Basic Care and Comfort Quiz

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? a. The baby has an axillary temperature of 100.4o F. (38o C) b. The baby is crying inconsolably for more than three hours c. The baby develops swelling or redness at the injection site d. The baby develops a localized or generalized rash

b. The baby is crying inconsolably for more than three hours

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? a. Positioning the client standing or supine. b. Measuring and assessing the stoma. c. Changing the pouch before a meal. d. Cleansing the peristomal skin with alcohol.

d. Cleansing the peristomal skin with alcohol. RATIONALE: This intervention is not appropriate. The peristomal skin should not be cleansed with alcohol.

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? a. "Have you noticed any bloody show or fluid coming from your vagina?" b. "When did your contractions begin?" c. "What happens to your contractions when you move about?" d. "Have you felt fetal movement over the last 24 hours?"

a. "Have you noticed any bloody show or fluid coming from your vagina?"

A nurse needs to determine a client's strength before ambulating. Which of the following should the nurse do? a. Ask the client to plantar flex the feet against resistance. b. Ask the client if they have been up before. c. Assess how strong the client feels today. d. Assess pedal pulses and feet for edema.

a. Ask the client to plantar flex the feet against resistance. RATIONALE: It is necessary to assess the client for muscle strength (legs and upper arms) as immobile clients have decreased muscle strength, tone, and mass, which affects the ability to bear weight and raise the body.

A nurse is caring for a client hospitalized with Guillain-Barré Syndrome who has been in the intensive care unit on a ventilator for four days. Which of the following would be most appropriate in assessing for complications of immobility? Select all that apply. a. Assess the character of bowel sounds and frequency of stools. b. Performing range of motion on the client's ankles, knees and hips. c. Observe skin color over sacral, heels and scapulae areas. d. Assess the client's ability to move lower extremities. e. Assess rate and depth of respiratory effort.

a. Assess the character of bowel sounds and frequency of stools. b. Performing range of motion on the client's ankles, knees and hips. c. Observe skin color over sacral, heels and scapulae areas. RATIONALE: Potential complications of immobility could include the following: loss of joint motion and contractures, decreased gastrointestinal motility and constipation, deep vein thrombosis with erythema and swelling of the calf areas, and skin breakdown with early evidence of pallor, erythema, blistering over bony prominences.

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education? a. Cheddar cheese b. Small amounts of kiwi c. Wheat bread d. Small sweet potato

a. Cheddar cheese RATIONALE: Client's with renal failure need to restrict protein and phosphorus which is present in cheese and many milk products.

A nurse is assisting a client with an advance directive. Which of the following nursing responsibilities should be included regarding advance directives? Select all that apply. a. Document the client's advance directive in the medical chart. b. Provide written information to the client about advance directives. c. Ensure that each family member receives a copy of the advance direction. d. Confirm that the advance directive is current. e. Inform all members of the client's family of the client's wishes.

a. Document the client's advance directive in the medical chart. b. Provide written information to the client about advance directives. d. Confirm that the advance directive is current. RATIONALE: The nursing responsibility regarding advance directives is to ensure that the advance directive is current and reflective of the client's current decisions.

A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery? a. Fresh vegetables b. Strained fruit juices c. Lean meats d. Cream cheese

a. Fresh vegetables RATIONALE: Fresh vegetables are high in fiber and therefore, should be avoided in the first weeks after surgery. During the first weeks after surgery, many providers recommend low fiber diets, particularly for clients with ileostomies, because the small bowel requires time to adapt to the diversion. As ostomies heal, clients are able to eat almost any food and high fiber foods are encouraged to help ensure a more solid stool to achieve success at irrigation, but high fiber foods should be avoided in the first weeks after surgery.

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching? a. Grilled chicken salad with fresh salsa b. French onion soup and salad c. Vegetarian wrap with chips d. Chicken bouillon and crackers

a. Grilled chicken salad with fresh salsa RATIONALE: Grilled chicken salad and fresh salsa are both made from fresh (preservative-free) materials and therefore are likely to be of lower sodium content than French onion soup, chips, chicken bouillon, or crackers.

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following assessment findings should the nurse expect? Select all at apply. a. Heart rate of 52 bpm b. Digoxin level 1.5 ng/ml c. Increased appetite d. Yellow vision e. Constipation

a. Heart rate of 52 bpm d. Yellow vision RATIONALE: An older adult client may experience the toxic effects of digoxin even though the drug level is within normal limits (0.5 - 2 ng/ml). Bradycardia is a sign of digoxin toxicity and is the reason an apical pulse is taken prior to administration of this drug. Clients with digoxin toxicity often have disturbed color vision or see halos.

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? a. Increase their independence b. Gratify their oral fixation. c. Finish a project they set out to do. d. Develop their sense of trust.

a. Increase their independence. RATIONALE: The drive for independence is expressed by the toddler opposing the desires of those in authority (tantrums) and attempting to do everything for themselves. The Erickson developmental stage for this age is "Autonomy vs. Shame and Doubt."

A nurse is caring for a client with Crohn's Disease. Which of the following foods can be included in this client's diet? Select all that apply. a. Pasta b. Eggs c. Raisins d. Wild rice e. Fresh celery

a. Pasta b. Eggs RATIONALE: Low-fiber, low-residue diets are recommended for clients with Crohn's Disease. Foods that are appropriate for clients with Crohn's Disease include: Tender, ground, well-cooked meat, eggs, fish, poultry, refined pasta and cereal, white rice and bread, canned or cooked vegetables without skin or seeds and juices without pulp. Foods that are appropriate for clients with Crohn's Disease include: Tender, ground, well-cooked meat, eggs, fish, poultry, refined pasta and cereal, white rice and bread, canned or cooked vegetables without skin or seeds and juices without pulp.

A nurse is managing client care. Which of the following should be implemented when prioritizing care? Select all that apply a. Prepare a written list. b. Postpone items that do not have immediate deadlines. c. Take on a task when inspired. d. Avoid delegation of difficult tasks. e. Respond to needs as soon as they arise.

a. Prepare a written list. b. Postpone items that do not have immediate deadlines. RATIONALE: Preparing a written list is a function considered in prioritizing client care. Items that are marked as to do later reflect trivial problems or those that do not have immediate deadlines; thus, they may be postponed when prioritizing care.

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? a. Rabbit b. Eggs c. Tuna d. Spinach

a. Rabbit RATIONALE: Of the "beasts of the earth" (which basically refers to land mammals with the exception of swarming rodents), clients observing Kosher laws may eat any animal that has cloven hooves and chews its cud. Any land mammal that does not have both of these qualities is forbidden. The Torah specifies that the camel, the rock badger, the hare and the pig are not kosher because each lacks one of these two qualifications. Cattle, sheep, goats, deer and bison are kosher.

An 87-year-old client has been admitted repeatedly to the acute care setting for pneumonia. The client's family asks what measures can help prevent recurrent respiratory issues. Which of the following measures should the nurse discuss to prevent respiratory issues? Select all that apply. a. Use a humidifier to moisten the air in the client's room, as needed. b. Ambulate the client regularly, daily. c. Encourage a diet in high protein. d. Administer a prior dosage of antibiotics when the client has a cough. e. Reassure the client during respiratory distress.

a. Use a humidifier to moisten the air in the client's room, as needed. b. Ambulate the client regularly, daily. e. Reassure the client during respiratory distress. RATIONALE: Encourage structured activities, after learning the client's physical capabilities and provide rest periods to prevent dyspnea. Using a humidifier during drier seasons can help prevent secretions from becoming thick and difficult to expectorate. If a client is having difficulty breathing, the caregiver(s) should provide support and reassurance to decrease the client's anxiety.

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary? a. "I don't take naps during the day." b. "I watch television until I fall asleep." c. "I go to bed and get up at the same time each day." d. "I drink some hot milk and take a bath before going to bed."

b. "I watch television until I fall asleep." RATIONALE: When activities other than sleeping, like watching TV, are done in bed, they are not correlated to the expectation of sleep like simply lying down to sleep. The nurse should facilitate maintenance of the client's usual bedtime routines as appropriate.

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? a. "I will tighten my pelvic muscles when coughing." b. "I will increase my fiber intake to stay regular." c. "I will avoid standing for prolonged periods of time." d. "I will increase my daily fluid intake."

b. "I will increase my fiber intake to stay regular."

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? a. "I can use spermicidal gels or creams to increase effectiveness." b. "I will remove the condom 30 minutes after intercourse." c. "My partner should leave an empty space at the tip." d. "My partner will put the condom on while his penis is erect."

b. "I will remove the condom 30 minutes after intercourse." RATIONALE: To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina.

A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? Sipped 8 oz. clear broth. 100 mL ice chips. Voided 450 mL. IV push pain medication 50 mL. Drank 4 oz. juice and 6 oz. hot tea. Vomited 120 mL and voided 600 mL. Jackson Pratt drain emptied 40 mL. a. 1068 mL b. 1210 mL c. 590 mL d. 680 mL

b. 1210 mL RATIONALE: 1210 mL output is the correct value. Input includes all liquids taken by mouth, including through nasogastric or jejunostomy feeding tubes, IV fluids, and blood or its components. Output includes urine, diarrhea, vomitus, and drainage from tubes such as through gastric suction and drainage from postsurgical wounds or other tubes.

A nurse is caring for a client who is one month post bariatric surgery and has been diagnosed with dumping syndrome. Which of the following recommendations is appropriate? Select all that apply. a. Sit up for at least an hour after each meal. b. Avoid consuming milk, sweets and sugars. c. Eat small, frequent meals during the day. d. Reduce the mount of protein and fat in the diet e. Eliminate liquids with meals, and for one hours before and after meals.

b. Avoid consuming milk, sweets and sugars. c. Eat small, frequent meals during the day. e. Eliminate liquids with meals, and for one hour before and after meals. RATIONALE: Dumping syndrome frequently occurs after bariatric surgery and symptoms can include vertigo, syncope, pallor, diaphoresis, tachycardia, and palpitations. Therapy includes: small, frequent meals rather than large ones; avoidance of milk, sweets, and sugars; elimination of liquids with meals and for one hour before and after meals; reduction in the amount of fluid ingested at one time, eating a high-protein, high-fat, and low-to- moderate carbohydrate diet; and lying down after meals to slow transit time of food in the intestines.

A nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client? a. Fresh strawberries and carrots b. Cooked spinach and celery c. Lettuce and alfalfa sprouts d. Raw cauliflower or broccoli

b. Cooked spinach and celery RATIONALE: Clients who are neutropenic are at increased risk for the development of infection. The reduced numbers of neutrophils and other white blood cells can limit the presence of common infection manifestations. The focus of care for client with neutropenia is on keeping the client's own normal flora under control and preventing the transmission of organisms. Raw or fresh foods may be a source of bacteria. The client should avoid raw fruits and vegetables, undercooked meats, eggs, or fish.

A nurse is changing a dressing on a preschool-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child? a. Assisting the child to take deep breaths and focus on relaxing. b. Encouraging the child to watch a favorite cartoon on television. c. Promising the child a special treat in exchange for cooperation. d. Teaching the child how to go 'to a different place' using their imagination.

b. Encouraging the child to watch a favorite cartoon on television. RATIONALE: Cartoons would be a very attractive distraction, and distraction is a powerful nonpharmacologic comfort intervention which works well with this developmental age.

A nurse is preparing to complete discharge teaching for a hearing impaired client. Which of the following interventions would best facilitate successful teaching? Select all that apply. a. Site bedside the client to discuss discharge information b. Include the client's spouse in the teaching session c. Provide the client with detailed written instructions. d. Turn off the TV and close the door to the hallway. e. Speak more loudly when talking to the client.

b. Include the client's spouse in the teaching session c. Provide the client with detailed written instructions. d. Turn off the TV and close the door to the hallway. RATIONALE: Eliminating background noise will facilitate hearing conversational tones. Written instructions will reinforce and clarify instructions for the hearing impaired client. If the client concurs, inclusion of the spouse will be of benefit when teaching a hearing impaired client because the spouse can serve to clarify and reinforce the information after discharge.

A nurse is caring for a client in Buck's Traction. Which of the following nursing interventions would ensure effective therapy? Select all that apply. a. Support the leg in adduction. b. Prevent wrinkling of the traction bandage. c. Maintain countertraction with weights. d. Ensure that all weights are free hanging. e. Assist the client to roll from side to side

b. Prevent wrinkling of the traction bandage d. Ensure that all weights are free hanging. RATIONALE: To ensure effective Buck's traction, it is important to avoid wrinkling and slipping of the traction bandage and to maintain countertraction. All weights must be free hanging to ensure effective traction.

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client? a. The infant demonstrates stranger anxiety b. The infant does not raise his head when placed on his abdomen c. The infant is unable to point to objects d. The infant is unable to sit with support

b. The infant does not raise his head when placed on his abdomen RATIONALE: When placed on the abdomen the 3 month old should attempt to raise his head. Some sources refer to this as "tummy time" which provides the infant with the stimulation to strengthen upper body and neck muscles in preparation for good head control when sitting upright and the some of the muscles required for crawling.

Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. Apply a dressing to a superficial laceration on the client's arm. b. Transport a client who is utilizing oxygen and has a peripheral IV catheter. c. Provide initial food by mouth for a client who has experienced a brain attack. d. Assist a client with a new transurethral prostectomy with perineal care. e. Obtain vital signs every 4 hours for a client with ulcerative colitis.

b. Transport a client who is utilizing oxygen and has a peripheral IV catheter. d. Assist a client with a new transurethral prostectomy with perineal care. e. Obtain vital signs every 4 hours for a client with ulcerative colitis. RATIONALE: Assisting followers in identifying situations appropriate for delegation is considered an effective leadership function. Assisting followers to use delegation as a time management strategy and team-building tool is considered an effective leadership function. Functioning as a role model, supporter, and resource person in delegating tasks to subordinates are leadership functions that are associated with delegation.

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation? a. Immediately before meals. b. When the client has the urge to defecate. c. Every hour while awake. d. When the client feels abdominal cramping.

b. When the client has the urge to defecate. RATIONALE: Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and subsequent constipation. Therefore, the best time to toilet a client to encourage bowel training is when the client has the urge to defecate.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "I can give him a tub bath in two days." d. "The circumcision will heal completely within a couple of weeks."

c. "I can give him a tub bath in two days."

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? a. "I should increase my fluid intake to 8-10 glasses of water a day." b. "I should consume a diet low in carbohydrates." c. "I should limit my sodium intake to 4 grams per day." d. "I should increase my consumption of protein."

c. "I should limit my sodium intake to 4 grams per day." RATIONALE: Excessively high protein and sodium diets put clients at risk for glomerulonephritis. Clients with this condition should implement sodium and protein restriction.

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? a. "We increase her protein intake when she's playing sports." b. "She eats a large breakfast every morning." c. "We allow her to pick out a treat at the grocery store for good behavior." d. "She enjoys helping to prepare her snacks in the kitchen."

c. "We allow her to pick out a treat at the grocery store for good behavior."

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? a. Your child is probably imitating behaviors that she has observed b. This is an early emergence of sexual expression that should be discouraged c. Awareness of body structures and sensations is normal and expected d. This is a possible infection or irritation in the genital area

c. Awareness of body structures and sensations is normal and expected RATIONALE: Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do which of the following? Select all that apply. a. Ensure the pouch is attached correctly. b. Lie down in a supine position. c. Begin abdominal massage. d. Apply moist towels to the abdomen. e. Drink hot tea.

c. Begin abdominal massage d. Apply moist towels to abdomen e. drink hot tea RATIONALE: Moist towels should be applied to the abdomen to facilitate drainage. Abdominal massage should be initiated to promote drainage. Hot tea may facilitate drainage and should therefore be encouraged.

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? a. Wheat bread b. Chicken breast c. Broccoli with cheese sauce d. Baked potato

c. Broccoli with cheese sauce RATIONALE: Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate? a. Place quad cane in right hand, extend left lower extremity, and then right hand with quad cane and left lower extremity. b. Place quad cane in left hand, extend left hand with quad cane, and then left leg followed by right leg. c. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. d. Place quad cane in right hand, extend right hand with quad cane and left lower extremity.

c. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. RATIONALE: Place quad cane in left hand, extend left hand with quad cane and right lower extremity followed by left leg. Holding the quad cane on the stronger side of the body and moving the cane in unison with the weaker leg gives support and helps to maintain stability for the client.

A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good understanding of how to use a bulb syringe to suction excess mucous from the infant's airway? a. "I should compress the bulb syringe after I place it in my baby's mouth." b. "The bulb syringe should reach to the back of my baby's throat." c. "The bulb syringe should be sterilized after each use." d. "I should suction my baby's mouth before the nose."

d. "I should suction my baby's mouth before the nose." RATIONALE: The mouth should always be suctioned before the nose to prevent aspiration during the gasp response that occurs when the nose is suctioned.

For which of the following clients would benefit most from use of a walker? a. A 67-year-old male client post cerebrovascular accident with minimal right sided weakness. b. A 43-year-old avid jogger one week status post right knee replacement. c. A 32-year-old female client who fractured her left tibia. d. An 82-year-old female client post right hip replacement that has had two falls in the past week.

d. An 82-year-old female client post right hip replacement that has had two falls in the past week. RATIONALE: Walkers are needed for clients with balance problems or those that cannot support their own weight.

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration? a. Instructing the client to cough forcefully as the feeding is started. b. Assisting the client into a supine position in preparation for the feeding. c. Performing nasotracheal suctioning before initiation of the feeding. d. Assessing gastric residual volume immediately before administering the feeding

d. Assessing gastric residual volume immediately before administering the feeding RATIONALE: Measuring the gastric residual volume (GRV) every 4 to 6 hours in clients who are receiving continuous feedings and immediately before the feeding in clients receiving intermittent feedings is an effective way to reduce the risk of aspiration. Nursing measures to reduce the risk of aspiration, such as keeping the head of bed elevated and routine assessment for aspiration, should be implemented for clients who are receiving tube feedings. Feedings should be withheld if the GRV is greater than 200 mL in two successive measurements.

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? a. Assess for perineal pain or discomfort. b. Examine condition of catheter and drainage tubing. c. Assess the client's knowledge of importance of perineal hygiene. d. Avoid inadvertently advancing the catheter into the bladder.

d. Avoid inadvertently advancing the catheter into the bladder. RATIONALE: Accidental advancement of the catheter into the bladder during cleansing increases the risk of introducing bacteria into the bladder. Therefore, avoiding inadvertent advancement of the catheter into the bladder is the priority intervention.

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? a. Mild diarrhea b. Abdominal distension c. Difficulty evacuating bowels d. Decreased urine output

d. Decreased urine output

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period? a. Suggest methods for reducing urinary incontinence, such as Kegel exercises. b. Administer a stool softener to prevent constipation. c. Teach the client how to care for a urinary catheter and leg bag. d. Encourage use of patient-controlled analgesia (PCA) as needed.

d. Encourage use of patient-controlled analgesia (PCA) as needed.

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? a. Roast chicken and cooked spinach. b. Grilled salmon and cooked apricots. c. Broiled liver and white rice. d. Pork chop and brown rice

d. Pork chop and brown rice