basic care and comfort

Which procedure would the nurse use to elevate the head of an infant in a spica cast?

Raising the entire mattress at the head of the crib

Which nursing interventions indicate client care that supports physical functioning? Select all that apply. One, some, or all responses may be correct.

Maintain client's nutritional status. Maintain client's regular bowel patterns.

Which intervention would the nurse suggest to promote comfort for a client experiencing pain during urination?

Drinking water

A client who is obese is diagnosed with a hiatal hernia. The nurse provides teaching about how to prevent esophageal reflux and should include which instruction?

"Eat less food at each meal."

Which interventions are appropriate for the client brought to the hospital with heat exhaustion? Select all that apply. One, some, or all responses may be correct.

0.9% normal saline intravenously (IV) Placing a moist sheet over the client Initial fluid bolus to correct hypotension Placing in a cold area and removing constrictive clothing

Which statements regarding acne are correct? Select all that apply. One, some, or all responses may be correct

Acne may be caused by stress. Family history could be a reason for acne. Propionibacterium acnes causes acne.Acne is commonly found on the face, chest, upper back, and neck.

Which developmental intervention would the nurse provide to promote safety among adolescents? Select all that apply. One, some, or all responses may be correct.

Helping parents minimize risks to their adolescents' safety Teaching parents to serve as role models by guiding expectations and providing education

Which intervention regarding skin care would the nurse include in a teaching plan for the client with scleroderma?

Keep skin lubricated with lotion.

Which dietary choice would the nurse teach for the client with peripheral arterial disease? Select all that apply. One, some, or all responses may be correct.

Limit salt intake. Eat whole-grain breads. Use liquid vegetable oils.

Which method is best for the nurse to assess an infant's response to oral rehydration therapy?

Obtaining the weight at the same time every day

Which sleep pattern would the nurse recognize as normal in preschoolers?

On average, a preschooler sleeps about 12 hours a night.

In preparing a teaching plan for a client with hyperthyroidism, the nurse anticipates which diet will be prescribed?

High-calorie diet

Discharge planning for a client with chronic pancreatitis includes dietary education. Which client statement indicates to the nurse that further teaching is needed?

"I can eat foods high in fat now that the acute stage is over."

Which statement from a client who has received prescriptions for digoxin, furosemide, and a 2-g sodium diet indicates that further teaching is needed?

"I can use a little table salt on my food as long as I do not use it when cooking food."

Which action would the nurse take next after successfully performing an abdominal thrust maneuver on an older adult client?

Touch the client's hand while providing verbal support.

A client consumes 4 ounces of apple juice, 6 ounces of tea, and 8 ounces of chicken broth. How many mL of fluid will the nurse document the client ingested? Record your answer using a whole number.

540

Which assessment is a component of the primary survey?

Disability

Which is the most appropriate lunch for a child who is on a restricted-sodium diet?

Hamburger on a bun, grapes, lemonade

Which intervention would the nurse include as a priority action when preparing to provide grief counseling to a client?

Provide an environment for the client to express their feelings

Which priority teaching intervention would the nurse include in the care plan for a client who has insomnia?

Sleep hygiene tips

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. Which is the rationale behind this?

To ensure adequate exposure to the blood vessels

The nurse is assisting with the end-of-life care of a client. Which activity is performed when the nurse views family as context?

Meet the client's comfort, hygiene, and nutritional needs.

A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. Which type of stool should the nurse expect?

Moist and formed

Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take?

Moisten the client's lips with a wet 4 × 4 gauze.

Which principle underlying the function of a portable drainage system will the nurse consider when caring for a client returning from surgery with a drain attached to a portable wound drainage system exiting from the surgical site?

Negative pressure

Which dietary need would the nurse and the nutritionist consider when planning meals for a client who practices the Russian Orthodox faith?

No meat on Wednesdays and Fridays

After the nurse has finished teaching methods of reducing fatigue to the client with multiple sclerosis, which statement made by the client indicates that the client has understood the nurse's instruction?

Rest in an air-conditioned room.

Which consideration would be included in caring for an infant who is failing to thrive (FTT)? Select all that apply. One, some, or all responses may be correct.

Dietary history Signs of malnutrition Familial stress factors Parent and infant interaction Sustained growth under 5th percentile

Which is the optimal nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs

Which action would the nurse take when the thigh-high antiembolism stockings that have been prescribed for a client with varicose veins fit on the lower legs but are too small to fit over the thighs?

Ask the health care provider if an elastic bandage can be used in place of the stockings.

Which descriptors for maturity-onset diabetes of the young (MODY) would the nurse identify as accurate? Select all that apply. One, some, or all responses may be correct.

Autosomal dominant Characterized by young age of onset

A client is diagnosed with chronic pancreatitis. Which dietary instruction is important for the nurse to share with the client?

Avoid ingesting alcoholic beverages.

Which response would the nurse make when trying to help a client with schizophrenia take a shower?

"I'll help you take your shower now."

Which information would the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)?

A low-phenylalanine diet is required.

Which intervention would the nurse recommend if a teenager being discharged with a cast experiences pruritus around the cast edges?

"Put an ice pack on the affected area."

Which initial objective would the nurse establish with the client when a health care provider prescribes a diagnostic workup for a client who may have myasthenia gravis?

"The client will maintain present muscle strength."

A client who had a severe weight loss is told the importance of eating more protein to provide the essential amino acids. The client asks the nurse why these substances in protein foods are essential. How should the nurse respond?

"They must come from your food because your body cannot make them."

The nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet would the nurse stress?

Bland foods

A client develops steatorrhea with malabsorption syndrome. How will the nurse document this finding in the client's medical record?

Bulky and foul-smelling

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which type of care will now be removed from the treatment plan? Select all that apply. One, some, or all responses may be correct.

Chemotherapy Blood transfusion Radiation therapy

Which iron-rich foods would the nurse encourage the client with mild anemia in early pregnancy to eat? Select all that apply. One, some, or all responses may be correct.

Dark leafy green vegetables Legumes Dried fruits Ground beef patty

Which action would the nurse take when observing that a postsurgical client has a urine output of 800 mL total in the first 24 hours after surgery?

Document the normal finding.

A client with advanced bone cancer is experiencing cachexia. The nurse reviews the nutritional components of palliative care with the client's family members. The nurse recognizes that the teaching is designed to achieve which outcome?

Enhance the quality of the client's life

Which intervention would the nurse incorporate into the plan of care for the older adult experiencing chronic pain?

Exercise

Which activity would the nurse teach a non-weight bearing client in order to prepare for crutch walking?

Exercise the triceps, finger flexors, and elbow extensors.

The nurse in the pediatric clinic is reviewing the health history of a 6-year-old child with celiac disease who has been on the dietary regimen for 6 months. Which evaluation criterion would the nurse use to assess the child's adherence to the diet?

Formed bowel movements

Which suggestion would the nurse share to help relieve the discomfort when an adolescent female presents with menstrual cramps? Select all that apply. One, some, or all responses may be correct.

Gentle exercise Lower back massage Progressive relaxation

Which preventive wellness recommendation will the nurse make to a male client who tests positive for the BRCA mutation after his mother and two sisters are found to carry the gene? Select all that apply. One, some, or all responses may be correct.

Get a baseline mammogram at 40 years. Get breast self-examination (BSE) training at 35 years. Get a clinical breast examination (CBE) every 6 months starting at

Which parent teaching would the nurse provide the parents of an infant being discharged after surgery for pyloric stenosis?

Hold the baby while continuing to feed a regular formula slowly and burp frequently."

An infant is found to have developmental dysplasia of the hip 6 weeks after birth. The parents ask the nurse why their infant must be restrained in a harness at such an early age. How would the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the

After surgery, a client is prescribed a clear liquid diet. Which items would the nurse offer to the client? Select all that apply. One, some, or all responses may be correct.

Jell-O Broth Ginger ale

Which description would the nurse expect when the parent of a child with celiac disease describes their child's stools?

Large, pale, foul-smelling

Which diet choice by a client who has heart failure indicates that the nurse's teaching about diet has been effective? Select all that apply. One, some, or all responses may be correct.

Lean steak, Fruit salad,Broiled chicken, Roasted potatoes

A client who has had a laparoscopic cholecystectomy reports pain in the shoulder. In which position would the nurse place the client?

Left lateral recumbent

Which diagnosis would the nurse suspect when an enlarged uterus and nodular masses are palpated on examination of a client with abnormal uterine bleeding, pelvic pressure, pressure during urination, and painful intercourse?

Leiomyomas

The nurse applies an ice pack to a client's leg for a total of 20 minutes. Which physiological effect would occur because of applying cold therapy?

Local anesthesia

Which age group would the nurse recommend that children be taught to swim under guided supervision?

Preschoolers

A client is experiencing stomatitis as a result of chemotherapy. Which action would the nurse take when caring for this client?

Provide frequent saline mouthwashes.

Which verbalization by the parents of a child who has cystic fibrosis (CF) provides evidence that they understand the child's dietary needs?

Provide high-calorie foods between meals.

The nurse is caring for a two days post-surgery hip- replacement client who has had a bowel movement. Which nursing intervention would the nurse perform next?

Provide perineal care.

Which term would the nurse use to document a client with drooping of the eyelid over the pupil?

Ptosis

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine?

Regularly offer the client a urinal.

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client

Removing the catheter within 24 hours

Which sleep disorder is an example of a dyssomnia? Select all that apply. One, some, or all responses may be correct.

Restless leg syndrome Obstructive sleep apnea Insomnia

A child who is cognitively impaired and blind does not speak or respond to the nurse. Which would the nurse do when entering the child's room?

Say the child's name and touch the child's arm before starting

The nurse is counseling a client with type 1 diabetes about choosing food items that are low in carbohydrate (CHO) content. Which food selection made by the client indicates effective teaching?

Skim milk

Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family of a terminally ill client who has died?

Social worker

Which action would the nurse implement when providing care for a client with continuous bladder irrigations?

Subtract irrigant from output to determine urine volume.

A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and having experienced 10 liquid bowel movements in the past 24 hours. The nurse suspects that the client is dehydrated based on which assessment findings? Select all that apply. One, some, or all responses may be correct.

Sunken eyes Dry mucous membranes

Which snack foods can the nurse recommend that are safe for a child with celiac disease?

Tortilla chips

Which step would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. One, some, or all responses may be correct.

Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention.

Which task would the nurse classify as low priority when planning client care for the day?

Turning and positioning a client after hip replacement surgery

A shoulder immobilizer device is prescribed after surgical repair of a client's rotator cuff. Which criterion would the nurse use to determine the client's correct alignment in the device?

Upper arm lies close to the chest

While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia?

Urinary tract infection

A client is hospitalized with acute pancreatitis. Which would be included in the client's plan of care?

Use intravenous (IV) fluids.

Which data would the nurse consider when determining whether a 5-month-old infant who weighs 14 lb (6.4 kg) is within expected range?

Birth weight

A low-residue diet is recommended for a client. Which food would the nurse encourage the client to select from a menu?

Creamed potatoes

Which physiological change in the cardiovascular system is related to the aging process? Select all that apply. One, some, or all responses may be correct.

Less sensitivity to β-adrenergic drugs Development of systolic murmurs Increase in systolic blood pressure

The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning?

Banana

Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer?

Biofeedback

A client reports right ear hearing loss. When performing a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?

Conduction hearing loss

Which exercise would the nurse teach a client who has a spinal cord injury at the T4 level and wants to use a wheelchair?

Push-ups to strengthen arm muscles

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is priority when the client becomes short of breath during the care?

Put the client in a high Fowler position.

Which information would the nurse include in teaching when a client with varicose veins has knee-length elastic support stockings prescribed?

Put the stockings on before getting out of bed.

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. Which action would the nurse take after obtaining the fetal heart rate and maternal vital signs?

Provide the client with comfort measures for relaxation.

A school-aged child with acute glomerulonephritis has fluid intake restricted to the previous day's output plus 40 mL. The child's output over the past 24 hours was 140 mL. From 3:00 PM to 11:00 PM the child is to receive one-third of the total daily fluid permitted. How much fluid would the nurse provide for the evening intake?

60 mL

Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

Administer the prescribed intravenous fluid with the added vitamin C.

An infant is hospitalized with severe diarrhea and has excoriated skin in the diaper area. Which is the nurse's explanation for leaving the child without a diaper?

Cleansing of the skin followed by air-drying reduces excoriation.

Which intervention is useful in promoting comfort for the client experiencing a headache?

Cold therapy

Which principle is represented by the application of local heat transferring temperature to the body such as when a primary health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated?

Conduction

Which meal selection by a client on a 2-g sodium diet indicates that more diet teaching is needed?

Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

Why is it important for the nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?

Different cultural groups favor different essential nutrients.

Which domain of the Nursing Interventions Classification (NIC) taxonomy includes care supporting the health of the community?

Domain 7

Which motion would the nurse perform on a client's ankle to demonstrate full range-of-motion?

Dorsiflexion, plantar flexion, eversion, and inversion

Which extrinsic factor is responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct.

Environmental hazards Inappropriate footwear Improper use of assistive devices

After an amputation of a limb, a client reports extreme discomfort in the area where the limb once was. Which goal would the nurse plan to focus interventions?

Identifying actions to decrease pain in the lost limb

An infant is found to have developmental dysplasia of the hip 6 weeks after birth. The parents ask the nurse why their infant must be restrained in a harness at such an early age. How would the nurse respond?

Infants' hip joints are cartilaginous, allowing molding of the acetabulum.

According to Hersey's Situational Leadership Model, which type of leadership behavior should the nurse use when delegating client care activities to recently hired, unlicensed assistive personnel (UAP) who appear competent and motivated?

Participating

Which intervention relieves pruritus associated with varicella (chickenpox)?

Pat the lesions while applying the prescribed calamine lotion.

Which nursing action is beneficial for the client who has pain due to muscle spasm?

Providing heat compresses at the site

Which nursing intervention helps prevent complications associated with a shortened urethra revealed by a recent intravenous pyelogram?

Providing thorough perineal care after each voiding

Which symptom might be explained by a medication-alcohol interaction of a client who mentions taking cefotetan and drinking a few cocktails at dinner? Select all that apply. One, some, or all responses may be correct.

Pruritus Diaphoresis Hypotension Stomach cramps

Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision.