the safety of the client and the nurse.

nurse is assessing a client at a followup clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

The client slides an object across the floor rather than lifting it. ​Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. Other: - client should keep back straight and bend at the knees - client should keep feet wide

The chain of infection has 5 variables. The infectious agent (the virus/bacteria), the resovoir (phones, bathrooms, door handles, water, plants and animals), the portal of exit (mouth, eyes, sneezing etc), mode of transmission (touch, kissing, sexually transmitted), and portal of exit (same as someone else's portal of exit). As a nurse, you should think of yourself as what variable of this process?

The mode of transmission. That's why we practice things such as clean technique and surgical asepsis: we can very well be a mode of transmission from one patient to another. Mode of transmission is also things like kissing, sexually, touching etc

A nurse is caring for a client who has recently fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurses notifies the provider. Which of the following findings should the nurse include in her documentation in the chart?

The provider was notified." Notifying the provider is important, and this information needs to be documented in the chart. - never chart that an incident report has been completed

the total amount of air inhaled and exhaled with one breath is referred to as....

Tidal volume

the amount of air contained within the lungs at maximum inspiration is referred to as...

Total lung capacity

A nurse delegates a nursing assistant to apply wrist restraints on a confused client. The nurse notices the nursing assistant padded the wrist restraints with sheep skin and secured the straps to the bed frame with a double knot. The nurse should do which of the following?

Untie the restraint straps and retie them with a slipknot. The restraints should be tied with a slipknot.

A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. These findings are associated with which of the following?

Urinary tract infection ​These findings are associating with a urinary tract infection. The urine appears cloudy and concentrated because of the presence of WBC, RBC, and bacteria. Pus and bacteria can cause the unpleasant smell. These are all characteristics of a UTI.

A nurse is planning care for an older adult client who is at high risk for developing pressure ulcers. Which of the following is an appropriate measure for the nurse to include?

Use a draw sheet to move the client up in bed. Using a draw sheet or a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

What are the three types of indirect transmission and how do they differ?

Vehicle: inanimate (food, water, dust, instruments, meds) Vector: animate; transmits from one host directly to another. (mosquitos, rodents, etc) Airborne/Droplet: ventilation system, respiratory tract

What vitamins and nutrition are vital to wound healing?

Vit A, B, C, K and protein

A nurse is caring for a client who needs a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for

blood. A guaiac test detects microscopic amounts of blood in the stool. It may also be referred to as a "stool for occult (hidden) blood." The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer.

A nurse is caring for a client who has a wound infection. Wound cultures identify vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the health care team initiate?

contact airbrorne would be varicella

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

cranberry juice

What's the difference between disinfection and sterilization?

disinfection = clean technique. Destroys pathogens only sterilization = type of surgical asepsis. free from living organisms and microorganisms

What are the 4 stages of infection? describe them

incubation: when the virus enters the body (hours to months) prodromal: when you first start to feel symptoms (MOST INFECTIOUS STAGE) illness: specific symptoms present, diagnosed convalescence: from having the sickness to when normal health returns

Which medication causes constipation?

iron supplements

What are the 4 postural reflexes and what do they do?

labryinthe sense: (in the inner ear) sense of position and movement visual/optic sense: (spatial relationships) nearness and distance of objects propioceptor: location of limb/body part extensor/antigravity sense: (knee/hip) stimulation of overstretched extensor muscles causes a reflex contraction that reestablishes erect posture

While using the braden scale, the __________ the number, the higher the risk.

lower think: the lower you're funtioning, the higher the risk

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?

orthrostatic hypotension

​A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following is an appropriate action when applying the pad?

place a thin towel over affected area

The Norton scale and Braden scale assess risk for....

pressure ulcers

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

take the client to the bathroom on an every- 2-hr schedule. ​It is important to attempt measures that might help prevent incontinence before resorting to measures that can cause complications like infection and skin breakdown. For some clients, regular toileting can help manage this problem.

What does pulse oximetry test?

the amount of oxygen saturation in the blood

What does it mean if a wound is dessicated?

too dry

What does it mean if a wound is macerated?

too moist

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

two nurses using a friction reduction device. ​Two nurses, using a friction-reducing device is the appropriate method to move the client up in bed. - this takes two assistants and the client - lifting under the shoulders could hurt the patient

The loss of urine without any identifiable pattern or warning is called...

urinary incontinence

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention

________ is used to increase the turbulence of exhaled air and loosen secretions from the lungs

vibration can be done before or after percussion

What are the smallest types of pathogens?

virus

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? ​"I'll urinate a little then stop." ​"I'll use the cleansing wipe from front to back." ​"I'll dry the outside of the container with a paper towel." ​"I'll use each cleansing wipe twice."

​"I'll use the cleansing wipe from front to back." ​The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.

A nurse is completing discharge teaching to a client with osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching about this disease process?

​"It occurs due to the aging process and results in disintegration of cartilage in a joint." ​Aging and obesity are the leading factors that cause osteoarthritis, a disease of progressive loss of cartilage. - ​"It is caused by inflammation that affects both joints and other body tissues." ​This statement describes rheumatoid arthritis. - "It is due to loss of calcium in the bones and fractures can then occur." ​This statement describes osteoporosis. - ​"It happens in several phases when deposits of crystals develop in joints and soft tissues." ​This statement describes gout.

A nurse is admitting a client who has pulmonary tuberculosis and a productive cough. Besides standard precautions, which type of precautions should the nurse add to the client's plan of care?

​Airborne ​Tuberculosis is a respiratory infection that spreads through the air, so clients who have it require airborne isolation. The client needs a private room with negative airflow and at least six to 12 air exchanges/hr. - contact would be MRSA - droplet would be meningococcal pneumonia - protective would be someone who has undergone a stem cell transplant

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

​Apply a moisture barrier ointment to the skin. ​Skin that is left in contact with urine for prolonged periods of time is at risk for maceration and breakdown. Cleansing the skin and removing items that are wet (e.g., incontinence pads, sheets, undergarments) is a priority to prevent breakdown. Moisture-barrier ointments and creams also are useful to prevent the urine from coming in contact with the skin. Moisture barriers should be applied to the client's skin after cleansing, keeping the epidermis lubricated but not oversaturated. - a client who has incontinence should be checked every 2 hours

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

​Ask the client to push their feet against the nurse's palms. ​Asking the client to push with the feet against the nurse's hands is an appropriate method of determining the client's level of strength.

A nurse is caring for a client on bedrest. Which of the following is the priority action to include in the client's plan of care?

​Change client's position at least every 2 hr. ​Changing the client's position every 1 to 2 hr relieves pressure on the skin and prevents pressure ulcer formation. This is the priority intervention.

A nurse is caring for a client who has an infection. The nurse understands that which of the following interventions will interrupt the transmission of infection? Changing linen for the client each day. ​Encouraging a diet high in protein. ​Following strict hand-washing protocols. ​Placing the client in a room positive pressure.

​Following strict hand-washing protocols. ​Transmission of microorganisms from one client to another is prevented when microorganisms are removed from the hands. Hand washing is the most important intervention in preventing and controlling the transmission of infection..

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client has a urinary tract infection. This is an example of which of the following types of infection? ​Endogenous ​Systemic ​Exogenous ​Health-care associated

​Health-care associated ​A health-care associated infection is one that results from care a client receives in a health care facility. Here, the infection resulted from an invasive procedure (urinary catheterization).

​A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

​Provide the client with a diet high in protein. ​Inadequate protein, iron, vitamins, and calories increase the risk for skin breakdown.

​A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following is an appropriate nursing action?

​Stopping or slowing the enema solution flow temporarily prevents cramping.

A nurse is assessing a client at a followup clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

​The client slides an object across the floor rather than lifting it. ​Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles.

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following nursing actions is mandatory?

​Wear a mask when giving the client care. ​The nurse should wear a mask whenever she is within 3 feet of a client who requires droplet precautions. - Negative airflow is a requirement for clients who require airborne precautions. Influenza does not require airborne precautions. - High-efficiency particulate air (HEPA) filtration is a requirement for clients who require airborne precautions. Influenza does not require airborne precautions. - ​A gown is a requirement when caring for clients who require contact precautions. Influenza does not require contact precautions.

A nurse is implementing a bowel training program for a client. For the program to be effective the client should be taken to the bathroom at which of the following times?

​When on a bowel training program, the client should be taken to the bathroom when the urge to defecate is recognized. Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and constipation.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, the nurse should

​check that the client lifts the walker and then places it down in front of her. ​The client should lift the walker and advance it about 6 inches, then set it down. This allows her a wide base of support while she moves forward.