Basic Care and Comfort

The nurse is reinforcing education for parents whose child is experiencing an episode of "midnight croup," or acute spasmodic laryngitis. What should the nurse be sure to include when reinforcing education? a. Give warm liquids. b. Raise the heat on the thermostat. c. Provide humidified air with cool mist. d. Take the child into the bathroom with a cold, running shower.

Provide humidified air with cool mist.

A nurse is caring for a 10-year-old child hospitalized for treatment of acute osteomyelitis. The child's left leg is immobilized in a splint. What is the nurse's most appropriate action? a. Support and handle the leg gently during turning and repositioning. b. Assist the client to bear weight on the affected limb. # contraindicated to prevent pathologic fractures c. Assist the client to ambulate with crutches. # restricted to bed rest d. Encourage the client to participate in age-appropriate activities # acutely ill child isn't likely to be interested in activities

Support and handle the leg gently during turning and repositioning.

The nurse is reinforcing the correct use of crutches to a client in the emergency. Which should the nurse include? a. The crutches should fit snugly under the axilla. b. The crutches should end 2 in (5 cm) below the axilla. c. The elbow should be flexed to 60 degrees. d. The elbow should be flexed to 90 degrees.

The crutches should end 2 in (5 cm) below the axilla. Explanation: The crutches should end 2 in (5 cm) below the axilla, and the elbow should be flexed 20 to 30 degrees.

The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of? a. A nursing diagnosis # is a statement about a client's actual or potential problem b. A client outcome c. Subjective data d. A nursing intervention #action

b. A client outcome # is a short- or long-term goal based on projected nursing interventions.

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? a. Administering digestive enzymes before meals as prescribed b. Providing small, frequent meals c. Administering antibiotics with meals as prescribed d. Providing high-fiber snacks

b. b. Providing small, frequent meals Providing small to decrease abdominal distention, cramps, and nausea + frequent meals # to restore nutritional balance

An older adult client who has recently been diagnosed with hypothyroidism lives independently in an apartment in a community development designed for older adults. The client asks the nurse assigned to the complex for advice about managing this condition. What is the best response by the nurse? a. "Stop taking your self-prescribed daily aspirin." b. "Stop attending group activities." c. "Keep the temperature in your apartment cooler than usual." d. "Increase fiber and fluids in your diet."

d. "Increase fiber and fluids in your diet." Explanation: Clients with hypothyroidism typically experience constipation.

A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program? a. Establishing a predetermined fluid intake pattern for the client # after assessing b. Encouraging the client to increase the time between voiding # after assessing c. Restricting fluid intake to reduce the need to void # 1.5 -2l/day d. Assessing present elimination patterns

d. Assessing present elimination patterns

The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client? a. number scale from one to ten b. face rating scale c. body diagram d. questionnaire

face rating scale

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should: a. talk with the client for a long time at night to reduce anxiety. b. encourage environmental stimulation during the evening. c. gently but firmly set limits on time spent in bed during the day. d. encourage the client to take an antianxiety agent as needed at bedtime.

gently but firmly set limits on time spent in bed during the day.

While examining a child with acute epiglottitis, the nurse should have which item available? a. cool mist tent b. intubation equipment c. tongue depressors # contraindicated, may cause the epiglottis to spasm d. viral culture medium

intubation equipment Explanation: Emergency intubation equipment should be at the bedside to secure the airway if examination precipitates further or complete obstruction occurs.

A nurse enters the room of a client who has recently been diagnosed with anorexia nervosa and finds the client engaging in strenuous exercise. Which nursing action is most important? a. Telling the client to stop exercising immediately b. Allowing the client to complete the exercise regimen c. Stopping the client and obtaining a weight d. Offering to go on a walk with the client

d. Offering to go on a walk with the client

A pregnant client tells the nurse that she doesn't like milk and can't possibly drink three to four glasses per day as recommended by her health care provider. What is the best response by the nurse? a. "I did not like milk either, but I drank it during pregnancy." b. "Are there any dairy products that you do like?" c. "It is important for the baby that you drink your milk." d. "Do not worry; you can just take calcium supplements."

"Are there any dairy products that you do like?"

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: a. "Does your child's ear hurt?" b. "Does your child have any hearing problems?" c. "Does your child tug at either ear?" d. "Does anyone in your family have hearing problems?"

"Does your child tug at either ear?" Explanation: questions about the child's behavior are most useful because a young child usually can't describe symptoms accurately.

The nursing instructor asks the nursing student why should an infant be quiet and seated upright when the nurse checks his or her fontanels. Which is the best response? a. "The mother will have less trouble holding a quiet, upright infant." b. "Lying down can cause the fontanels to recede, making assessment more difficult." c. "The infant can breathe more easily when sitting up." d. "Lying down and crying can cause the fontanels to bulge."

"Lying down and crying can cause the fontanels to bulge."

A parent brings her 3-month-old to the clinic for a well-baby examination. Which statement by the parent should concern the nurse? a. "She spits up a small amount after each feeding." b. "She drinks 6 oz of iron-fortified formula every 4 to 5 hours." c. "She's eating rice cereal and applesauce." d. "She loves to be cuddled during and after her feedings."

"She's eating rice cereal and applesauce."

An elderly client asks a nurse how to treat chronic constipation. What is the best recommendation the nurse can make? a. "Taking magnesium citrate when necessary will help." # lead to dependence b. "Take a stool softener, such as docusate sodium (Colace), daily." c. "Use a tap-water enema weekly to evacuate the rectum." lead to dependence & electrolyte imbalance d. "Administer a phospho-soda enema when necessary." # lead to dependence

"Take a stool softener, such as docusate sodium (Colace), daily."

A client reports abdominal pain. Which question asked by the nurse would provide the most information about the client's pain? a. "Is the pain radiating anywhere else?" b. "Does the pain come and go?" c. "Does resting make the pain better?" d. "What does the pain feel like?"

"What does the pain feel like?" # An open-ended question. other options are close ended questions # yes/no

A nurse is caring for a client with suspected acute pulmonary edema. What nursing intervention should the nurse perform to promote oxygenation? a. monitor oxygen saturation level and vital signs b. tell the client to take deep breaths and cough c. place the client in high Fowler position d. perform chest physiotherapy # expectoration of secretions

1st place the client in high Fowler position 2nd monitoring oxygen saturation levels and vital signs at least every 15 minutes until the client is stable. 3th Deep breathing and coughing

When collecting data on a client during a routine checkup, the nursing student reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. The student asks the nurse what is aphthous stomatitis? What is the nurse's best response? a. "Aphthous stomatitis is a canker sore of the oral soft tissues." b. "Aphthous stomatitis is an acute stomach infection." c. "Aphthous stomatitis is acid indigestion." d. "Aphthous stomatitis is an early sign of peptic ulcer disease."

Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks.

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse observes the client during feeding and is concerned most with which potential development? a Hyperglycemia b Fluid volume excess c Aspiration d Constipation

Aspiration

When caring for a client during the second stage of labor, which action would be most appropriate? a. Assisting the client with ambulation # first stage of labor b. Encouraging the client to void every 2 hours # first stage of labor c. Allowing the client clear liquids # ice chips d. Assisting the mother with pushing

Assisting the mother with pushing Explanation: Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? a. Putting slippers on the client's feet b. Crossing the client's ankles every 2 hours # contraindicated, cause excess pressure & damage veins # thrombus formation c. Placing hand rolls on the balls of each foot d. Attaching braces or splints to each foot and leg

Attaching braces or splints to each foot and leg prevents foot drop # a lower leg contracture by supporting the feet in proper alignment.

The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first? a. Sit with the client for a few minutes. b. Administer an analgesic. c. Inform the nurse-manager. d. Call the physician immediately.

Call the physician immediately. Explanation: The headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately.

Which nursing intervention has the highest priority in the care of an infant during the first 24 hours after surgery for cleft lip

Carefully clean the suture line after feedings using sterile technique.

An unconscious client is admitted to the emergency department. During rapid data collection, which pulse will the nurse palpate in this client? Radial Brachial Femoral Carotid

Carotid

The nurse is preparing for the discharge of a neonate with a cleft lip and palate. Which nursing instruction is of highest priority? a Cleanse face following feeding b Administer supplemental vitamins c Apply a dressing to the lip d Establish a feeding technique

Establish a feeding technique to promotes adequate nutrition while preventing aspiration # requires specific teaching and use of a special nipple.

Before a cancer client receiving total parenteral nutrition (TPN) resumes a normal diet, the nurse teaches him about dietary sources of minerals. Which foods are good sources of zinc? a. Fruits and yellow vegetables # vitamins and minerals b. Yeast # source of chromium and legumes # copper, manganese, and molybdenum. c. Fruits # vitamin C and green vegetables # vitamins and minerals d. Whole grains and meats

Good sources of zinc include whole grains, meats, dairy products, and seafood.

A client diagnosed with glossitis is prescribed a diet high in folic acid. When assisting with the development of a teaching plan for this client, which food products will the nurse reinforce to fulfill the need for increased folic acid? a. poultry # vitamin B b. strawberries # vitamin C c. spinach d. yogurt # vitamin B

Green, leafy vegetables, such as spinach, are high in folic acid.

A pregnant client's last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as: a. June 5. b. June 19. c. July 5. d. July 19.

July 19. EDD = subtract 3 months, adding 7 days e.g a. oct - 3 month = july b. 12 + 7 = 19 date

A client who suffered blunt chest trauma in a car accident reports chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position? a. Semi-Fowler's with head turned left b. Leaning forward while sitting c. Supine with arms at sides d. Prone with knee supports

Leaning forward while sitting Explanation: When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis.

A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs? a. Obtain the client's weight daily. b. Perform a calorie count. c. Measure intake and output. d. Obtain vital signs.

Measure intake and output.

When assisting to plan nursing care to maintain skin integrity for an adult female bed bound client, which interventions should the nurse include? SATA a. Apply a pleasantly scented dusting powder to the axillae and groin, beneath the breasts, and between the toes. # nonirritating dusting powder, such as cornstarch, b. Monitor the skin for breakdown daily during client's bath. c. Apply deodorant or antiperspirant immediately after shaving under the arms. NON d. Keep skin clean and dry to prevent breakdown. e. Always use alcohol for back rubs. # lotion f. Turn and reposition the client every two hours.

Monitor the skin for breakdown daily during client's bath. Keep skin clean and dry to prevent breakdown. Turn and reposition the client every two hours.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a. Administering an analgesic once per shift, as prescribed, to prevent drug addiction # analgesic PNR b. Positioning the client on the side with the knees flexed c. Encouraging frequent visits from family and friends d. Administering frequent oral feedings

Positioning the client on the side with the knees flexed # promotes comfort by decreasing pressure on the abdominal muscles.

A client requests something to treat his constipation. The client's medication administration record contains an order for a laxative to be administered every other day as needed. Which assessment finding by the licensed practical nurse indicates the need to notify the registered nurse RN before administering the laxative? a. Incontinence of liquid stool # SS constipation b. Complaints of abdominal fullness # SS constipation c. Presence of blood in the client's stool d. Abdominal distention # SS constipation

Presence of blood in the client's stool

A nurse is caring for a client in active labor who is crying and asking for something for pain. Her medical record shows that she does not tolerate prescribed opioid analgesics. Which of the following nonpharmacologic interventions might be helpful to this client? a. Turn on the lights in the room. b. Administer ibuprofen as ordered. c. Encourage the client to drink very cold tea. d. Provide back massage to the client.

Provide back massage to the client.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? SATA a. Reposition the client every 2 hours. b. Perform range-of-motion exercises. c. Use commercial soaps to keep the skin dry. d. Tuck bed covers tightly in the foot of the bed. e. Encourage the client to eat a well-balanced diet.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

The nurse is caring for a client with stomatitis. To make eating less painful, which foods should the nurse suggest? a. Hot foods b. Soft, bland foods c. Liquid foods d. Dry foods

Soft, bland foods # which are less irritating to sore mouth tissue

The nurse explains to a client with thyroid disease that the thyroid gland normally produces: a. iodine and thyroid-stimulating hormone TSH # pituitary gland to regulate the thyroid gland b. thyrotropin-releasing hormone TRH # hypothalamus gland to regulate the pituitary gland c. TSH, T3, and calcitonin. d. T3, T4, and calcitonin.

T3, T4, and calcitonin. # thyroid gland

A client is prescribed transcutaneous electrical nerve stimulation TENS for pain relief. Which finding indicates that the client is responding appropriately to TENS therapy? a. Muscle tension in the area of TENS application is not palpable. b. The nurse observes decreased joint stiffness and improved mobility. c. There is a reduction in tissue swelling in the affected area on inspection. d. The client reports an improvement in discomfort over the painful area.

The client reports an improvement in discomfort over the painful area Explanation: The rationale for using TENS for pain relief is to block painful stimuli traveling over small nerve fibers.

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which client statement indicates an accurate understanding of the nurse's instructions? a. "I'll decrease my intake of green, leafy vegetables." b. "I'll limit fluid intake to four 8-oz glasses." c. "I'll increase my intake of unrefined grains." d. "I'll take iron supplements regularly."

To increase peristalsis and relieve constipation, the client should increase intake of high-fiber foods such as unrefined grains, fruits, and green, leafy vegetables and fluids.

When assessing pain in a 5-year-old verbal child, which appropriate pain scale would the nurse use? a. Pain Intensity Scale # >7y b. Pain Distress Scale # >7y c. FLACC Pain Scale # <3y d. Wong-Baker Faces Pain Scale

Wong-Baker Faces Pain Scale # 3 t0 7y

A nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the diet? a. "I need to read food labels carefully to avoid gluten additives in foods." b. "My child needs a diet rich in all grains." c. "I should avoid feeding my child potatoes, rice, flour, and cornstarch." d. "My child can safely eat frozen and packaged foods."

a. "I need to read food labels carefully to avoid gluten additives in foods." celiac disease must eat a gluten-free diet. If foods containing gluten

Which intervention would the nurse recommend to a client having severe heartburn during pregnancy? a. Eat several small meals daily. b. Eat crackers on waking every morning. c. Drink a preparation of salt and vinegar. d. Drink orange juice frequently during the day.

a. Eat several small meals daily.

When observing a newly hired nurse change a wet-to-dry dressing, which action by the nurse would indicate to the nurse mentor that further teaching is needed? a. The nurse loosens the wet-to-dry dressing with normal saline. b. The nurse discards the drape that became wet when normal saline was poured. c. The nurse disposes of the used dressing in a red biohazard bag. d. The nurse keeps the hands between the waist and nipple level.

a. The nurse loosens the wet-to-dry dressing with normal saline.

The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to: a. provide total care because the toddler is too young to assist. b. place the toddler in a bathtub and check on him frequently. c. allow the toddler to bathe himself using a basin with water at the bedside. d. allow the toddler to bathe as much of himself as he can with supervision.

allow the toddler to bathe as much of himself as he can with supervision.

The physician has ordered a wet-to-dry dressing containing normal saline solution for an infected pressure ulcer. The client asks what is the purpose of this treatment. What would the nurse say the primary reason for this treatment is to accomplish which action? a. "The treatment will prevent the spread of the infection." b. "The wet-to dry dressings will debride # remove dead tissue from the wound." c. "The treatment will keeping the wound moist." d. "The wet-to-dry dressings will reduce your pain."

b. "The wet-to dry dressings will debride # remove dead tissue from the wound."

The diaphragm of the stethoscope is typically placed over which artery to obtain a blood pressure measurement? a. brachial b. brachiocephalic c. radial d. ulnar

brachial

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint? a. "Did you let them know that you needed help?" b. "When did you last have someone bathe you?" c. "I'm sorry you haven't been bathed. I'm available to bathe you now." d. "I don't understand why they didn't bathe you; they indicated during shift report that they did."

c. "I'm sorry you haven't been bathed. I'm available to bathe you now."

An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the child to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? a. Grapefruit and white toast b. Pancakes and a banana c. Ham and eggs d. Bagel and cream cheese

c. Ham and eggs

A client was admitted with an injury to the occipital lobe. Which nursing action should the nurse perform? a. Test water temperature before bathing or showering. # parietal lobe for sensory fx b. Assist client while walking due to loss of balance. # cerebellum for blance c. Monitor client for visual disturbances. d. Evaluate the client's hearing condition. # temporal lobe for hearing

c. Monitor client for visual disturbances.

The student nurse describes how to position a client for a lumbar puncture to the primary care nurse. Which description indicates that the student nurse understands the correct positioning for the procedure? a. prone, with the head turned to the right b. supine, with the knees raised toward the chest c. lateral recumbent, with flexed knees d. lateral, with the right leg extended

c. lateral recumbent, with flexed knees

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? SATA a. curative surgery to remove the tumor b. chemotherapy and radiation therapy for a possible cure c. parental support enabling the parents to participate in the infant's care d. serum blood analysis to monitor cancer levels e. pain management and comfort measures

pain management and comfort measures parental support enabling the parents to participate in the infant's care Explanation: Palliative care means comfort not cure. Pain management, comfort measures, and parental support are all part of palliative care. Surgery, chemotherapy, radiation, and blood work used to treat the cancer or cure the disease are not indicated in palliative care.

The nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat: a. grains # carbohydrates and milk # vit D & protein b. tomatoes # citrus vit A, C and fish # protein c. eggs # protein and citrus fruit # vit A & C d. spinach and beef.

spinach and beef. Common food sources of iron include green, leafy vegetables, spinach, red meat, egg yolks beef, liver, prunes, pork, broccoli, dried fruits, Peanut butte, legumes, and whole wheat breads and cereals.

A client with osteoarthritis may be on bed rest for prolonged periods. Which nursing intervention would be appropriate for these clients? a. encouraging coughing and deep breathing, and limiting fluid intake b. providing only passive range of motion (ROM), and decreasing stimulation c. having the client lie as still as possible, and giving adequate pain medicine d. turning the client every 2 hours, and encouraging coughing and deep breathing

turning the client every 2 hours, and encouraging coughing and deep Explanation: A bedridden client needs to be turned every 2 hours, have adequate nutrition, and cough and deep-breathe. Adequate pain medication, active and passive ROM, and hydration are also appropriate nursing measures.

A 10-hour-old neonate appears exceptionally irritable, crying easily and startling when touched. A drug screen test indicates that the neonate is positive for cocaine. When assisting with developing the plan of care for this neonate, which action would be most helpful in soothing the neonate? a. leaving the light on beside the bassinet at night # kept in a quiet, dimly lit environment b. wrapping the neonate snugly in a blanket c. providing multisensory stimulation while the neonate is awake # minimum d. giving the neonate a warm bath or removal of clothing # changes in temperature increase stimuation

wrapping the neonate snugly in a blanket # to provides a safe, secure environment and maintains body warmth, both of which are soothing. A cocaine-addicted neonate # withdrawal 8 to 10 hours after birth with SS constant crying, jitteriness, poor feeding, emesis, respiratory distress, and seizures

Which nursing intervention would help a client diagnosed with Alzheimer's disease AD perform activities of daily living? a. urge the client to perform all basic care without help b. tell the client that morning care must be done by 9 a.m. c. give the client a written list of activities he's expected to do d. provide ample time for the client to complete basic tasks

d. provide ample time for the client to complete basic tasks

The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray? a. cranberry juice b. vanilla yogurt c. iced coffee d. chicken broth

vanilla yogurt

A client who is recovering one day after an extensive abdominal surgery is having incisional pain. When should the nurse plan to administer analgesics for this client? a. Every 3-4 hours b. Three times a day c. Four times a day d. When requested by the client

Every 3-4 hours Explanation: Pain should be assessed minimally every 4 hours around the clock as well as after any treatments

When collecting data on a child with impetigo, the nurse expects which findings? a. Small, brown, benign lesions # warts b. Honey-colored, crusted lesions c. Linear, threadlike burrows # scabies d. Circular lesions that clear centrally # Tinea corporis/ ringworm

b. Honey-colored, crusted lesions

A nurse is caring for a client who is awaiting surgery for a hip fracture. Which nursing intervention has the highest priority when providing skin care for this client? a. Change the bed linens frequently for an incontinent client. b. Keep the skin clean and dry without using harsh soaps. c. Gently massage the skin around pressure areas. d. Rub moisturizing lotion over pressure areas.

b. Keep the skin clean and dry without using harsh soaps.

A hospitalized client notes difficulty resting. Which intervention would help promote rest? a. leaving the client's door open so in order to see into the hallway b. assisting the client with deep-breathing exercises c. offering the client a cup of tea d. encouraging the client to take prescribed sedatives daily

b. assisting the client with deep-breathing exercises

An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause: a. cerebral edema. b. dehydration. c. heart failure. d. hypovolemic shock.

cerebral edema

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? a. Establish a predetermined fluid intake pattern for the client. b. Encourage the client to increase the time between voiding. c. Restrict fluid intake to reduce the need to void. d. Evaluate present elimination patterns.

d. Evaluate present elimination patterns

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.)(0800), & 60 ml (9 a.m.) (0900). Based on these amounts, what should the nurse do? a. Continue to monitor and record hourly urine output. b. Notify the physician. c. Irrigate the indwelling urinary catheter. d. Increase the I.V. fluid infusion rate.

a. Continue to monitor and record hourly urine output. Rationale 1 normal urine 60mL/day or approximately 1,500 ml/24 hours 2 report if <30mL/hour # SS of dehydration or altered renal function

An older adult client admitted to the hospital with chest pain has difficulty hearing. Which method should the nurse use when collecting data from this client? a. obtain an ear wick b. shout into the better ear c. lower voice pitch while facing the client d. ask the family to go home and get the client's hearing aid

c. lower voice pitch while facing the client

A nurse reinforces education that has been provided to an older adult about good bowel habits. Which statement indicates that the client understands the information? a. "I should eat a diet that is low in fiber-rich foods." b. "Using a laxative each day will help to prevent constipation." # dependence c. "I need to drink two to three glasses of fluid every day." d. "Fifteen minutes of exercise three times a week improves bowel habits."

d. "Fifteen minutes of exercise three times a week improves bowel habits."

When inserting a urinary catheter on a male client, which action should the nurse take to facilitate the insertion? a. ask the client to urinate while inserting the catheter b. instruct the client to breathe deeply c. move the client close to the edge of the bed d. hold the shaft of the penis firmly

instruct the client to breathe deeply Explanation: Breathing deeply relaxes the urinary sphincter, making urinary catheter insertion easier.

A nurse is caring for a client with a burn injury. Which statement best describes the client's nutritional needs? a. The client needs 100 cal/kg throughout hospitalization. b. The hypermetabolic state after a burn injury leads to poor healing. c. Controlling the temperature of the environment decreases caloric demands. d. Maintaining a hypermetabolic rate decreases the client's risk of infection.

The hypermetabolic state after a burn injury leads to poor healing. Explanation: A burn injury causes a hypermetabolic state resulting in protein and lipid catabolism that affects wound healing adversely. Caloric intake must be 11/2 to 2 times the basal metabolic rate, with at least 1.5 to 2 g of protein per kg of body weight daily. An environmental temperature within normal range lets the body function efficiently and devote caloric expenditure to healing and normal physiologic processes. If the temperature is too warm or too cold, the body devotes energy to warming or cooling, which takes away from energy used for tissue repair. High metabolic rates increase the risk of infection.

A nurse is caring for a client who required chest tube insertion for pneumothorax. To confirm pneumothorax resolution, what should the nurse anticipate the client will require? a. Monitoring of arterial oxygen saturation (SaO2) b. Arterial blood gas (ABG) studies c. Chest auscultation d. A chest X-ray

d. A chest X-ray Explanation: Chest X-ray reveals air or fluid in the pleural space and therefore displays the status of pneumothorax. SaO2 values may initially decrease with pneumothorax but typically return to normal within 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to pneumothorax. Chest auscultation determines overall lung status but doesn't clearly determine if the chest is sufficiently re-expanded.

A female client with a history of four UTIs in the past 3 months comes to the urology clinic reporting of burning and urinary urgency and frequency. Which instructions should the nurse give the client to help prevent recurring infections? SATA "Increase the intake of carbonated beverages." discouraged, use plenty of fluid & cranberries a "Avoid using irritating substances such as bubble bath and scented toilet paper." b "Change laundry detergents frequently." c "Take antibiotics until symptoms abate. "# complete the entire course of antibiotic d "Clean the perineal area from front to back."

"Avoid using irritating substances such as bubble bath and scented toilet paper." "Clean the perineal area from front to back."

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? a. Acute pain related to biliary spasms b. Deficient knowledge related to prevention of disease recurrence c. Anxiety related to unknown outcome of hospitalization d. Imbalanced nutrition: Less than body requirements related to biliary inflammation

a. Acute pain related to biliary spasms

The client calls the nurse in the clinic and states that the cast feels very rough around the edges and is scratching the skin. What is the best response by the nurse? a. Apply moleskin or pink tape around the edges. b. Elevate the limb above the level of the heart. # prevent swelling c. Break off the rough area and file it down. d. Distribute pressure evenly.# prevent pressure ulcers

a. Apply moleskin or pink tape around the edges.

The nurse is caring for a client who had a stroke. Which nursing interventions does the nurse use to promote urinary continence? SATA a. encouraging intake of at least 2 L of fluid daily b. giving the client a glass of soda before bedtime # soda acts as a diuretic and may make the client incontinent c. taking the client to the bathroom twice per day d. consulting with a dietitian twice per week e. offering the client the bedpan at least every 2 hours throughout the day

a. encouraging intake of at least 2 L of fluid daily # helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void e. offering the client the bedpan at least every 2 hours throughout the day

A client with cirrhosis is jaundiced, edematous and experiencing severe itching with dryness. Which intervention is best to help the client? a. put mitts on the hands # prevent scratching f b. use alcohol-free body lotion c. lubricate the skin with baby oil # block pores d. wash the skin with soap and water

b. use alcohol-free body lotion

A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate? a. speaks clearly and at a normal pace b. eliminates background noise as much as possible c. before speaking, gets the client's attention d. moves around and multitasks when speaking

d. moves around and multitasks when speaking

An 18-month-old child comes to the primary health care provider's office for a well-baby checkup. Which foods should the nurse recommend as providing the best sources of dietary iron for the child? a. peanut butter, green vegetables, and raisins b. cheese, yogurt, and fresh fish c. yellow vegetables, citrus fruits, and white bread d. berries, turkey, and cheese

peanut butter, green vegetables, and raisins # source of iron

A middle-age client recovering from major back surgery must wear a back brace and walk with a cane after experiencing leg weakness. During routine care, the client tells a nurse, "I'm sorry I had this operation. Before surgery I didn't look like I had a problem, but now I do." Which response by the nurse is appropriate? a. "People often suffer setbacks before they improve." b. "Maybe you should consult with your attorney." c. "I'm not sure why you went through with the surgery; you were told of the risks." d. "You sound concerned about your appearance. In what way are you worse off than before?"

"You sound concerned about your appearance. In what way are you worse off than before?"

A nurse provides care for a client who developed hives after having an allergic reaction to strawberries. Which finding indicates to the nurse that the client has experienced improvement of symptoms? a. Itching is relieved. b. The rash improves. c. The pain of the rash subsides. d. Erythema decreases.

Itching is relieved. Explanation: Urticaria (hives) causes wheals surrounded by redness, swelling, and severe itching. When the client obtains relief from urticarial (blocking the histamine response), the symptoms, including itching, subside. Treatment will help to improve the rash, redness, and skin irritation that are signs of an allergic reaction. Symptoms are subjective findings reported by the client.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care? a. Avoiding using soap on the irradiated areas b. Applying talcum powder to the irradiated areas daily after bathing c. Wearing a lead apron during direct contact with the client d Removing thoracic skin markings after each radiation treatment

a. Avoiding using soap on the irradiated areas

A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program? a. intermittent catheterization b. Kock pouch # continent ileostomy c. transurethral prostatectomy # for obstruction to urinary outflow by BPH or for the treatment of cancer d. ureterostomy

intermittent catheterization # starting with 2h intervals & then increasing to 4-6h intervals

Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking? a. A breast-fed, 7-lb, 2-oz (3.2-kg) neonate who produces three stools and wets six diapers per day b. A breast-fed, 7-lb, 4-oz (3.3-kg) neonate who feeds on demand and averages ten feedings per day c. A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day d. A bottle-fed, 7-lb, 4-oz (3.3-kg) neonate who drinks 23 oz of formula per day over the course of eight feedings

c. A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day Explanation: A neonate with adequate nutrition voids six to eight times per day and has two or more bowel movements. Beast fed Q2H; formula 17.5 to 21oz/ day

After collecting data on a client, the nurse helps formulate relevant nursing diagnoses. Which is a complete nursing diagnosis statement that the nurse would suggest be implemented? a. Ineffective airway clearance related to mucus plugs and nonproductive cough b. Hyperventilation related to anxiety c. Tachycardia d. Shortness of breath related to anxiety

Ineffective airway clearance related to mucus plugs and nonproductive cough taxonomy NANDA # actual or potential health problem + the etiology + the signs and symptoms essential to the diagnosis

The nurse is collecting admission data from a newly admitted client. Which question should the nurse include when asking the client about orthopnea? a "Do you cough up blood?" # hemoptysis b "Does the symptom move to another area?" # pain c "Is the sensation sharp, stabbing, or aching?" # pain d "How many pillows do you use?"

"How many pillows do you use?"

A family of four involved in a house fire is brought to the hospital for treatment of burns. The local media arrives at the hospital requesting information about the condition of the family members. Which response by the nurse is most appropriate? a. "You'll have to speak to the emergency department physician." b. "I'm sorry; I'm not allowed to give out information." c. "I need to obtain permission from the parents or their representative before I can release any information." d. "You'll need to speak with our public relations office."

"I need to obtain permission from the parents or their representative before I can release any information."

A client is having trouble sleeping. Which nursing intervention should the nurse suggest to the client? a. "Take a warm bath in the early morning, just after rising." # in the evening b. "Maintain the same schedule for waking and sleeping." c. "Exercise after dinner each night to bring on fatigue." d. "Take frequent naps, especially in the afternoon." # limited to 1 or 2 hours

"Maintain the same schedule for waking and sleeping." # to maximize the ability of the client having trouble sleeping to sleep without disturbance

The nursing instructor asks the nursing student to describe the anatomic position. How would the student correctly respond? a. "The client's body is supine." b." The client's arms are elevated at shoulder level." c. "The client's palms are turned forward." d."The client's body is facing backward."

"The client's palms are turned forward." Explanation: In the anatomic position, the body is erect, facing forward with arms at the sides and palms turned forward.

During a routine assessment, a pregnant client tells the nurse that she hasn't had a bowel movement for "close to a week." What should the nurse do to help this client? a. Suggest that the client take Milk of Magnesia when she returns home. b. Recommend that the client take castor oil before bedtime. c. Discuss the client's diet, focusing on her fiber and water intake. d. Ask the health care provider to prescribe a laxative for this client.

Discuss the client's diet, focusing on her fiber and water intake. Explanation: Many medications are not safe during pregnancy

The nurse is caring for a client who practices reflexology. When collecting client data, the nurse notes that the client's ankles are edematous. Which intervention by the nurse supports the client's beliefs in reflexology and helps reduce edema? a. Lowering the client's legs b. Elevating the client's legs c. Abducting the client's legs d. Adducting the client's legs

Elevating the client's legs xplanation: Reflexology is based on the theory that fluid in interstitial spaces blocks oxygen supply to tissues. Therefore, elevating the client's legs helps decrease fluid in the ankles, thereby increasing oxygen supply to the tissues.