Basic care and comfort
A client asks a nurse if a large enteric-coated tablet can be cut in half. What is the best response by the nurse?
"Cutting the medication in half alters the medication's absorption."
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The student nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. The nursing instructor asks the student which step of the nursing process is he performing. How would the student respond?
"Data collection"
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:
"Does your child tug at either ear?"
A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse?
"Extreme fatigue from the delivery is common, and mothers often focus initially on recovery and taking in the birth experience."
The nurse reinforces the client's teaching on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional instruction has been effective?
"I chose a baked potato with broiled chicken for dinner."
Which instruction should the nurse include in teaching about diet to parents of a preschool-age child who's prescribed corticosteroids?
"You need to make sure your child consumes a low-sodium diet."
The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?
38.9° C
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?
"I'll increase my intake of unrefined grains."
A nurse reinforces preoperative instructions for a client who is scheduled for a left above-the-knee amputation. Which statement made by the client indicates an understanding of the instructions?
"Isometric exercise will help me to maintain the muscle tone of my remaining limb."
A nurse who is caring for a client who underwent a hemorrhoidectomy begins preparing a sitz bath for the client to use after the rectal packing has been removed. The client is reluctant to take the sitz bath and says to the nurse, "What good is it anyway?" Which response by the nurse would be most appropriate?
"It helps reduce swelling in the rectal area, which helps relieve the discomfort."
A female client with a history of four urinary tract infections (UTIs) in the past 3 months comes to the urology clinic reporting of burning and urinary urgency and frequency. A health care provider makes the diagnosis of UTI. Which instructions should the nurse give the client to help prevent recurring infections? Select all that apply.
-"Avoid using irritating substances such as bubble bath and scented toilet paper." -"Clean the perineal area from front to back."
The nurse is collecting data from a postoperative client. The nurse documents which subjective data? Select all that apply.
-client's description of pain -client's nausea
The nurse is preparing to feed the infant. Which actions by the infant indicate readiness to feed? Select all that apply.
-hand to mouth -rooting -mouthing
The nurse is providing care for a client who has had a stroke. Since the onset of symptoms, the client has been experiencing left-sided hemianopsia. Which nursing interventions would be appropriate? Select all that apply.
-place the client's belongings on the right side of the bed -stand on the right side of the bed when providing care -Dim the lights in the room to prevent eye strain.
A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program?
Assessing present elimination patterns
Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis?
Avoid making noise when in the child's room.
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?
Avoiding using soap on the irradiated areas
A client reports a lot of gas in the colostomy bag. Which instruction is best to give this client?
Burp the bag.
The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?
Call the physician immediately.
An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler?
Coin rubbing
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?
Continue to monitor and record hourly urine output.
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Providing a solution of hydrogen peroxide and water for use as a mouth rinse
A client has severe pruritus from hepatitis B. Which nursing intervention would best enhance the client's comfort?
Provide sponge baths for the client using tepid water.
A pregnant client comes to the clinic for a follow-up visit and reports swelling in the feet and ankles. Which recommendation would be most appropriate for the nurse to suggest?
Elevate the feet daily.
The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include?
Encourage a high-calorie, high-protein diet.
A client with a knee-to-toe cast applied informs the nurse that they are having severe itching in the ankle area and need something to scratch it with. What is the priority nursing action?
Encourage the client to avoid scratching, and confer with the health care provider if severe itching persists.
The nurse is preparing for the discharge of a neonate with a cleft lip and palate. Which nursing instruction is of highest priority?
Establish a feeding technique
All of the following components may be part of a client's medical record. When reviewing the client's chart, which will the nurse identify as the major source of subjective data about the client's health status?
Health history
The nurse is caring for a child undergoing cardiac surgery? Which home care instruction is most appropriate?
Maintain the prescribed medication regimen until the health care provider makes a change.
The nursing staff is developing a care plan for a client who's receiving palliative care for end-stage leukemia. The client is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the client's care plan?
Meeting with the pain management team to devise a more effective pain control plan
To verify the placement of a nasogastric feeding tube, what action should the nurse perform?
Obtain a chest X-ray.
A child is diagnosed with diabetes insipidus has developed a viral illness including congestion, nausea, and vomiting. What instructions should the nurse reinforce?
Obtain an alternate route for desmopressin acetate administration.
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?
Offering to go on a walk with the client
When caring for an infant with bronchopulmonary dysplasia, which is the best intervention to avoid fatigue and to decrease respiratory effort?
Place the infant on a set schedule.
A client has been diagnosed with hyperthyroidism. In assisting with the plan of care, the nurse should give priority to which goal?
Provide adequate rest and sleep.
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?
Provide humidified air with cool mist.
A client with Alzheimer's disease has a nursing diagnosis of Imbalanced nutrition: less than body requirements related to forgetfulness. What nursing intervention should be included in the care plan to encourage adequate nutritional intake for this client?
Stay with the client and encourage him or her to eat.
A nurse is reinforcing education with parents on providing adequate nutrition for their toddler who has cerebral palsy. Which observation by the nurse indicates that the education has been effective?
The child eats finger foods independently.
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?
The nurse loosens the wet-to-dry dressing with normal saline.
The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?
Using a peri bottle to clean the perineum after each voiding or bowel movement
When collecting data on a client with cellulitis of the right leg, which of the following would the nurse expect to find?
Warm, reddened, and swollen skin
The nurse is reviewing diagnostic test results for a child admitted with asthma. Which finding on the chest x-ray results does the nurse determine is characteristic of this disorder?
atelectasis
A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle?
autonomy of the client
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to:
divide daily food intake into five or six meals.
A nurse is caring for a client with a neuromuscular condition who is unable to receive oral nutrition. Which nursing action is a priority when providing continuous enteral feeding?
elevating the head of the bed at least 30 degrees
A client newly diagnosed with type 2 diabetes is admitted to the metabolic unit for treatment initiation and education. Which information should the nurse reinforce to this client as a goal for treatment?
exercise and a weight-reduction diet
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?
face rating scale
When inserting a urinary catheter on a male client, which action should the nurse take to facilitate the insertion?
instruct the client to breathe deeply
The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child?
leukocytosis
An older adult client with pneumonia has copious secretions but is having difficulty coughing them up. Which nursing action would be most appropriate?
monitoring the need for suctioning every hour
A client is in the manic phase of bipolar disorder. To help the client effectively maintain adequate nutrition, the nurse should plan to:
offer finger foods and sandwiches.
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?
peanut butter, green vegetables, and raisins
The nurse observes a client, who has left-sided paralysis from a stroke, dress independently. Which action by the client indicates proper technique for dressing the upper-extremities?
places the affected arm in the shirt before the unaffected arm
The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client?
providing pain control
A nurse in a long-term care facility is delegating a task to the unlicensed assistive personnel (UAP). Which task is appropriate to assign to the UAP?
repositioning a client every 2 hours
A nurse is examining the progress record of a client with femur fractures who has had bilateral leg skeletal traction applied. The nurse reinforces education of the child on performing Kegel exercises. What is the most important purpose of these exercises?
to maintain good perineal muscle tone by tightening the pubococcygeus muscle
A client with cirrhosis is jaundiced, edematous and experiencing severe itching with dryness. Which intervention is best to help the client?
use alcohol-free body lotion
