PrepU Unit 1: 231

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." "Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." "That's correct, but be sure that you don't increase your laxative doses over time."`

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition? "This happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid." "This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart." "This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." "There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement."

"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount."

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? 3 in (7.5 cm) 1 in (2.5 cm) 2 in (5.0 cm) 5 in (12.5 cm)

3 inches

Which type of mobility aid would be most appropriate for a client who has poor balance? a cane with four prongs on the end (quad cane) a single-ended cane with a half-circle handle a single-ended cane with a straight handle axillary crutches

A cane with four prongs on the end (quad cane)

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. Fires are responsible for most hospital incidents. Between 15% and 25% of falls result in fractures or soft tissue injury. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action? A risk that the peristomal skin will become excoriated The appliance will need to be changed daily. The appliance will fit securely to the client's skin. A heightened risk that the stoma will prolapse

A risk that the peristomal skin will become excoriated

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply. airborne precautions droplet precautions contact precautions respiratory precautions microbial precautions body fluid precautions

Airborne precautions droplet precautions contact precautions

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. Allow the low intermittent suction to continue during the assessment of bowel sounds. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

The nurse is caring for a client who is receiving continuous enteral feeding. The client develops nausea. Which actions should the nurse provide? Select all that apply. Discover if suction equipment is ready at the bedside. Lower the head of the bed to decrease strain on the abdomen. Provide an ordered antiemetic as prescribed. Assess the gastric residual and auscultate for bowel sounds. Use a stylet to unclog the nasogastric tube.

Discover if suction equipment is ready at the bedside. Provide an ordered antiemetic as prescribed. Assess the gastric residual and auscultate for bowel sounds.

The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply. Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers Hyperextension of fingers

Extension of fingers Flexion of fingers Adduction of fingers Abduction of fingers

A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs? Gastrostomy tube Nasogastric tube Nasointestinal (NI) tube Salem sump tube

Gastrostomy tube

A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed? Hemoglobin 12 mg/dL Hematocrit 35% Transferrin 360 mg/dL Blood urea nitrogen (BUN) 17 mg/dL

Hematocrit 35%

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful? "I will not visit my family member in the first 3 days of my cold." "I will use tissue to cover my nose and mouth while I am visiting and will refrain from touching my family member." "I will obtain a mask from the staff and wash my hands before touching my family member." "If I sneeze or cough, I will make sure to cover my mouth with hand or tissue."

I will obtain a mask from the staff member and wash my hands before touching my family member

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? Use a small syringe and insert 10 mL of air. If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. Continue to instill air until fluid is aspirated. Place the client in the Trendelenburg position to facilitate the fluid aspiration process.

If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding? When checking for residue, if a large amount is aspirated, replace the residue before proceeding with feeding. If the client complains of nausea after tube feeding, lower the head of the bed and administer an antiemetic. If the tube is found to be in the stomach instead of the esophagus, follow the recommended steps to replace the tube. If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog.

If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog

The nurse is educating a client and caregivers about recurrent infections the client has experienced. What priority intervention can the nurse include that is a first line of defense? the cell-mediated immune response early intervention with antibiotics staying home when sick intact skin and mucous membranes low levels of flora

Intact skin and mucous membranes

A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding? Feeds must be warmed prior to instillation to reduce the risk of nausea and vomiting. Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. Continuous feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeding intolerance is less likely to occur with larger volumes.

Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time.

A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? Migration of leukocytes to the area of the wound Constriction of the small blood vessels near the wound Release of histamine Production of antibodies

Migration of leukocytes to the area of the wound

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching? "My body does not make its own vitamins." "Cooking can change the vitamin contents in foods." "I drink orange juice fortified with added calcium." "My husband and I are ordering a product that has megadoses of vitamins."

My husband and I are ordering a product that has megadoses of vitamins.

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a patient-centered plan of care? Select all that apply. prescription for warfarin recent unwitnessed fall diagnosis of periodontitis dyspnea with exertion prescription for carvedilol current chemotherapy treatment low platelet count altered mental status

Prescription for warfarin diagnosis of periodontitis current chemotherapy treatment low platelet count

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. Let the skin hang loose and shave in long, downward strokes. Shave against the direction of hair growth, using short strokes. Pull the skin taut and use short, upward strokes.

Pull the skin taut and use short, upward strokes

Which action is the best example of a nurse donning/removing protective equipment properly? Removing respirator after leaving client's room Removing gown after leaving client's room Donning gown after entering client's room Donning respirator inside of client's room

Removing respiratory after leaving client's room

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident? Report this sentinel event to the Joint Commission and to relevant state agencies Inform the public that the incident occurred, while protecting the confidentiality of the clients. File an incident report with the American Nurses Association describing plans for preventing similar events in the future. Offer compensation to the affected client in a timely manner, while maintaining the client's confidentiality.

Report this sentinel event to the Joint Commission and to relevant state agencies

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? supine slight Trendelenburg Sims' prone

Slight trendelenburg

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply. The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. The client should be asked to defecate into a clean bedpan or toilet bowl, depending on the nature of the study. The client should be instructed not to place toilet tissue in the bedpan or specimen container. Medical aseptic techniques are always followed. Handwashing is performed before and after glove use when handling a stool specimen. Generally, 2 inches of formed stool or 20 to 30 mL of liquid stool is sufficient for a stool specimen.

The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. The client should be instructed not to place toilet tissue in the bedpan or specimen container. Medical aseptic techniques are always followed. Handwashing is performed before and after glove use when handling a stool specimen

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk? Using a tongue depressor to access stool Taking sample directly from commode insert Wearing disposable gloves Not removing commode insert from commode

Wearing disposable gloves

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: fluid and electrolyte levels. ability to reposition. pain level during infusion. nausea or vomiting.

fluid and electrolyte levels

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? Lean into the cane as it supports you. Hold your cane on the right side. Hold the cane 6 in (15 cm) in front of you. You may switch hands with your cane if you become tired.

hold your cane on the right side

A nurse is delivering meal trays to clients on the unit. One client has a fractured dominant arm which is in a sling. What is the first nursing action when bringing the tray into the client's room? Identify the name of the client. Remove the lids covering the foods. Assist the client with opening containers of liquids. Cut food into bite-size pieces.

identify the name of the client

Which medication causes constipation? Magnesium antacids Bisacodyl Aspirin Iron supplements

iron supplements

As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise? isotonic aerobic isometric anaerobic

isometric

A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support? low prealbumin levels proteinuria low random blood glucose levels increased white blood cells

low prealbumin levels

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of: positive nitrogen balance. anabolism. negative nitrogen balance. digestion.

negative nitrogen balance

A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely: thiamin. folate. niacin. riboflavin.

niacin

A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene? "Vegetarians have a lower incidence of colorectal cancer than people who eat high fat diets." "Protein complementation is important so that you get the right amount and proportion of amino acids needed." "Vegans consume plants sources for protein. " "Obesity is closely linked with vegetarianism."

obesity is closely linked with vegetarianism

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in? underweight healthy weight overweight obese

overweight Explanation: A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? palpation percussion auscultation inspection

palpation

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should: use a pull sheet whenever moving the client. manually roll the client to the side of the bed. provide the client with an overhead trapeze. teach the client to pull up with the headboard.

provide the client with an overhead trapeze

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube? Radiographic confirmation of position Confirmation that pH of the aspirate is less than 5.5 Green fluid with particles aspirated Off-white fluid aspirated

radiographic confirmation of position

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client? increases the volume of the stool, making defecation easier removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit softens and facilitates the removal of intestinal polyps

removes hardened fecal impactions from the rectum

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus? "I can't transmit the virus other people if I shake their hands." "I probably got the virus when I sat on the toilet seat in a dirty bathroom." "I received a blood transfusion in 1989, which could be a factor in contracting the disease." "I may have gotten the virus when I got a tattoo while I was in prison."

"I probably got the virus when I sat on the toilet seat in a dirty bathroom."

A client with a localized inflammatory response asks the nurse why the area is reddened. Which response by the nurse would be most appropriate? "It's due to the fluid accumulating in the area." "It is the result of blood accumulating in the dilated vessels." "There is pressure on, and injury to, the local nerves." "There is bleeding into the interstitial space in the area."

"It is the result of blood accumulating in the dilated vessels."

Which symptom is a known side effect of antibiotics? Diarrhea Constipation Fecal impaction Abdominal bloating

Diarrhea

The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order.

Inspection Auscultation Percussion Palpation

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? Fungi Rickettsiae Protozoans Helminths

fungi

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid? Potassium Sodium Magnesium Iodine

iodine

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be: green. yellow. beige. brown.

yellow

The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team? "You should remove your mask before you remove your gown." "Avoid touching the outside of your gown when removing it." "Whenever possible, remove your PPE outside the client's room." "it's best to let me assist you with removal of your gown."

Avoid touching the outside of your gown when removing it

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? Client receiving chemotherapy Client with a history of eczema Client on a short course of vancomycin Client in the ICU for one day

Client receiving chemotherapy

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply. Communication ability Community population Developmental level Mobility Type of health care facility

Communication ability, developmental level, mobility

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next? Perform hand hygiene Don a new pair of gloves to dispose of materials Wrap all used materials together and discard in biohazard container Use an appropriate lotion that does not interfere with antimicrobial effect of gloves or soaps

Perform hand hygiene

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? The nurse should notify the primary care physician about the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises. The nurse should request permission from the client to photograph the bruises.

The nurse should question the client about the source of the bruises

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 shower with assist bag bath tub bath

Traditional bed bath with linen change

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from: viral infection. bacterial infection. chickenpox. hepatitis.

bacterial infection

Otitis media occurs in children because the: eustachian tube is long and twisted. eustachian tube has a downward turn. eustachian tube is shorter and straighter. eustachian tube is widened.

eustachian tube is shorter and straighter.

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? remove the garments that are most contaminated make contact between two contaminated surfaces make contact between two clean surfaces handwashing before leaving the client's room

handwashing before leaving the client's room

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? permits selection of antibiotic concentration helps in reducing proliferation of multidrug-resistant organisms narrows the therapeutic range to avoid prolonged use helps to determine prescribed antibiotic therapy

helps to determine prescribed antibiotic therapy

Which level of health care provider may make the decision to apply physical restraints to a client? nurse practitioner LPN team leader RN nurse manager senior personal care assistant

nurse practitioner

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? contacting the primary care physician placing a small towel under the neck administering a muscle relaxer positioning the client on the stomach

placing a small towel under the neck

An older adult is admitted to the hospital with a fractured hip. The client suddenly develops acute onset of confusion and hallucinations. Which action should the nurse implement first? Leave to notify the health care provider concerning a change in client status Apply limb restraints to ensure client safety Promptly document the change in client status Reduce distressing environmental stimuli to maximize client safety

reduce distressing environmental stimuli to maximize client safety

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? a change in pulse from 80 to 84 after walking up 20 stairs shortness of breath after walking up five stairs joint stiffness after sitting for an hour walking with a slow and uncoordinated movement

shortness of breath after walking up five stairs

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next? File the safety event report in the appropriate file and document in the nurse's notes the date and time that it was filed. Make a copy of the safety event report for the client. Place the safety event report in the client's medical record for future reference. Submit the safety report to the appropriate department within the facility so that it can be reviewed.

submit the safety report to the appropriate department within the facility so that it can be reviewed

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins? Neutrophils Eosinophils T-lymphocytes Monocytes

t-lymphocytes

Which should be documented by the nurse? The fact that sterile technique was used for a given procedure The fact that the nurse donned gloves two different times during a procedure The fact that the nurse washed her hands before a procedure The specific items that the nurse transferred into a sterile field

the fact that sterile technique was used for a given procedure

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 the importance of teaching their children adequate personal hygiene habits the fact that the health problem is self-limiting the need to destroy all clothing and bedding that the child has used

the importance of completely finishing the prescribed treatment

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? transfer belt transfer boards mechanical lift roller sheet

transfer belt

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: Between 37.1°C and 38.2°C Above 38.2°C Greater than 40.5°C Between 35°C and 36.8°C

Greater than 40.5 C

The nurse educator is reminding a group of new nurses about precautions. Which statement by a new nurse requires further teaching by the nurse educator? "I will always wash my hands thoroughly and often." "It is important to refrain from recapping needles." "Masks, gloves, and gowns should be used to protect from infectious agents." "Wearing an N95 respirator is critical when I care for clients in droplet precautions."

"Wearing an N95 respirator is critical when I care for clients in droplet precautions."

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation? "Do not touch this, or I will have to start over. " "Everything is ready, I will leave the tray here for the provider." "I have set up this sterile field for your procedure, so please do not touch anything around the tray." "It is alright if you want to look at the supplies. Just be careful not to touch them."

"I have set up this sterile field for your procedure, so please do not touch anything around the tray."

The nurse is caring for four clients. For which client is a sitz bath most appropriate? 42-year old recovering from a C-section delivery 51-year old with hemorrhoids 60-year old who is 1-day postop from a knee replacement 73-year old with pneumonia who can get up to bedside commode

51-year old with hemorrhoids

A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure? Assist the client to a 30- to 45-degree position, unless this is contraindicated. Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. If Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. If unable to irrigate the tube, remove it and obtain an order for replacement.

Assist the client to a 30- to 45-degree position, unless this is contraindicated.

While the nurse is conducting morning rounds, the nurse notices that the client's temperature has gradually increased for the past 3 days. Which assessment(s) should the nurse do next? Select all that apply. Auscultate lung sounds. Check site of wound. Check IV site for infiltration. Review how compliant the client has been with ambulation. Call the laboratory for blood culture test.

Auscultate lung sounds. Check site of wound. Check IV site for infiltration. Review how compliant the client has been with ambulation.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide? Open doors and windows. Wait inside until emergency personnel arrive. Allow emergency personnel to apply oxygen. Recommend that carbon monoxide detectors be installed in the home.

Open doors and windows

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Warm the solution for 40 seconds in a microwave to prevent chilling the client. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer analgesia 30 minutes before the procedure. Administer the solution gradually over 5 to 10 minutes.

administer the solution gradually over 5-10 minutes

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety? transferring the client from one location in the hospital to another electronically reporting the results of diagnostic testing to the client's primary care provider administering medications to the client admitting the client to the health care facility

administering medications to the client

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

an adolescents skin ordinarily has enlarged sebaceous glands and increased glandular secretions

The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's priority action? Assess the client for signs and symptoms of hypoglycemia. Obtain a sample from the opposite hand for comparison. Promptly inform the primary care provider. Obtain a full set of vital signs.

assess the client for signs and symptoms of hypoglycemia

A 6-year-old is being cared for on an inpatient unit for treatment of intestinal malabsorption syndrome. What assessment by the nurse would indicate that the child may have calcium deficiency? Select all that apply. Bowed legs Enlarged skull Pale mucous membranes Hypertension Constipation

bowed legs enlarged skull hypertension

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection? changing the soiled dressing wearing clean unsterile gloves when changing the dressing isolating the client's belongings applying a face mask with shield

changing the soiled dressing

The poison control nurse receives a call from the caregiver of a young school-age child who may have ingested a poisonous substance. Which is the priority response by the nurse? "Check breathing and heart rate." "What do you think that the child might have ingested?" "At what time did the child ingest the substance?" "Induce vomiting while you wait for emergency personnel to arrive."

check breathing and heart rate

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess? clear mucus productive cough dyspnea abnormal breath sounds

clear mucus

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify: increased humoral immunity response. decreased cellular immunity. increased effectiveness of phagocytosis. decreased susceptibility to infection.

decreased cellular immunity.

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin? airborne droplet contact none

droplet

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? airborne droplet contact none

droplet

A client with dysphagia prepares to eat dinner. How does the nurse best help this client? Ensure the head of the bed is high-Fowler. Prepare the foods on the client's tray. Converse with the client during the meal. Play the client's favorite music or video.

ensure the head of the bed is in high fowlers

Which of the following is a fat-soluble vitamin? vitamin C vitamin B12 vitamin E vitamin B6

vitamin E

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure? "It is okay to turn the drape on the other side." "I use my whole hand to touch the non-waterproof surface before placing the sterile equipment on it." "The way you are doing it helps to minimize contamination of the non-waterproof side." "Using either side of the drape is okay, as long as you do not contaminate the sterile supplies on the field."

"The way you are doing it helps to minimize contamination of the non-waterproof side."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? "This antibiotic is the best choice since the causative organism is not known." "This antibiotic causes fewer side effects than a narrow spectrum antibiotic." "Drug resistance can develop when the wrong antibiotic is used for pneumonia." "Pneumonia is usually caused by multiple organisms."

"This antibiotic is the best choice since the causative organism is not known."

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

5, 7, 2, 1, 3, 4, 6

A nurse is preparing to obtain blood cultures from a client with an infection. Which action would be important for the nurse to do? Select all that apply. Vigorously cleanse the specimen port on the client's current intravascular line. Allow the tops of the culture bottles to dry after cleaning. Change the needle on the syringe containing the specimen before inoculating the culture bottles. Use two different venipuncture sites for the specimen collection. Obtain the specimen immediately after the client's temperature goes down.

Allow the tops of the culture bottles to dry after cleaning. Change the needle on the syringe containing the specimen before inoculating the culture bottles. Use two different venipuncture sites for the specimen collection.

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that: without an elevated temperature, infection is not present. the client's symptoms are typical of an older adult client. an older adult can have an infection without a fever. an infection was present and has dissipated.

An adult can have an infection without a fever

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention? Place the client in a protective supine position to facilitate easy removal. Before removing the tube, discontinue suction and separate the tube from suction. Attach a syringe and flush with 50 mL of water or normal saline before removal. Quickly and carefully remove tube while the client breathes out.

Before removing the tube, discontinue suction and separate the tube from suction

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume? chicken egg yolks brown rice chocolate

Brown Rice

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing sending a VRE-positive client to the radiology department for a chest X-ray without a face mask delivering a meal tray to a VRE-positive client without first donning gloves and a gown

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact. removing the staples from a VRE-positive, postoperative client's incision without prior handwashing sending a VRE-positive client to the radiology department for a chest X-ray without a face mask delivering a meal tray to a VRE-positive client without first donning gloves and a gown

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

A nurse is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure? Position the client supine, as dictated by client comfort and condition. Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client not to bear down while extracting feces in order to prevent vagal response.

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as: iatrogenic. endogenous. exogenous. antibiotic resistant. An infection is referred to as iatrogenic when it results from a treatment or diagnostic procedure. There is not enough information to determine if the infection was exogenous (causative organism is acquired from other people) or endogenous (causative organism comes from microbial life harbored in the person). An antibiotic-resistant organism is an organism against which most common antibiotics are ineffective.

Iatrogenic

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized? identifying systemic factors on the unit that may have contributed to the event reinforcing the standards for nursing care to staff members who were involved ensuring that the client's nurse is held accountable and educated about best practice communicating the potential consequences of the near miss to the client involved

Identifying systemic factors on the unit that may have contributed to the event

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective? Incentivizing health care workers to utilize hand hygiene Revising the facility's infection control protocols Encouraging visitors to adhere to isolation precautions Limiting visitors to family members over the age of 18

Incentivizing health care workers to utilize hand hygiene

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.

Incubation period prodromal stage full stage of illness convalescent period

A nurse is volunteering in a free community health clinic. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints? Select all that apply. Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall. Children over 30 lb (13.5 kg) only need a lap and shoulder belt. Infants should remain in the infant seat until the age of 2 years. A child may sit in the front seat when 8 years old

Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4 ft 9 in (145 cm) tall.

The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply. Instruct the UAP to leave the linens on the floor for now and suggest a meeting to discuss the actions being performed Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back Assist the UAP to pick up the linens and place them in the linen basket Avoid confronting the UAP until there is a more appropriate time

Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Investigate the possibility of discontinuing his or her catheter. Limit the resident's fluid intake in order to reduce his or her urge to void. Collaborate with the resident's health care provider to have his or her diuretics discontinued. Increase the resident's physical activity to reduce evening restlessness.

Investigate the possibility of discontinuing his or her catheter.

During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent? New foods should be introduced one at a time for a period of 2 to 3 days. It is too early to add solid foods to the infant's diet. A new solid food should be introduced daily to the infant's diet for a week. Adding solid foods is fine at this age, but avoid iron-fortified foods.

New foods should be introduced one at a time for a period of 2 to 3 days.

A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose? normal mildly elevated severely elevated low

Normal Normal blood glucose is 80 to 110 mg/dL (4 to 7 mmol/L).

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? Pour the liquid onto gauze on the sterile field until the gauze is moist. Pour the liquid into the cap of the bottle and dip the gauze as needed. Pour the liquid into a sterile container within the sterile field. Pour the liquid into the palm of a sterile gloved hand for use.

Pour the liquid into a sterile container within the sterile field.

What interventions to keep the mouth and throat free of accumulating secretions should the nurse perform when caring for this client? Select all that apply. Provide frequent mouth care. Apply mineral oil to the lips. Arrange for suctioning to remove mucus. Change the client's position every 2 hours. Assist the client to a lateral position.

Provide frequent mouth care. Arrange for suctioning to remove mucus. Assist the client to a lateral position.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the: AI level UL level EAR level RDA level

RDA Level

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? Clostridium difficile and diabetic ketoacidosis Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Tuberculosis and pneumonia Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

The nurse notices a student preparing to enter the room of a client with tuberculosis wearing gloves and a gown. What is the appropriate nursing action? Offer the student a mask Remind the student to remove PPE before leaving the room Ask the student to perform thorough hand hygiene after providing care Remind the student that a fitted N95 respirator is required

Remind the student that a fitted N95 respirator is required

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply. Remove extension cords from open spaces. Check the batteries in all smoke detectors. Store prescription medications on the counter. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

Remove extension cords from open spaces. Check the batteries in all smoke detectors. Ensure appropriate lighting in hallways and entrances to the home. Remove throw rugs from high traffic areas.

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? The new nurse touches 1.5 in (4 cm) from the outer edges. The sterile field is set up at waist level. Direct visualization of the sterile field is maintained. The top flap of the package is opened away from the new nurse's body.

The new nurse touches 1.5 in (4 cm) from the outer edges.

The nurse is caring for several clients assigned single rooms on a medical-surgical unit. In which client(s) can the nurse safely carry out hand hygiene using hand sanitizer instead of washing hands with soap and water? Select all that apply. The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room. The nurse is exiting a room after completed indwelling urinary catheter care. The nurse has assisted a client with changing and caring for a new colostomy.

The nurse is going from one room to another to introduce themself at the start of the shift. The nurse has entered the client's room to adjust settings on the intravenous pump. The nurse has just completed documentation and is entering another client's room.

Which are recommended guidelines for daily care of a client who has an indwelling urinary catheter? Select all that apply. Perform care of the indwelling urinary catheter before perineal care. Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. Put on sterile gloves before cleaning the catheter. Clean 6 to 8 in of the catheter, moving from the meatus downward. Slightly pull on the catheter during the cleaning motion to dislodge crusts. Inspect the meatus for drainage and note the characteristics of the urine.

Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. Clean 6 to 8 in of the catheter, moving from the meatus downward. Inspect the meatus for drainage and note the characteristics of the urine.

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

Using a tool to remove a contact lens that has adhered to the resident's eye

Which vitamin is found only in animal foods? vitamin C vitamin B12 vitamin A vitamin D

Vitamin B 12

A nurse is changing the dressings of a client in the burn unit. Which action(s) should the nurse perform to maintain asepsis and client comfort? Select all that apply. Wash hands thoroughly and then don sterile gloves. Utilize isolation precautions including donning gloves, gowns, and face mask. Ensure family visitors know they cannot bring flowers or fresh fruit to the client. Keep nails short with no polish. Practice good personal hygiene including showering before each shift.

Wash hands thoroughly and then don sterile gloves. Utilize isolation precautions including donning gloves, gowns, and face mask. Ensure family visitors know they cannot bring flowers or fresh fruit to the client. Keep nails short with no polish. Practice good personal hygiene including showering before each shift.

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client? Place the client in a private room that has monitored negative air pressure. Keep visitors 3 feet (1 m) from the client. Use respiratory protection when entering the room. Wear gloves whenever entering the client's room.

Wear gloves whenever entering the clients room

A nurse is caring for a child who is hospitalized for diphtheria. Which guideline would be appropriate when caring for this client? Use a private room with the door closed at all times. Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client. Place client in a private room that has monitored negative air pressure. Ensure that hard surfaces in the room are disinfected at least once per day.

Wear personal protective equipment (PPE) when entering the room for all interactions that may involve contact with the client.

The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR? an older adult client a client who has a fever a client who is fasting a client who is asleep

a client who has a fever

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of: ataxia. tremors. chorea. athetosis.

ataxia

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information? Measure abdominal girth. Ask when the client last had a bowel movement. Observe the abdominal dressing. Auscultate for bowel sounds.

auscultate for bowel sounds

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes? A bony bump on the joint at the base of the big toe Breaks in skin integrity and fungal nail infection Cold feet Redness and swelling in the joint of the big toe with reports of pain

breaks in skin integrity and fungal nail infection

A client undergoing chemotherapy who has had a stroke will need a hospital bed at home. Which essential information does the nurse teach the family to maintain a safe client care environment? Select all that apply. Check that the bed wheels are locked. Keep the bed at the highest position. Keep the foot of the bed elevated at 30 degrees. Keep bed side rails up when your family member is in the bed. Keep the head of the bed always at 45 degrees angle

check that the bed wheels are locked keep bed side rails up when your family member is in bed

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts? exit route vehicle of transmission infectious microorganism susceptible host

exit route

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? Mummy restraint Elbow restraint Waist restraint Extremity restraint

extremity restraint

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: complete an incident report to determine who was primarily responsible for the event. document strategies in the client's health record for preventing future incidents. fill out an incident report, with the goal of preventing a similar event in the future. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents.

fill out an incident report, with the goal of preventing a similar event in the future

When discontinuing use of a gown in the care of a client in droplet precautions, which method does the nurse use to dispose of this personal protective equipment (PPE)? fold soiled side to the inside and roll with inner surface exposed fold soiled side to the outside and roll with outer surface exposed fold soiled side to the inside and roll with outer surface exposed fold soiled side to the outside and roll with inner surface exposed

fold soiled side to the inside and roll with inner surface exposed

A nurse is reviewing laboratory test results and finds that a client's neutrophil levels are elevated. The nurse understands that these cells are important for: antigen-antibody response. synthesis of immunoglobulins. generation of a fever response. disposal of cellular debris.

generation of a fever response

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? hand washing sterile technique putting on gloves signs of healing

hand washing

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? remove the garments that are most contaminated make contact between two contaminated surfaces make contact between two clean surfaces handwashing before leaving the client's room

hand washing before leaving the client's room

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply. decreased pulse rate increased respiratory rate absence of pain lymph node enlargement fever

increased respiratory rate lymph node enlargement fever

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next? Inform the physician about this finding. Encourage the client to brush his teeth 3 times a day. Assess for the expiration dates of the antibiotics being administered. Inform the client that the antibiotics will resolve this problem.

inform the physician about this finding

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Contact the physician for a restraint order. Administer the client's sedative as ordered. Put up all four side rails on the bed. Initiate use of a bed alarm.

initiate use of bed alarm

The circulating nurse is observing a surgical technician donning a surgical gown. Which action by the technician indicates that the nurse should intervene to maintain sterile donning technique? picking up the gown at the sterile neckline holding the gown away from the body and other unsterile objects unfolding the gown while avoiding contact with the floor inserting an arm within each sleeve while touching the outer surface of the gown

inserting an arm within each sleeve while touching the outer surface of the gown

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? signs and symptoms of infection intravenous antibiotic administration hand hygiene measures vital sign monitoring

intravenous antibiotic administration

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? should have an orthopedic consultation. is demonstrating a common gait for the older adult. requires a better walking shoe. requires crutches for mobility.

is demonstrating a common gait for older adult

A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise? isometric isokinetic isotonic range-of-motion

isotonic

A new mother has brought her infant into the pediatric clinic. The infant has a red rash on the buttocks. What should the nurse instruct the mother? Leave the baby's buttocks open to air for 2 hours each day. Apply gentian violet to the buttocks with every diaper change. Change diaper as soon as it is soiled and apply cornstarch. Keep the diaper and buttocks clean and dry and apply zinc oxide.

keep the diaper and buttocks clean and dry and apply zinc oxide

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of: mass trauma terrorism. chemical terrorism. bioterrorism. nuclear terrorism.

mass trauma terrorism

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include? Supervise your child on the changing table. Place all household cleaners out of reach. Buy protective sporting equipment. Peer pressure causes children of this age to take risks.

peer pressure causes children of this age to take risks

The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection? perform meticulous hand hygiene only accept clients who are not immune compromised and perform meticulous hand hygiene perform meticulous hand hygiene and don a new mask with each client encounter wear a mask and don gloves with each client encounter until symptoms are completely gone.

perform meticulous hand hygiene and don a new mask with each client encounter

The nurse is preparing a client in airborne precautions for severe acute respiratory syndrome (SARS) to be transported to radiology. Which intervention will the nurse select to transport the client? Select all that apply. place a mask on the client refuse to transport the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

place a mask on the client cover the client with a sheet during transport communicate about precautions with the health care team prepare the transport stretcher with a clean sheet

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? instruct the client to place arms on the side rails place a small pillow under each arm elevate the head of the bed place a trochanter roll under the arms

place a small pillow under each arm

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor installing hardwood floors

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? Rescue anyone who is in immediate danger. Evacuate clients and staff. Activate the fire alarm on the unit. Attempt to extinguish the fire.

rescue anyone who is in immediate danger

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding? primary constipation secondary constipation iatrogenic constipation pseudoconstipation

secondary constipation

A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask? "Do you want to bathe regularly?" "What are your expectations about bathing at this time?" "Are you not able to bathe yourself?" "What kind of soap do you like to use?"

what are your expectations about bathing at this time

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation? After completing a wound dressing Before direct contact with clients After direct contact with clients When hands are visibly soiled

when hands are visibly soiled

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

when inserting an endotracheal tube