Advanced Skills Unit 2

A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I am going to try to lose about 50 pounds."

A nurse is reinforcing teaching for with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

"I watch television until I fall asleep at night."

A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will avoid drinking large amounts of fluids immediately before bedtime."

During a routine well-child visit, a nurse is reinforcing teaching with the parents of a preschool-age child whom they have difficulty getting to sleep. Which of the following statements by the parents indicates an understanding of the teaching?

"I will encourage my child to fall asleep with his favorite toy."

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

"It sounds like you're having a difficult time."

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements by the client indicates the need for further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A nurse is collecting data from a client who reports using long-term oral comfrey to promote wound healing. The nurse should realize that which of the following laboratory tests is appropriate to determine an adverse effect of oral comfrey?

Liver function tests

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply?

-Consider the client's individual expression of pain. -Use a scale from 0 to 10 to monitor the severity of the client's pain.

A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hyrdroxine preoperatively. Which of the following effects of this medication should the nurse include in the teaching?

-Decreasing anxiety -Controlling emesis -Reducing the amount of narcotics needed for pain relief

A nurse is preparing to exit the room of a client who has a draining wound that contains methicillin-resistant Staphylococcus aureus (MRSA) and requires contact precautions. Identify the sequence the nurse should follow to remove personal protective equipment (PPE) after caring for this client.

-Gloves -Eyewear -Gown -Mask

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Reposition the client at least every 2 hr.

A nurse at an outpatient surgery center is reinforcing discharge teaching with a client's partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching?

The client should wear dark glasses while outdoors.

While collecting data from an older adult client, the nurse learns that the client has had difficulty sleeping at night for several months. When evaluating the client's sleep disturbances, the nurse should factor in which of the following principles that can affect older adults and sleep?

Chronic pain and illness interfere with the sleep patterns of older adults.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following items should the nurse wear?

Clean gloves

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.

A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

Cleanse with 0.9% sodium chloride irrigation.

A nurse is caring for a client who has a wound infection that contains vancomycin-resistance Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

Contact

A nurse is caring for a client who is 6 days postoperative from abdominal surgery. The nurse observes that the client's wound is in evisceration. After calling for help, which of the following actions should the nurse take next?

Cover the area with a sterile dressing, moistened with saline.

A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Cover the area with saline-soaked sterile dressings.

A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?

Cover the wound with a moist sterile dressing.

A nurse is reinforcing teaching with a client who has frequent urinary tract infections (UTIs). The nurse should identify that the client can use which of the following herbal supplements to help prevent UTIs?

Cranberry juice

A nurse in a long-term facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement?

Get the client ready for sleep at the same time each night.

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement clients might use to help boost their memory?

Ginkgo biloba

A nurse is reinforcing teaching with a client who has peripheral arterial disease and reports pain when walking. The nurse should indentify that the client can use which of the following herbal supplements to increase pain-free walking distance?

Ginkgo biloba

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

Granulation tissue

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of a wound?

Granulation tissue on the surface of the wound

A nurse is reinforcing teaching with a client about diets that help with wound healing. Which of the following foods should the nurse indicate contains the best source of protein?

Grilled salmon

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC count (white blood cells)

A nurse is caring for a client who wants information about a complimenatry or alternative healing modality to help reduce her stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?

Yoga

A nurse is assisting with speaking in front of a group of nurses about new guidelines to prevent pressure ulcers. Which of the following actions by the nurse demonstrates confidence?

The nurse stands tall before talking.

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?

The wound has a halo of erythema on the surrounding skin.

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

There is full-thickness skin loss with a crater.

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

Vitamin C

A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infections?

-An increase in neutrophils -Localized edema

A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths?

"Let's play a game of blowing cotton balls across your table."

A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?

"My belly doesn't hurt anymore."

A nurse is preparing an education program about herbal supplements. Which of the following information should the nurse include when discussing St. John's Wort?

"St. John's Wort may improve symptoms of depression."

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

"You may feel some cramping during the procedure."

A nurse is caring for an older adult client who is scheduled for surgery. The client becomes upset when the nurse asks her to remove her dentures prior to the surgery. Which of the following is a therapeutic response by the nurse?

"You seem worried. Are you concerned someone may see you without your teeth?"

A nurse in an outpatient clinic is caring for a client who reports bilateral knee pain after a hike in the mountains this past weekend. He tells the nurse that he is worried because his cousin died from bone cancer recently. Which of the following responses should the nurse make?

"You seem worried. Let's talk about how you are feeling."

A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted to surgery. Which of the following instructions should the nurse include in the teaching?

"You should bring the infant's favorite blanket to the hospital."

A nurse is reinforcing preoperative teaching to a client who is undergoing total hip replacement surgery. Which of the following statements should the nurse include in the teaching?

"You will use a special soap to shower with the evening before your surgery."

A nurse is caring for a 3-year-old client whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse recommend including in the child's plan of care?

-Have a parent stay with the child during procedures. -Provide a distraction for the child. -Allow the child to keep a toy from home with her. -Limit the number of visitors in the room during procedures.

A nurse is caring for client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take?

-Offer the client a back rub -Remind the client to use incisional splinting. -Identify the client's pain level -Change the client's position

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care?

-Perform leg exercises every 2 hr. -Encourage hourly use of an incentive spirometer while awake. -Document the color, consistency, and amount of nasogastric drainage.

A nurse is caring for a client who has a surgical wound. Which of the following factors places the client at risk for dehiscence?

-Poor nutritional state -Obesity -Wound infection

A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow.

-Remove the wound dressing -Clean the skin along the sides of the incision -

A nurse is reviewing home medication of a male client who has a new prescription for warfarin. Which of the following of the client's herbal medications should the nurse identify as being contraindicated to warfarin?

-Saw palmetto -Glucosamine -Gingko biloba

A nurse is collecting data from a client who has narcolepsy. Which of the following manifestations should the nurse expect?

-Sudden attacks of sleep -Sleep-wake cycle hallucinations

A nurse is reinforcing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins should the nurse include in the teaching as promoting wound healing?

-Vitamin A -Vitamin C

A nurse is caring for a client who has a closed wound drainage system connected to a portable bulb suction device. Which of the following actions should the nurse take to care for her drain?

-Wipe the top of the drainage port with an alcohol swab after emptying -Squeeze the suction bulb while inserting the plug into the drainage port

A parent of a school-age child tells the nurse in the family practice clinic that she is concerned about the amount of sleep her son is getting. The nurse should explain that school-age children should get at least which of the following amounts of sleep each night?

11 hr

A parent of a preschooler tells the nurse in the pediatric clinic that he is concerned about the amount of sleep his daughter is getting. The nurse should explain that preschoolers should get an average of which of the following amounts of sleep each night?

12 hr

A parent of a toddler tells the nurse in the provider's office that she is concerned about the amount of sleep her daughter is getting. The nurse should explain that toddlers should get about which of the following amounts of sleep each night?

14 hr

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

A client who has swelling and tenderness around the wound

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

A deep crater without visible bone, tendon, or muscle

A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take first?

Empty the suction device every 4 hr.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10.

A nurse is explaining different types of complementary and alternative healing modalities to a client who has chronic pain. Which of the following healing modalities should the nurse describe as the use of needles to stimulate specific points on the body to relieve discomfort, promote health, and cure disease?

Acupunture

A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?

Administer an opoid analgesic to the client 30 min prior to initiating CPM exercises.

A nurse is admitting a client who reports recurrent flank pain and nausea for 24 hr. Which of the following actions should the nurse taken first?

Administer pain medication

A nurse is caring for a client who is 2 days postoperative from abdominal surgery. The client reports discomfort from abdominal distention and flatus. Which of the following suggestions should the nurse include?

Ambulate several times a day.

A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Apply an antibiotic ointment to the suture site.

A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first?

Apply pressure directly to the wound.

A nurse is caring for a client who has is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.

Aromatherapy

A nurse is caring for a client who is scheduled to undergo abdominal surgery and tells the nurse that he is very anxious about the operation. Which of the following actions should the nurse take?

Ask him to describe his concerns.

A nurse is assisting with the preparation of a presentation at a community center about alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?

Biofeedback

A nurse is collecting data from a client who has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings?

Dyspnea on exertion

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

Edema

A nurse is caring for a client who has unilateral leg edema associated with associated pain and a low-grade temperature. Which of the following action should the nurse take?

Elevate the affected leg.

A nurse collecting a medication history from a client who takes herbal supplements and is scheduled for a surgical procedure in 10 days. The nurse should inform the client that which of the following dietary supplements increases the risk of bleeding?

Feverfew

A nurse is reinforcing teaching with a client who reports having migraine headaches. The nurse should indentify that the client can use which of the following herbal supplements prophylactically to manage migraine headaches?

Feverfew

A nurse is reinforcing teaching with a client who reports constipation and wants to use an herbal supplement. The nurse should identify that the client can use which of the following herbal supplements to treat constipation?

Flaxseed

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions of the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Fully recollapse the reservoir after emptying it.

A nurse is reinforcing teaching with a client who has hypertension and asks if there is a herbal supplement he can use to help lower blood pressure. The nurse should identify that the client can use which of the following herbal supplement to help lower blood pressure?

Garlic

A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health-care associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

Identify the clients at greatest risk for development of pressure ulcers.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure? When completing an incident report about the pressure ulcer. Which of the following actions should the nurse take?

Include any revelant statements the client made about the incident.

A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse expects the wound on the client's leg has and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?

Laceration

A nurse is reinforcing teaching with a client who has trouble sleeping at night. Which of the following beverages should the nurse recommend the client to drink to avoid caffeine consumption?

Lemon-lime soda

A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?

Maintain the integrity of the sac.

A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

Make sure the client understands that he is leaving against medical advice.

A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?

Obtain consent from a relative of the client.

A nurse is caring for a client who has wound dishcence one week postoperative. Which of the following actions should the nurse take?

Place the client supine with the knees flexed.

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

Place the dressing in a biohazardous waste container.

A nurse is setting up sterile field to perform wound irrigation on client's leg. Which of the following actions should the nurse identify as contaminating the sterile field?

Places sterile supplies within the 2.5 cm (1 in) border of the sterile field

A nurse in the clinic is collecting data from a client who reports wrist pain caused by carpal tunnel syndrome. The nurse should expect which of the following findings?

Positive Phalen's sign

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?

Provide the client a diet high in Vitamin C.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Purulent

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opoid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

Reducing anxiety

A nurse on a medical-surgical unit is providing care for a client who is a hospital employee. Several nurses have called seeking information about the client. Which of the following actions should the nurse take in response to inquiries from the nurses?

Refer questions to the nursing supervisor.

A nurse is caring for an older adult client who has cancer and is receiving opiods for pain relief. The client has a new prescription for docusate PO daily. When collecting data from the client, which of the following therapeutic effects of docusate should the nurse expect?

Relief from constipation

An older adult client on an orthopedic unit has an intracapsular fracture of the right hip following a fall. The client is in Buck's traction and will have hip prosthesis surgery in the morning. The nurse should reinforce with the client that this type of traction promotes which of the following outcomes?

Relief from muscle spasms

A nurse is assisting with the preparation of an educational program about the use of oral contraceptives. The nurse should include that which of the following herbal supplements reduces the effectiveness of oral contraceptives?

St. John's wort

During an admission interview, a client tells the nurse that he takes echinacea, but does not remember why his provider recommended for him. The nurse should remind the client that this herbal supplement has which of the following actions?

Stimulates the immune system

A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?

Tell the client to remain in the bathroom after toileting and obtain a wheelchair.

A nurse is performing wound care for an older adult client who has a stage 1 pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Transparent

A nurse is assisting with the admission of a client who has an open wound that is infected from community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA). The client's wound has not responded to treatment with surgical drainage. The nurse should anticipate that the client will require which of the following interventions?

Trimethroprim/sulfamethoxazole

A nurse is collecting data regarding the pain level of a 3-year-old child on the second postoperative day following an appendectomy. Which of the following actions should the nurse take?

Use the FACES scale to assess the child's pain level.

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement clients might use to treat insomnia?

Valerian