NURSING CONCEPTS CHAPTER 31 AND 33

The nurse is helping a client perform oral hygiene. When asked whether the client flosses, the client states, "I don't like to floss because it makes my gums bleed." What is the appropriate nursing response? Select all that apply.

"Flossing removes plaque and food debris that a toothbrush may miss." "The chance of tooth and gum disease can be reduced by flossing."

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first?

"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse?

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

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instructions?

"I will go to the nurses station for assistance."

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (select all that apply)

A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. D. Use smooth movements when lifting and moving clients.

A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care?

A. Schedule rest periods during morning care

A nurse is preparing to administer a cleaning enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.)

A. The nurse should warm the enema solution because cold fluid can cause abdominal cramping, and hot fluid can injure the intestinal mucosa B. The nurse should place the client in this left side with right knee flexed position to promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. C. The nurse should lubricate the tubing to prevent trauma or irritation to the rectal mucosa

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take?

A. Turn the client's head to the side

A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should

A. lock the wheels on the bed and stretcher. Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. This is the priority action for transferring a client.

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. Correct response:

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to room closest to the nurses' station?

An older adult who is postoperative following a below-the-knee amputation

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

Assess both eyes for contact lenses

An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?

Assess the client's cultural views regarding hygiene and self-care.

Nurse is caring for pt in a long term care facility with EN via NG. Which actions should the nurse do before admin feeding (select all that appl

Auscultate bowel sounds B. Assist pt to sit upright C. Test pH of gastric residue

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (select all that apply)

B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible.

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (select all that apply)

B. Immunocompromised individuals are at risk for complications from food poisoning. C. Clients who are at high risk should eat or drink only pasteurized dairy products. E. Handling raw and fresh food separately can prevent food poisoning.

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (select all that apply)

B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home.

A nurse is caring for a client who is receiving eternal tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

B. Semi-Fowlers

A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client's skin turgor, the nurse should

B. grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back.

To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should

B. place the bed in a high horizontal position.

A nurse is explaining the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client?

Bathing reduces the possibility of infection.

A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae.

A nurse is preparing to perform denture care for a client. Which of the following actions shoudl the nurse plan to take?

Brush the dentures with a toothbrush and denture cleaner

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures

At the surgical scrub sink, a surgical nurse demonstrates the proper surgical hand-washing technique by scrubbing

C. with her hands held higher than her elbows. Hands must be held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a nonskid floor.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

Determine the client's ability to help with transfer.

The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?

Dry the cleaned areas and apply an emollient as indicated.

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

I will use conditioner so that the lice eggs will slide off my hair.

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection

Illness

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

Independent showering

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?

Inform the UAP that she should be wearing gloves.

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.

It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene measures have no affect on skin." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene."

The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?

Keep hair off the face and wash hair daily.

A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?

Keep the diaper and buttocks clean and dry and apply zinc oxide.

The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?

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

*While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Lower the enema fluid container To relieve the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema solution container.

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority?

Move clients who are nearby

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal?

Normal saline

A nurse is shaving a male client's face. Which should the nurse do

Pull the skin taut and shave in the direction of hair growth using short strokes.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height.

Nurse is prepping to insert NG for pt needed decompression. Which action should the nurse do before beginning produces (select all that apply)

Review signal for pt if any distress B. Lay towel across pts chest

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action?

Setting limits by telling the client not to grab people is an effective way of dealing with this behavior.

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night?

Sit on the side of her bed and rest her arms over pillows on top of her bedside table.

The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning?

Use a special cleaning solution for eye glass lenses

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

Use an electric razor for shaving purposes.

An older adult client has been admitted to the hospital and the nurse is preparing to provide hygiene to the client. The nurse brings a soft toothbrush and toothpaste to the bedside and the client's daughter begins to laugh, stating, "She doesn't actually have a single tooth left!" What should the nurse do?

Use the toothbrush as planned, despite the client having no teeth.

A nurse is delivering an EN feeing to a client who has an NG tube for intermittent feelings,. When the nurse pours water into the syringe after the formula drains from the syringe, the pt asks the nurse why the water is necessary. What should the nurse respond

Water helps clear the tube so it doesnt get clogged

In which situation would it be appropriate to shave the beard of an unconscious client without his permission?

When inserting an endotracheal tube

When providing oral care, what does the nurse recognize as the most important component of the oral care process?

a thorough, mechanical cleaning

When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compressions?

absence of pulse

a nurse is instructing a client who has an injury to the left lower extremity about the use of a cane. which of the following instructions should the nurse include (select all that apply)

after advancing care, more weaker leg forward

a nurse is caring for a client who is postop. which of the following interventions should the nurse take to reduce the risk of thrombus development (select all that apply)

apply elastic stocking and assist client to change position often

The nurse is caring for an older adult client who has refused a bath for several days and has now developed a rash on the buttocks. What is the priority nursing intervention?

Explain that cleanliness helps to remove bacteria from skin, which can prevent infection.

A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

Glossitis

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with come crusting. The nurse should identify the client has manifestations of which condition

Herpes zoster

A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?

back massage

Which of the following nutrients is the body's preferred energy source?

carbohydrates

The purpose of flushing a tube after an enteral feeding is given is to

clear the tubing to prevent clogging

Which of the following is appropriate for a nurse to give a client who is on a low-residue diet?

dairy products

NCLEX a nurse is planning care for a client who is on bed rest. which of the following interventions should the nurse plan to implement

encourage client to perform antiembolic exercises q2

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first?

face

Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of

friction

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has a heat stroke will have which of the following?

hypotension

A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings (select all that apply.)

hypotention high temperatures poor skin tugor

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

one cup of medium apple with skin

Which health problem is most clearly suggestive of a history of inadequate dental care?

periodontitis

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that HCP are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting (Select all that apply)

planning and evaluating control and prevention strategies B. determining public health priorities ensure proper medical treatments monitor common source of contamination

a nurse is caring for a client who has been sitting in a chair for 1 hr. which of the following complications is the greatest risk to the client

pressure ulcer

A nurse is caring for a client receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority if aspiration of tube feeding is suspected?

stop feeding

A pt on continuous feeds - what is the intervention of highest priority if suspect aspiration

stop feeding

The proper way to secure a nasogastric tube is to apply

tape from the client's nose to the nasogastric tube.

The highest priority nursing assessment before initiating an enteral feeding is determining

that the tube is correctly placed.

A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?

the importance of completely finishing the prescribed treatment

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?

the specimen cannot be contaminated with urine

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that:

there is a need to determine if the bottled water has fluoride.

a nurse is evaluating teaching on a client who has a new rx for a sequential compression device. which of the following client statements should indicate the client understands

this thing will keep the blood pumping through my leg

A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?

to tuck her chin when swallowing.)

The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)?

traditional bed bath with linen change

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:

understand that his culture may influence his hygiene and ask him his preference.

If their diets are not adequately supervised, school-age children tend to have dietary deficiencies in which of the following?

vitamins

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care (Select all that apply)

wear a make when providing care within 3 ft C. place a surgical mask on client if transportation to another department is unavoidable wear a gown when performing care that might result in contamination from secretions

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority?

A. Complete a fall-risk assessment

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (select all that apply)

A. Inspect feet daily B. Use moisturizing lotion on the feet E. Wear cotton socks

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

These brown spots are senile lentigines and are common when you get older."

A parent reports that their home water is not fluoridated and questions the nurse whether it would be benefitial to start giving fluoride supplements to the 9-year-old child. Which response by the nurse is most appropriate?

"In the absence of fluoridated water supplies, supplementation is often recommended."

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response?

"It is very upsetting to see an adult client regress." This response illustrates the therapeutic communication tool of restating and clarifying. It encourages the AP to express any feelings about the client soiling the bed for attention.

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicated understanding of the instructions?

"Once my infant starts to push up, I will remove the mobile from over the crib."

A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized vs. systemic infection. The nurse indicates understanding when she states which of the following are manifestations of a system infection (Select all that

. Fever B. Malaise Inc in pulse and RR

A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long term goal of weight loss?

A. Attempt to develop the clients' self-motivation.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time, and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (select all that apply)

C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessmen

While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

C. Remove the gloves carefully and follow with hand hygiene. Standard precautions require the use of gloves and hand hygiene in the care of all clients.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

Contact a podiatrist to care for toenails

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling?

D. Carbon monoxide binds with hemoglobin in the body

The nurse is teaching a client about hearing aid care. Which teaching is appropriate?

Store the hearing aid in a cool environment.

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

Suction toothbrush

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

The nurse has completed a change of a client's bedding while the client is seated in a wheelchair. When removing the bedding, what action best maintains the principles of infection control

The nurse should avoid contact with the soiled bedding as much as possible and should avoid placing it on surfaces where it could transmit microorganisms. Such surfaces include the floor and chairs.