NUR311 - Safety, Activity, & Hygiene

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

"Let me assess the patches. They may indicate the development of a fungal infection." Rationale: The yellow or white patches in the oral cavity may indicate a fungal infection called thrush. They are not normal, nor are they the result of ineffective brushing or of drinking whole milk.

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse?

"Allow me to show you how to use your walker again." Rationale: The nurse should correct any inappropriate use of assistive devices immediately upon observing improper use. Asking the client to activate the call light does not prevent the client from ambulating independently in an unsafe manner. Utilizing a wheelchair is a safe option but does not correct the improper use of the walker for future use. The best action is to re-demonstrate the proper walker use.

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why he or she needs to ambulate in halls three times a day. What is the correct response by the nurse?

"Ambulation helps prevent thromboembolism" Rationale: Regular ambulation can decrease the risk of thromboembolism in the postsurgical client. It does not affect risk of surgical wound infection or hypoglycemia. This client should no longer be experiencing any acute effects of anesthesia.

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

"Consult with your health care provider about beginning an exercise program." Rationale: The nurse should advise the client to consult with the health care provider to create a plan for an exercise program. Regular exercise, including cardiovascular exercise, helps maintain strength and flexibility and can help slow bone loss, all of which aid in fall prevention. However, the type of exercise and equipment should be determined by the health care provider or another qualified health care professional, not by the nurse.

The nurse considers applying restraints to an agitated client. Which actions does the nurse take?

"Dim the lights and speak softly about something the client enjoys." Rationale: The nurse attempts multiple techniques before restraining a person, even when the person is agitated. Among those techniques is providing a calming environment and distraction. The nurse can assess the client for injuries anytime he or she is agitated, but this is not immediately relevant. The client must at least be able to reach the call bell to request assistance and water, if allowed. Family members are not always helpful for someone with agitation, and a family member may find it difficult to accept that level of responsibility.

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow." Rationale: If a client asks to use baby powder it is most appropriate for the nurse to explain that baby powder is not recommended for use because it creates a medium for bacteria to grow, putting the client at risk for infection. The nurse would not want to use the baby powder from home because of this increased risk of infection, not because it increases costs or increases the risk for allergic response.

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

"Microbial contamination can occur when cleaning the anal area first." Rationale: The nurse needs to teach the staff member that wiping "front to back" is done to avoid carrying germs, like Escherichia coli, from the anus to the urinary meatus, causing a urinary tract infection. Telling the staff member that this action can prolong the hospital stay is correct but doesn't help the staff understand why the action was incorrect. Changing washcloths between the genitals and the rectal area is ideal, but it is more important to ensure cleaning is done in the proper sequence, whether with disposable or washable cloths.

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond?

"Mouth care during this time helps prevent complications." Rationale: The best response by the nurse is to explain that mouth care for the unconscious client prevents dental problems such as decay and prevents pneumonia due to bacterial growth in the oropharynx. This most completely addresses the spouse's question. Bacteria would normally be partially washed away by saliva, dental care does remain important, and moist oral mucosa does feel good to the client. However, these responses do no completely address the spouse's concern.

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need?

"Place all four feet of the walker on the ground before stepping forward." Rationale: The client should move the walker 6 to 8 in (15 to 20 cm) in a forward direction and set all four feet down and ambulate to the walker. All four walker feet should always be on the ground before the client ambulates. The client should lead with the leg he is most comfortable with. Setting only two walker feet on the ground creates a risk for falling for the client.

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

"Powder in the genital area can create a medium for bacterial growth." Rationale: Powder can create an environment for bacterial growth. This is a teaching moment for the nurse with the client and is the best response, addressing the client request and the reasons not to accommodate it. There is some evidence suggesting that ovarian cancer may result from excessive talcum powder exposure. However, there are talcum-free powders available. Powder can sometimes create additional redness, because it gathers moisture and sticks to groin folds and is no longer routinely recommended for care.

The nurse is caring for a 2-year-old child for whom elbow restraints have been prescribed. The nurse should remove the restraints and assess the child every how many hour(s)? _______

1 Hour Rationale: Children under 9 years of age should have elbow restraints removed at least once every hour to make sure the restraints are not too tight and are not impeding circulation.

The nurse has instructed the client with a knee injury on how to perform crutch walking with a four-point gait. Which statement clarifies client understanding?

"The four-point gait uses one crutch, then one leg, followed by the other crutch, and then the other leg." Rationale: The four-point gait utilizes "four" legs: one crutch, then one leg, the other crutch, and then the other leg. The two-point gait utilizes "two" legs: one crutch and the opposite leg move together, then the other crutch and opposite leg move together. The three-point gait utilizes "three" legs: both crutches and the affected leg at the same time, then followed by the unaffected leg. The swing-to gait utilizes the client swinging both legs to the crutch position in front of them.

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse?

"The health care provider will see the client and assess whether the restraint prescription should be renewed." Rationale: After restraints have been worn for 24 hours, the health care provider who is responsible for the care of the client must see and assess the client before writing a new prescription for the use of restraint or seclusion for the management of violent or self-destructive behavior. The health care provider will indicate that the client should remain in restraints if violent or self-destructive behavior continues. The client must be taken out of restraints before discharge, but the nurse would not know whether the health care provider would continue to renew the prescription for restraints for each 24-hour period until the client's discharge. If tests were needed to determine why the client is violent, the health care provider would have prescribed them before this time.

A nurse delegates the application of graduated compressions stockings to a licensed practical nurse. A while later, the client's spouse pulls the nurse aside and says, "I think the other nurse put the stockings on backwards. The opening is facing up." Which response by the nurse would be most appropriate?

"The opening is face up to prevent any interference with the circulation." Rationale: When applying graduated compression stockings, the heel pocket is down and the client's heel is centered in the pocket. If the stockings have a toe window, it is positioned correctly when it faces up. Proper positioning ensures toe comfort and prevents interference with circulation. The toe window should face up and the stocking should be smooth to prevent uneven pressure and interference with circulation. The statement about trusting the nurse is inappropriate and does not address the spouse's concern.

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"Use of special bathing products and avoidance of scrubbing help keep your skin intact." Rationale: Nurses should examine bathing practices and consider the effect on the client's skin. In general, they should avoid using soap and hot water and avoid excessive friction and scrubbing, as these can compromise the integrity of the client's skin, especially that of an older client, whose skin tends to be more fragile.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear." Rationale: All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Place the following instructions in the correct order. Use all options.

1)"Place both crutches under your left arm." 2)"Grasp the stair railing with your right arm." 3)"Place your unaffected leg on the first stair tread." 4)"Transfer your weight to the unaffected leg." 5)"Move up onto the stair tread." 6)"Move your crutches and the affected leg up onto the stair tread." Rationale: Crutches can be used when climbing stairs. The client grasps both crutches as one on one side of the body and uses the stair railing. Have the client stand in the tripod position facing the stairs. The client transfers his or her weight to the crutches and holds the railing. The client places the unaffected leg on the first stair tread. The client then transfers his or her weight to the unaffected leg, moving up onto the stair tread. The client moves the crutches and affected leg up to the stair tread and continues to the top of the stairs. Using this process, the crutches always support the affected leg.

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.

The nurse must apply a mummy restraint to a small child. Place the steps in the correct order. Use all options.

1)Secure a prescription from the health care provider. 2)Explain the reason for use to the client and family. 3)Open the blanket or sheet and place the child on the blanket. 4)Position the child's right arm alongside the body and pull the right side of the blanket tightly over the child's right shoulder and chest. 5)Secure the blanket under the right side of the child's body. 6)Fold the lower part of the blanket up and pull over the child's body.

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100oF Rationale: Although water temperature should be adjusted to 100oF (38oC) to less than 120o to 125oF (49oC to 52oC), the lower temperature limit of 100oF (38oC) is suggested for children and adults older than 65 years of age. A temperature of 90oF (32oC) would cause chilling.

The nurse has just transferred a client to the chair. The client begins to experience a tonic-clonic seizure. Which actions are appropriate for the nurse to take? Select all that apply.

> Ease the client to the floor > Loosen constricting clothing > Move furniture and other objects out of the immediate area > Place a folded blanket under the client's head Rationale: Getting the client to the floor prevents injury that might occur if the client falls to the floor. Removing objects and loosening clothing prevents possible injury. A blanket placed under the head prevents injury from striking the head against a hard surface, such as the floor. Restraint can injure the client. Attempting to open the mouth and/or insert anything into the mouth can result in broken teeth and injury to the mouth, lips, or tongue.

The nurse is caring for a client wearing a pneumatic compression device. The nurse has set the device properly when the pressure is in what range?

35 to 55 mm Hg Rationale: The normal pressure range of a pneumatic compression device is 35 to 55 mm Hg. The other pressure ranges are incorrect.

A client's health care provider has prescribed the use of knee-high graduated compression stockings. To ensure that the correct size is obtained for the client, the nurse would measure which area? Select all that apply.

> Around the widest part of the calf > From the bottom of the heel to the back of the knee Rationale: To ensure that the correct size is obtained, the nurse would Measure the client's legs to obtain the correct size stocking. For knee-high length stockings, the nurse would measure around the widest part of the calf and the leg length from the bottom of the heel to the back of the knee, at the bend. For thigh-high length stockings, the nurse would measure around the widest part of the calf and the thigh and the leg length from the bottom of the heel to the gluteal fold.

A client has been out of bed, sitting in the chair for the past hour. The nurse is preparing to apply knee-high length graduated compression stockings as prescribed by the client's health care provider. Which action would be appropriate for the nurse to do? Select all that apply.

> Assist the client back to bed. > Elevate the client's feet and legs for about 15 minutes. Rationale: If the client is sitting or has been up and about, 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. Flexing and extending the legs would be inappropriate. The nurse could apply powder to the leg lightly unless client has a respiratory problem, dry skin, or sensitivity to the powder. If the skin is dry, a small amount of lotion may be used. Powders and lotions are not recommended by some manufacturers, so the nurse should check the package material for manufacturer specifications. Flexing and extending Hair does not need to be removed.

The nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply.

> Bath blanket > Towels > Linen > Gown > Protective pads Rationale: Prior to giving a client a bed bath, the nurse would gather the following supplies not found in the client's room: bath blanket, towels, gown, linen, and protective pads. The basin is located in the side cabinet in the client's room.

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply.

> Check the walker for signs of damage, frame deformity, or loose or missing parts before use > Wear nonskid shoes or slippers > Choose a walker with wheels on the front legs if you have a faster gait Rationale: The nurse should instruct the client to wear nonskid shoes or slippers when using a walker to prevent falling. The nurse should instruct the client to inspect the walker for damage or missing parts to make sure that it is safe to use each time. The client should choose a walker with wheels if the client has a faster gait, as the wheels allow the person to move more quickly. The client should never use a walker on the stairs, which is dangerous. The client should use the arms of the chair or a stand-assist device for leverage when getting up from a chair and should not pull on the walker to get up, as the walker could tip or become unbalanced. A walker with wheels, not a standard walker, is better for clients who have difficulty lifting.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply.

> Ensure the parent engages in regular exercise > Provide frequent reorientation > Increase the parent's social interaction Rationale: The nurse should instruct the adult child to provide frequent reminders of person, place, and time to help keep the client oriented in the environment and decreases the chance that the client will wander. The nurse should also instruct the adult child to ensure the parent engages in regular exercise and to work to increase the parent's social interaction, both of which help clients with dementia channel stress more appropriately. Taking naps frequently does not help to reorient the client with dementia or to channel energies. Changing the parent's routine frequently can disorient a client with dementia and increase the chance that the client will wander.

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply.

> Falls > Contractures > Delirium > Pressure injuries Rationale: Restraint-free care is the standard of practice and an indicator of quality care in all health care settings. Physical restraints do not prevent falls, and they increase the possibility of serious injury due to a fall. Restraint use in older adults is associated with falls and injurious falls, pressure injuries, and other adverse outcomes. Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, and even death.

The nurse is caring for a postsurgical client. The client asks the nurse why he needs to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factors? Select all that apply.

> Increase joint flexibility > Improve respiratory function > Aid gastrointestinal motility Rationale: Ambulation helps the client increase joint flexibility, improve respiratory function and aid gastrointestinal motility. It does not necessarily help with pain control. In fact, clients may need pain medication prior to ambulation, especially if they are postsurgery. Ambulation is not related to wound infection risk.

The nurse is assigned a client for whom an elbow restraint is prescribed. Which general principles of correct placement of the elbow restraint will the nurse follow? Select all that apply.

> Pad bony prominences > Confirm the restraint does not extend below the wrist or place pressure on the axilla > Ensure the restraint is the correct size for the client

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply.

> Polypharmacy > Clutter > Extension Cords Rationale: In the home of an older adult, the use of extension cords and clutter in the walkways are environmental hazards that increase the risk of falls in the home. Polypharmacy is common risk in the home of an older adult client. Placing objects in familiar places helps to decrease the risk in the home of an older adult. Using ambulation devices helps to decrease the risk of falls in the home of the older adult.

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate? Select all that apply.

> Support the client's body against the nurse and gently slide the client onto the floor > Firmly grasp the client's gait belt Rationale: Firmly grasping the client's gait belt ensures a safe hold on the client. Supporting the client's body against the nurse's and gently sliding the client onto the floor enables the nurse to support the client's weight with large muscle groups and protects the nurse from back strain. The client should not be left alone. The cause of the weakness in unknown and it may not pass. Oxygen is not indicated. Assessing for the potential causes of the weakness should occur after client safety is assured.

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply.

> Use a night light > Avoid climbing on a chair or table to reach items that are too high to reach > Keep electrical and telephone cords against the wall and out of walkways > Remove clutter from walkways Rationale: A teaching plan for fall prevention in the home should include the recommendations: avoid climbing on a chair or table to reach items that are too high to reach; use a night light; remove clutter from walkways; and keep electrical and telephone cords against the wall and out of walkways. Considering the use of an electronic personal alarm would not help prevent a fall, but it may be used to help alert others to the fact that one has fallen.

A client who is recovering from surgery is beginning to ambulate. This client is strong enough to walk without assistance but has poor balance. Which type of mobility aid would be most appropriate for this client?

A cane with four prongs on the end (quad cane) Rationale: The quad cane provides a wide base of support and thus is recommended for clients with poor balance. A single-ended cane with a half-circle handle is recommended for clients requiring minimal support and for those who will be using stairs frequently. A single-ended cane with a straight handle is recommended for clients with hand weakness because the handgrip is easier to hold but is not recommended for clients with poor balance. A walker with four fixed legs must be completely lifted off of the floor between steps and is not recommended for clients with poor balance.

Which action does the nurse perform to institute seizure precautions for a client after a subdural hematoma?

Apply padding to the bed side rails bilaterally Rationale: Rail padding decreases the risk for injury. Depending on facility protocol, this may involve having three or four bed side rails raised. A bite guard is not used as a precautionary measure. Clients may be given lorazepam or another medication for seizures, but this is not included in seizure precautions. The nurse may raise the bed while applying the rail pads, but must ensure, as a part of seizure precautions, that the bed is in the lowest possible position while not at bedside.

After monitoring the client during a seizure, the nurse determines the seizure has ended and the client is stable. Which action does the nurse take?

Allow the client to sleep Rationale: The client will likely sleep after the seizure during the postictal state. Because the client was stable at the conclusion of the seizure (secure airway, normal vital signs), the nurse allows the client to sleep until he or she naturally awakens, at which time the nurse can orient the client to the situation. It is not necessary to awaken the client in 30 minutes and assess the neurological status, nor is it necessary to obtain frequent vital signs during the postseizure period.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next Rationale: A full bed bath every day may cause excessive dryness in many older adults, and a continent client may not require a bath every day. If dry skin is a problem, water and skin lotion or bath oil may be used on alternate days with a bed bath. Do not use bath oil in tub water, as it can cause tub surfaces to become slippery. Bed baths should not be avoided altogether but simply given every other day.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?

Asses the client's need for fluids and toileting every 2 hours Rationale: Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance. According to the UAP Nurse Practice Act, the duties of a UAP do not include performing assessments. The nurse should assist with the client's ADLs but allow the client the independence of performing as many as possible for oneself. The restraints should be secured to a non-movable part of the bed frame, and, thus, not to the side rail.

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

Apply a thin barrier of skin protectant to the perineal area Rationale: The nurse would apply a thin barrier of skin protectant to the perineal area to protect the skin from breakdown associated with contact with stool or moisture. Baby powder is a medium for bacterial growth and should not be used in the perineal area. Antibiotic ointment and betadine ointment are not indicated at this time.

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 interventions is appropriate?

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

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure. Which intervention should take priority?

Assess the circulation to the client's fingers and hands. Rationale: In this situation, assessing the circulation to the client's fingers and hands should be the priority intervention, because elbow restraints can impair circulation if applied too tightly. Keeping a call bell within easy reach would be a lower priority intervention, because the client is undergoing a procedure and is already in the company of the provider or other health care professionals. Assessing respirations to help prevent asphyxiation would be a priority intervention if the client were prescribed a waist restraint, not an elbow restraint. Encouraging the client to wear low-heeled, rubber-soled shoes would be a pertinent intervention for a client at high risk for falls.

After assisting a bed-bound client with oral care, what action does the nurse take?

Assist the client to a comfortable position in the bed Rationale: During oral care, the client either sits straight up in the bed or must lean toward the bedside. After completion of oral care for the bed-bound client, the nurse assists the client to a comfortable position. Oral care supplies are recapped or rinsed, stored in a drawer, cabinet, or on a shelf, and reused when needed to avoid unnecessary waste. Inspection of the oral cavity should occur prior to care to minimize oral trauma and to correctly assess for hydration.

The health care provider has prescribed application of total-leg pneumatic compression device sleeves to a client's legs. Where would the nurse place the opening in the sleeve?

At the popliteal space behind the knee Rationale: When applying total-leg sleeves, the nurse would place the opening in the sleeve behind the knee at the popliteal space to prevent pressure behind the knee.

For the client at risk of seizures, which action does the nurse take?

Attach an oxygen regulator at the head of the bed Rationale: If the client has a seizure, the client is at risk for hypoxia and aspiration. An oxygen and vacuum regulator must be attached at the wall with the correct supplies for delivery of oxygen and suctioning of secretions or vomitus. Also, an oral airway and resuscitation bag, a bag-valve mask device, must be at the wall behind the bed. Intubation supplies are ready on the crash or code cart for emergencies if needed. Unless the client already demonstrates hypoxia, placing an oxygen mask on the client is not warranted. The client may lie in any position that is comfortable and does not aggravate existing conditions, as long as the client is not actively having a seizure.

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath Rationale: The gown should be removed without disconnecting the IV equipment or cutting the gown. This provides uncluttered access during the bath and prevents the destruction of the gown, while maintaining IV fluids at the prescribed rate. Leaving the gown in place is inappropriate, as a fresh gown is part of a routine bath.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home Rationale: The nurse should recommend that the client's family ensure that walking paths and floors in the home are free of clutter, which is an environmental hazard that increases the risk of falls in the home. Changing routines, taking walks outside, and using the stairs will not reduce the risk of falling in the home.

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment?

Cognitive function level Rationale: Assessment of cognitive function is most important to assure safety for the client with using the walker. A client unable to follow or retain direction would be at risk for injury. Vital signs should be reviewed and checked if the client is at risk for orthostatic hypotension. Muscle strength is an appropriate assessment but not the priority assessment in this situation. Medication allergies should not affect teaching proper ambulation technique with a walker.

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

Decreasing the incidence of hospital-acquired pneumonia Rationale: Diligent oral care inhibits the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, hospital-acquired non-ventilator pneumonia and ventilator associated pneumonia. While the other choices are expected outcomes of oral care, preventing respiratory complications is the priority.

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

Disposable gloves, Toothbrush, Toothpaste, Emesis basin, Towel Rationale: Necessary supplies for tooth brushing include toothpaste, toothbrush, emesis basin, towel, and disposable gloves. The nurse would also include other PPE as needed, a glass of water, and mouth rinse. Lip lubricant is optional but should be offered to the client.

When providing oral care to an unconscious client, the nurse takes which action?

Ensure there is a towel and basin positioned for drainage Rationale: The nurse ensures that liquids can be easily captured and cleaned by placing a towel and basin beneath the unconscious client's head during oral care. The unconscious client should not be placed in an upright position during oral care due to risk of aspiration. The tongue and teeth must be brushed adequately, but multiple times is not necessary. Oral suction should be set up to collect drainage in the oral cavity or the posterior oropharynx, but endotracheal suction will not be needed if oral care is done correctly.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency?

Every 1 to 2 hours Rationale: The nurse would plan on increasing the frequency of client observation and surveillance, conducting client/nursing rounds every 1 to 2 hours. These rounds would include assessing for pain, assisting with toileting, providing client comfort, ensuring that personal items are within reach, and meeting client needs. Client care rounds/nursing rounds improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

Every 60 Minutes Rationale: If a client who is at high risk for falls has no access to an activated bed or chair alarm, a nurse should observe the client every 60 minutes. Unless the client is on one-to-one observation, every 30 minutes is too frequent. Once a shift, or at 2- or 4-hour intervals, is too infrequent.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity Restraint Rationale: The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

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?

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 manufacturer's directions. The other methods are not as effective or efficient.

A nurse is caring for a 3-year-old who has just been admitted to the hospital due to a severe case of influenza. The child experiences a seizure. The nurse should suspect which as the most likely cause of the seizure?

High Fever Rationale: Most seizures in children are caused by disorders that originate outside of the brain, such as high fever, infection, head trauma, toxins, or cardiac arrhythmias. Febrile seizures are the most common type during childhood and are usually benign. Moreover, we know from the scenario that the child likely has a fever due to having influenza. There is no indication that the child has epilepsy or has experienced head trauma from a fall or intracranial hemorrhage.

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted?

Insert the fist between the restraint and the client. Rationale: The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

How should the nurse teach the client who is ambulating with a cane?

Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

The nurse is talking to a client who has been using crutches for ambulation. The client reports intermittent numbness of the upper arms. What should the nurse instruct the client to avoid?

Leaning for prolonged periods by the axilla on the crutches Rationale: Leaning on the crutches can create pressure on the axillary nerves, creating numbness, tingling, and pain down the arms. The client should not be leaning on the crutches for long periods of time. The crutches should have been fit to the client's height upon being dispensed. No additional padding should be necessary because it could alter the fit of the crutches. Likewise, adjustments made to the height without professional assistance increases risk of injury. The type of gait used with crutches does not contribute to numbness of the arms.

The nurse is caring for a client, after hip replacement, and receives a prescription to apply a pneumatic compression device. On what part of the body would the nurse place this device?

Legs Rationale: A pneumatic compression device is placed on the client's legs to enhance blood flow and venous return in the legs.

The nurse is caring for a hysterical child who requires assessment of a dog bite near the eye. The parent is in emotional state that is not appropriate for helping to immobilize the child. The nurse should implement which restraints to best enable the health care provider to examine the client's injury?

Mummy Restraint Rationale: The mummy restraint is appropriate during an examination or while providing care for the head or neck, because it provides short-term restraint designed to control all movement. The vest restraint, extremity restraint, and elbow restraint are not appropriate in this situation.

After applying a restraint to a client, the nurse is required to stay with the client while it in use. Which type of restraint has the nurse applied?

Mummy restraint Rationale: A mummy restraint restricts all movement, and thus the nurse should stay with the client while it is in place. The other types of restraint do not restrict the client's movements as completely and thus require checks at specified intervals, but not the constant presence of the nurse.

The client has decreased strength in the left leg. How should the nurse instruct the client to hold a cane for assistance?

On the right side Rationale: The cane should be held in the hand opposite of the weakened leg.

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint?

Pad bony Prominences Rationale: Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. The nurse should remove PPE after applying the restraint.

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?

Perform a circulation check and offer toileting and hydration Rationale: Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids. Restraints are not used on an as needed basis but are used for a 24-hour period with breaks only for basic needs, like toileting. Even if the client suddenly seems calm, removal of the restraints is not permitted. Once this is done, a new prescription must be obtained and there are legal issues to consider. Bargaining with the client for restraint removal is not an acceptable nursing action. Restraint use is a safety measure, not a punishment.

Proper application of a pneumatic compression device includes which step?

Place a sleeve under the client's leg with the tubing toward the heel. Rationale: Proper application of a pneumatic compression device includes placing a sleeve under the client's leg with the tubing toward the heel. The sleeve is applied properly when two fingers can fit in between the tube and client's leg. The tubing should not be wrapped around client's bedrail, but it should be free of kinks. The cotton liner of a pneumatic compression device is applied facing up.

The nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint. The elbow restraint should not impede circulation. Which pulse will the nurse assess to decide if circulation is compromised?

Radial Rationale: The nurse should determine if circulation is compromised by assessing the radial pulse and the circulation to the fingers and hand. Assessing the apical, carotid, and jugular pulses will not help the nurse decide if the elbow restraint is compromising circulation.

The nurse is caring for a middle-aged adult who has been prescribed elbow restraints. The nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. What is the best action by the nurse?

Remove restraints more frequently and perform range of motion (ROM) Rationale: If a client cries or reports discomfort or pain when elbow restraints are removed, the nurse should remove the restraints more frequently and perform active or passive ROM. Eliminating the restraints would alleviate the client's pain only if the reason for which the restraints were prescribed has resolved. The nurse could reassess and consider another type of restraints, but it is better to continue with the type of restraints prescribed by the health care provider. A padded dressing will not alleviate the client's pain, because the restraints are already padded.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

Remove the antiembolism stockings before the bath. Rationale: Antiembolism stockings should be removed before the bath to allow for assessment during the bath

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

Retract the foreskin when washing the prepuce of adolescents and older Rationale: The nurse would retract the foreskin and wash the area under it when providing perineal care for an uncircumcised male who is an adolescent or older. The nurse would then pull the foreskin back into place over the glans penis to prevent constriction of the penis, which could result in edema and tissue injury. It is not recommended to retract the foreskin for cleaning during infancy and childhood because injury and scarring could occur.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place Rationale: In an uncircumcised male client (teenage or older), retract the foreskin (prepuce) while washing the penis but pull it back into place over the glans penis immediately afterwards to prevent constriction of the penis, which may result in edema and tissue injury. However, it is not recommended to retract the foreskin for cleaning during infancy and childhood, because injury and scarring could occur. The nurse should clean the tip of the penis first, not soak it in water, by moving the washcloth in a circular motion from the meatus outward.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. Rationale: In an uncircumcised male client (teenage or older), retract the foreskin (prepuce) while washing the penis but pull it back into place over the glans penis immediately afterwards to prevent constriction of the penis, which may result in edema and tissue injury. However, it is not recommended to retract the foreskin for cleaning during infancy and childhood, because injury and scarring could occur. The nurse should clean the tip of the penis first, not soak it in water, by moving the washcloth in a circular motion from the meatus outward.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

Scrotum Rationale: When performing perineal care for a male client it is important that the nurse be particularly gentle and avoid pressure when handling the scrotum, because pressure on the scrotum may cause pain for the client. Gentle, but firm handling of the penis including the meatus, glans penis, and shaft reduces the chance of the client having an erection, which can be embarrassing for the client and the nurse.

The nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint. The infant's parent asks the nurse what will be used to implement the mummy restraint on the infant. What is the best response by the nurse?

Sheet or blanket Rationale: A small blanket or sheet is applied and folded to construct the mummy restraint. A vest restraint is made for adult clients. Towels are too small to be able to fold in the prescribed manner around the child. There are no manufactured mummy restraints.

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client?

Side-lying Rationale: Putting the unresponsive client in a side-lying position while performing oral care facilitates the drainage of any liquid from the client's mouth and prevents aspiration. Prone position would not be conducive to oral care. Supine and semi-Fowler's position would increase the risk for aspiration in the unresponsive client.

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

Sitting at the edge of the bed Rationale: To prevent aspiration, it is best to assist the client to a sitting position. If the client is unable to sit, the side-lying position is also acceptable. The other options would place the client at risk for aspiration.

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

Start with cleanest areas and end with most soiled areas Rationale: The nurse should start with cleanest areas and end with most soiled areas, to avoid transferring microorganisms from soiled areas to the clean areas. The other approaches are not valid

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client?

Suction toothbrush Rationale: A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration. A regular toothbrush and an oral suction catheter may also be used. An emesis basin, towel, and toothpaste would be expected for use for any client during oral care.

The nurse is caring for a client in the postanesthesia care unit (PACU) who has just undergone a third foot surgery. Which gate is best for the nurse to teach this client?

Swing-to gait Rationale: The swing-to gait utilizes the client swinging both legs to the crutch position in front of them. This eliminates the client bearing all the weight on the affect foot. The four-point gait utilizes "four" legs; one crutch, then one leg, the other crutch, and then the other leg. The two-point gait utilizes "two" legs; one crutch and the opposite leg move together, then the other crutch and opposite leg move together. The three-point gait utilizes "three" legs; both crutches and the affected leg at the same time, then followed by the unaffected leg.

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift. Rationale: Antiembolism stockings should be removed once every shift for 20 to 30 minutes to allow for assessment of circulatory status and the condition of the skin on the lower extremity and for skin care. The nurse should not disregard the health care provider's prescription and allow the client to remove the stockings indefinitely, as this could endanger the client's health.

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

The UAP begins cleansing from the anus toward the pubic bone. Rationale: When performing perineal care, it is important to wash from the area that is least likely to be contaminated to most likely to be contaminated (front to back) to prevent contaminating of bacteria from the anal area to the urethra. Cleansing form anus to pubic bone would be cleaning "back to front" and put client at risk for urinary tract infection. The other options are appropriate when performing perineal care.

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 Rationale: 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.

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

The client continually tries to move from head of the bed toward the foot of the bed Rationale: Research suggests that waist restraints pose the same risks for asphyxial death as vest restraints. When the client is very mobile in the bed or chair, the risk for asphyxiation increases. The nurse should pad skin and bony prominences that will be covered by the restraint to reduce friction and pressure to skin and underlying tissue. Restraints ground a client's center of gravity, thus helping to prevent injuries and falls such as rolling off a stretcher or falling out of bed. Because the nurse should be following the removal schedule (every 2 hours), the client is at less risk for incontinence and dehydration because these needs are being met every 2 hours.

The nurse is teaching proper cane use to a client who has had ankle surgery. The client has been cleared to begin bearing weight on the affected leg. What outcome would be unexpected?

The client reports increased strength in the weaker leg Rationale: Increased strength in the weaker leg is not considered a projected outcome for proper cane usage. Rather, the cane is used for balance and support to increase safety and independence.

What should the nurse teach the client about climbing stairs with a cane?

The client should advance the stronger leg up the stair first, followed by the cane and weaker leg. Rationale: The client should advance the stronger leg up the stair first, followed by the cane and weaker leg. This helps support the weaker leg. The other techniques could increase client fall risk.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can Rationale: When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should let the client bathe himself to the extent that he can effectively do so. Bathing is performed in a matter-of-fact and dignified manner. If this approach is followed, clients generally do not find care by a person of the opposite gender to be offensive or embarrassing. Just because the man has dementia does not mean that he is not capable of bathing himself, at least in part. Calling a family member to bathe the client is both unnecessary and impractical.

A toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint. The procedure is expected to take about 10 minutes. Which approach might the nurse suggest as an alternative to using a mummy restraint?

Therapeutic Holding Rationale: An alternative approach for temporary restraint is therapeutic holding, which makes use of a secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 minutes or less. A vest or mitt restraint would not be an alternative to a mummy restraint. Straddling the child would be inappropriate.

A nurse is explaining to a client's caregiver the purpose of antiembolism stockings, which the client has received a prescription to wear. Which best explains their purpose?

They promote venous blood return to the heart. Rationale: By applying pressure, antiembolism stockings increase the velocity of blood flow in the superficial and deep veins. The purpose is not to treat edema, but to promote blood return to the heart. They have a smooth surface and can increase the risk for falls. They can increase the risk for impaired skin integrity if not applied correctly.

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

Tip of the penis Rationale: The nurse would always clean from the least contaminated area to the most contaminated area. The nurse would clean the tip of the penis first, from the meatus outward, washing the shaft of the penis using downward strokes toward the pubic area. The scrotum would be cleaned next, followed by the anal area.

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned?

To either side and slightly behind the client with near hand on gait belt Rationale: When ambulating a client with a gait belt, the nurse should stand to either side and slightly behind the client with near hand on gait belt. The other positions do not allow the nurse to properly use the gait belt to help provide stability and balance.

The nurse applies a gait belt to a client prior to ambulation. For what reason might the nurse use a gait belt when ambulating certain clients?

To improve grasp and help provide more stability and balance Rationale: A gait belt helps to improve the nurse's grasp and help provide stability and balance. It does not help with center of gravity. It is not used as a weight for added exercise. A gait belt alone does not increase the client's activity tolerance.

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth?

Twice a day

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate?

Tying the restraint behind the chair Rationale: The nurse should run the restraint under the arm rests and tie it behind the chair. Tying the restraint out of the client's reach promotes security. Tying the restraint to the side rail or in the front of the chair would allow the client to untie the restraint. Tying the restraint under the chair would not provide the nurse with swift access to the quick-release knot.

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

Uncover only the area being cleaned Rationale: Performing perineal care is personal, so it is important for the nurse to maintain privacy and dignity. This is achieved by being sensitive to the client and uncovering only the area that is necessary for cleaning. Cleansing from "front to back" and using a clean portion of the washcloth are important to prevent infection. It is not necessary to obtain two identifiers before performing perineal care.

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds Rationale: Skin-fold areas may be sources of odor and skin breakdown if not cleaned and dried properly. Although all the areas listed should be bathed, they do not require the same level of attention as do the skin-folds.

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?

Use a safety monitoring device Rationale: A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance. Restraining the client takes away independence and can increase agitation and confusion. Asking a family member to sit with the client may help calm the client, but inappropriately transfers the nurse's responsibility to the family member. Checking on the client every 30 minutes is insufficient, because the client could fall and sustain injury during the unobserved intervals.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers Rationale: Moisture barriers and special perineal skin cleansers will help prevent skin breakdown and excoriation. Do not use antibiotic or other antimicrobial cleaners or betadine at the urethral meatus. Decreasing the frequency of bathing is unnecessary to preserve skin integrity, as long as special precautions are taken. A full bed bath may not be necessary each time the client has an episode of incontinence. A partial bed bath may be given in some instances.

A nurse is directed to apply a pneumatic compression device for a client, after surgery. What postoperative complication would this device help to prevent?

Venous Thrombus Rationale: The pneumatic compression device is applied to a client's legs to enhance blood flow and venous return to prevent deep-vein thrombosis. Coughing exercises help to prevent pneumonia, and frequent dressing assessments help to detect infection and hemorrhage.

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?MC

Waiting outside of the closed bathroom door while the client uses the toilet Rationale: To prevent falls for a client who is at high risk for falls, the nurse should not wait outside the closed bathroom door but should remain with the client in the bathroom and assist the client in toileting. The other actions are appropriate measures for a client who is at high risk for falls and would not require the charge nurse to intervene.

The nurse is demonstrating proper ambulation technique with crutches to a child with a fractured ankle. What is priority assessment should the nurse perform?

Weight bearing status Rationale: The nurse should assess the client's weight to help determine which crutch gait to demonstrate. The nurse should consider pain, neuromuscular, and neurovascular status when ambulating a client; however, ignoring weight bearing status could cause increased injury to the client as well as impair the client's safety with crutch ambulation.

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms?

Wiping down the handles of the walker once the client has returned to bed Rationale: Proper cleaning of equipment between client use prevents the spread of microorganisms. While washing the client's hands upon return to bed will decrease the possibility of infection, the walker would remain contaminated and at risk being touched by many people passing by the walker.