Activity and exercise, and hygiene
The nurse is helping a client who was recently diagnosed with type 2 diabetes mellitus with foot care. Which interventions should the nurse implement during foot care? Select all that apply.
1) Assess for skin changes that indicate complications.; 2) Teach the client about the importance of daily diabetic foot care.
After providing foot care for a client, the nurse is providing follow-up teaching. Which statement by the client indicates a need for further teaching? Click on the Question Video button.
"I should wear snug-fitting hosiery every day to make sure my feet get adequate circulation."
The home care nurse has been caring for an older client diagnosed with chronic pruritus. The nurse determines that the client has followed through with the suggested measures to promote skin hydration when they make which statement?
"I've stopped taking a daily shower or tub bath."
The nurse is listening to a lecture on preventing client injury from the use of crutches. Which statement by the nurse indicates that the teaching has been effective?
"Incorrect crutch measurements could damage the brachial plexus".
The nurse provides information about the care of crutches to a client with a leg cast. The nurse determines that the instructions were understood when the client makes which statement?
"It is important to keep spare crutch tips available."
The nurse observes clients to evaluate for the correct height of crutches. The nurse should determine that which client is correctly fitted with crutches?
Two to three fingers fit between the client's axillae and the top of the crutches.
A client who has experienced a stroke has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is not sufficient to provide support. The nurse determines that the client could benefit from the greater support, stability, and safety provided by which devices? Select all that apply.
Walker; Tripod cane; Quadripod cane
A client who sustained a fractured leg has learned how to use crutches. The nurse should determine that the client has a need for further teaching if the client makes which statement about using crutches?
"I will keep the set of crutches my son used as a spare pair."
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly?
The mother begins to wash the newborn infant by starting with the eyes and face.
The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding assigned clients' hygiene needs. In what priority order should the UAP assist the clients? Arrange the clients in the order that they should be cared for. All options must be used.
1) A 75-year-old confused client who is incontinent of feces and urine.; 2) A 35-year-old client who is on bed rest after multiple trauma.; 3) A 72-year-old client who was admitted for diagnosed dehydration and failure to thrive.; 4) A 42-year-old client who is independent with activities of daily living (ADLs)
A client has a newly fractured fibula that was plaster casted in the emergency department. Because the client will need to use crutches, which crutch-walking gait should the nurse teach the client before discharge?
Three-point gait
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?
Limit the intake of milk and milk products.
The nurse is giving a bed bath to a client who is on bed rest. In order to increase venous return from the extremities, which action should the nurse implement to bathe the client's extremities?
Long, firm strokes from distal to proximal areas
The nurse has given a postoperative thoracotomy client discharge instructions about how to perform arm and shoulder exercises. The nurse determines that the client needs further instructions about effective techniques when the client identifies which movement as relevant?
Making circles with the wrist
The nurse is providing instructions to a client regarding the use of crutches on stairs. What should the nurse tell the client when instructing the client to go up the stairs?
Move the unaffected leg up first, followed by the affected leg and crutches.
The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and determine the client needs further teaching if the client is observed taking which action?
Moving the cane when the right leg is moved
A client with rheumatoid arthritis demonstrating right-sided weakness is being instructed in the safe use of a cane. Which position should the nurse teach the client to use when holding the cane?
In the left hand
The nurse is preparing a discharge plan for a client who has undergone total knee replacement and is being admitted to an intensive 3-week rehabilitation program. Which type of services/settings would most meet the client's needs? Select all that apply.
1) Skilled nursing facility; 2) Freestanding rehabilitation center.; 3) Rehabilitation unit within the hospital
The nurse observes a mother providing care to a hospitalized infant who has diarrhea. Which observation should require the nurse's immediate intervention and indicates a need for further teaching to the mother regarding skin integrity?
The mother uses a damp washcloth to clean the buttocks after a stool.
Upon transfer from the post-anesthesia care unit (PACU) after spinal fusion, which technique should the nurse use to transfer the client from the stretcher to the bed?
A transfer board and the assistance of four people
A client has been taught to use a walker to aid with mobility after the internal repair of a hip fracture. The nurse determines the need for further teaching when the client is observed taking which action when walking?
Advancing the walker with reciprocal motion
A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem?
Alternating pressure mattress
The nurse assists a postoperative client from a lying to a sitting position to prepare for ambulation. Which nursing action is most appropriate initially to maintain the safety of the client?
Assess the client for signs of dizziness and hypotension.
The nurse prepares to transfer a client who has residual right-sided weakness as a result of a stroke from the bed to the wheelchair. With the client dangling on the side of the bed, which location should the nurse best position the wheelchair in for safety?
At a right angle to the client's left leg
The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?
Balance, muscle strength, and confidence
An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking?
Forearm muscle weakness
An unlicensed assistive personnel (UAP) is providing a bed bath to an assigned client. Which actions, if observed by the registered nurse (RN), indicate the need to intervene and the need for further teaching?
Completing all bathing activities as quickly as possible
A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention should the home care nurse's plan include when planning for the client's care?
Considers the use of active, passive, or active-assisted exercises in the home
A client with a right leg fracture is prescribed a non-weight-bearing status. Which finding indicates that the client demonstrates compliance with this restriction?
Does not bear weight on the right leg
To promote self-care, the nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item is most helpful for this client for achievement of this goal?
Overhead trapeze
The nurse is teaching a client how to stand on crutches. What information should the nurse give the client related to placement of the crutches?
Place the crutches 6 inches to the front and side of the toes.
The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?
Position the residual limb flat on the bed.
After being on bed rest in a private room for 1 week, the client begins to exhibit periods of confusion. To best comply with the primary health care provider's prescription to start progressive ambulation as tolerated, the nurse should implement which intervention?
Progressive ambulation in the hall 3 times a day
A client is at risk for infection after a radical vulvectomy. Which intervention should the nurse implement when giving perineal care to this client?
Provide a sitz bath.
A client demonstrating left-sided weakness has been taught how to use a cane. The nurse recognizes that the instruction was effective when the client holds the cane in which manner?
Right hand and 6 inches lateral to the right foot
A home care nurse assesses an older client's functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse's assessment?
Self-care activities
The nurse is observing a client with gout who is crutch walking after a period of bed rest. The nurse should immediately stop the activity if the client exhibits which sign/symptom?
Shortness of breath and diaphoresis
Which instructions should the nurse provide to the client being taught how to perform a three-point gait?
Simultaneously move both crutches and the affected leg forward; then move the unaffected leg forward.
The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply.
Stop movement of the affected part.; Place continuous gentle pressure on the muscle group until it relaxes.
The nurse teaches a client to move from a standing position to sitting in a chair using the crutches. Which observation tells the nurse that the client is performing the procedure correctly?
The client supports her or his body weight on the unaffected leg and crutches.
The nurse is measuring a client to determine the correct height of crutches. Which measurement tells the nurse that the crutches fit correctly?
The crutches are 3 finger widths from the axilla and extend to a point 6 inches lateral to the heel.
The nurse is assessing a client with a lower leg cast who has just been measured and fitted for crutches. Which observation should help the nurse determine if the client's crutches are fitted correctly?
The elbow is at a 30-degree angle when the hand is on the handgrip.
The nurse prepares to place a client in a sitting position in a chair. Which body alignment guidelines should the nurse implement? Select all that apply.
The head is erect.; The thighs are parallel and in a horizontal plane.; The client's arms are supported on the armrest or in the lap.
The nurse is preparing to shampoo the hair of a client who is bed bound as a result of multiple trauma. What is the priority order of nursing actions? Arrange the actions in the order that they should be performed. All options must be used.
1) Perform hand hygiene and apply gloves.; 2) Place a waterproof pad under the shoulders.; 3) Brush and comb the hair.; 4) Shampoo the hair.; 5) Rinse hair with water.
The nurse is preparing to provide oral care to the client who has full upper and lower dentures. Which interventions should the nurse implement during care of the dentures? Select all that apply.
1.Hold the dentures close to water. 2.Fill the emesis basin with tepid water. 3.Put the dentures in a secure place to prevent loss.
The nurse is helping a client who is undergoing chemotherapy with oral hygiene. The nurse should implement which actions during oral care? Select all that apply.
2.Assess oral mucous membranes. 3.Assess for missing teeth and cavities. 4.Observe the client during mouth care.
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
A bed trapeze
A stable client with left-sided weakness will begin ambulating with a cane. To promote client safety, where should the nurse plan to be positioned in relation to the client?
Slightly behind the client's left side and have the client move the cane forward about 1 foot followed by the left leg, and then move the right leg forward ahead of the cane and the left leg
The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?
"Crutch walking instructions should be scheduled before surgery."
The nurse educator is teaching a group of new orthopedic nurses how to use crutches to navigate stairs. Which statement by one of the new nurses indicates that teaching has been effective?
"The client should first place the crutches on the stair, then transfer body weight to the crutches, and move the affected leg forward."
