Foundations - Unit 5

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding fo the teaching? 1 - "I will be sure to keep the crutch tips dry." 2 - "I will hold a crutch in each hand when sitting down." 3 - "I will place my weight on my underarms." 4 - "I will lead with my right leg when going up stairs."

1 - "I will be sure to keep the crutch tips dry." Rational 1 - The nurse should instruct the client to inspect the crutch tips frequently and keep them dry at all times to decrease the risk for slipping. 2 - The nurse should instruct the client to hold both crutches in one hand and use the other hand for balance when sitting down. 3 - The nurse should instruct the client to place his weight on his arms while grasping the handgrips. Weight should never be borne on the axillae. 4 - The nurse should instruct the client to lead with the unaffected leg when going up stairs.

A nurse is reinforcing teaching with a client who is receiving PCA. Which of the following statements by the client indicates an understanding of the teaching? 1 - "I will not allow anyone to press the PCA button for me." 2 - "I will overdose if I press the PCA button more than six times an hour." 3 - "I will wait to press the PCA button until my pain in intolerable." 4 - "I will inform my nurse of my pain level before I press the PCA button."

1 - "I will not allow anyone to press the PCA button for me." Rational 1 - This statement indicates an understanding of the teaching. An important safety measure when using PCA is to avoid allowing others to operate the PCA pump. To avoid complications, such as respiratory depression, the client should be the only individual operating the PCA pump. 2 - The nurse should instruct the client that the PCA pump has a safety mechanism in place that limits the number of times a dose can be administered within a time frame to prevent oversedation. 3 - The nurse should instruct the client that the goal of the PCA is to maintain a constant level of analgesia. Waiting until the pain reaches an intolerable level can limit the ability of the medication to control the pain. 4 - The nurse should instruct the client that the PCA pump allows him to have control in managing his pain and does not require a nurse to intervene.

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the client's spiritual needs? 1 - "Tell me what the afterlife means to you." 2 - "You should discuss the afterlife with your priest." 3 - "Keep praying. A miracle could happen." 4 - "Maybe your condition will lead you close to God."

1 - "Tell me what the afterlife means to you." Rational 1 - This statement respects the client's spiritual needs by using open-ended therapeutic communication to assist the client to talk about her concerns. 2 - This statement avoids the client's concerns, which is a nontherapeutic form of communication. 3 - This statement uses unwarranted reassurance, which is a nontherapeutic form of communication. 4 - This statement uses stereotyping, which is a nontherapeutic form of communication.

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? 1 - A state 3 pressure ulcer on the coccyx 2 - A contaminated wound that is closed after 72 hours 3 - A puncture wound that is sutured 4 - An abdominal surgical wound with intact staples

1 - A state 3 pressure ulcer on the coccyx Rational 1 - The nurse should identify a pressure ulcer and other wounds with edges that are not approximated as healing by secondary intention. 2 - The nurse should identify a contaminated wound that is left open for monitoring and then closed after several days as healing by tertiary intention. 3 - The nurse should identify a wound that is sutured as healing by primary intention. 4 - The nurse should identify a surgical wound that has intact staples as healing by primary intention.

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent or oral temperature of 38.9° C (102°F). Which of the following interventions should the nurse include in the plan of care to treat the fever? 1 - Administer acetaminophen 2 - Apply ice packs to the client's axillae 3 - Maintain the room temperature at 18.3°C (64.9°f) 4 - Assist the client to ambulate for times a day

1 - Administer acetaminophen Rational 1 - The nurse should administer acetaminophen or an NSAID such as ibuprofen to the client to reduce the body's temperature. Acetaminophen inhibits the synthesis of prostaglandins, resulting in a reduced fever. 2 - The nurse should not apply ice packs to the client's axillae or groin because this measure can lead to shivering, which increases the client's body temperature. 3 - The nurse should maintain the room temperature between 21.1° to 26.7° C (70° to 80° F). A room temperature that is too low can lead to shivering, which increases the client's body temperature. 4 - The nurse should limit the client's physical activity to decrease body heat production.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? 1 - Administer an analgesic 30 min before starting the procedure 2 - Hold the syringe 5 cm (2 in) above the upper end fo the wound 3 - Place the irrigation solution in a basin of cool water 4 - Perform the wound irrigation with a 10-mL syringe with an angiocatheter

1 - Administer an analgesic 30 min before starting the procedure Rational 1 - The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure. 2 - The nurse should hold the syringe 2.5 cm (1 in) above the upper end of the wound and over the area she is cleaning to prevent syringe contamination and unsafe pressure of flowing solution. 3 - The nurse should place the irrigation solution in a basin of hot water to warm the solution to body temperature. This action will reduce vasoconstriction of the tissues. 4 - The nurse should use a 35-mL syringe with a 19-gauge needle or an angiocatheter to ensure an irrigation pressure within the correct range.

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? 1 - Check the pH of the gastric aspirate 2 - Observe the color of the gastric aspirate after adding blue dye to the formula 3 - Auscultate over the epigastrium 4 - Measure the length of the inserted NG tube

1 - Check the pH of the gastric aspirate Rational 1 - The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding. 2 - The nurse should not add blue dye to the formula as a way of checking for tube placement, because blue dye can cause adverse reactions. 3 - The nurse should not auscultate over the epigastrium because this is not a reliable indication that the tube is in place. 4 - The nurse should measure the length of the inserted NG tube immediately after insertion of the tube. However, measuring the length of the tube at this point is not a reliable indication that the tube is in place.

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first. 1 - Clamp the infusion tubing 2 - Remove the dressing 3 - Withdraw the catheter from the vein 4 - Ensure the catheter is intact

1 - Clamp the infusion tubing Rational 1 - Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal. 2 - The nurse should remove the dressing while applying countertraction to the skin to prevent discomfort. However, evidence-based practice indicates the nurse should take a different action first. 3 - The nurse should withdraw the catheter from the vein by slowly pulling it along the line of the vein. However, evidence-based practice indicates the nurse should take a different action first 4 - The nurse should ensure the catheter is intact because a broken catheter poses harm to the client and warrants notification of the provider. However, evidence-based practice indicates the nurse should take a different action first.

A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take (select all) 1 - Ensure that the client is wearing nonskid slippers 2 - Move the bedside table away from the bedside 3 - Place the client in a room near the nurses' station 4 - Keep the bed's full side rails in the up position 5 - Reinforce teaching about how to use the call bell

1 - Ensure that the client is wearing nonskid slippers 3 - Place the client in a room near the nurses' station 5 - Reinforce teaching about how to use the call bell Rational 1 - Nonskid slippers provide better traction and can help prevent slipping and falling. 2 - The nurse should keep the bedside table within the client's reach to facilitate access to items he needs. Reaching for objects increases the risk for falling out of bed. 3 - Keeping the client close to the nurses' station allows for more frequent observation to help identify actions that increase the risk for falls. 4 - Because the client might attempt to climb over the bed's full side rails and fall, the nurse should keep half side rails up and only when necessary. 5 - Even if the client is confused, it is important to reinforce the use of the call bell for assistance to help prevent the client from attempting actions that could increase the risk for falls.

A nurse is caring for a client who has an NG tube and is receiving a continuous enteral feeding. Which of the following actions should the nurse take? 1 - Hold the feeding for two consecutive gastric residuals greater than 250 mL 2 - Change the bag and tubing every 12 hr 3 - Flush the tube with 0.9% sodium chloride irrigant every 8 hours 4 - Heat the formula to body temperature before administering

1 - Hold the feeding for two consecutive gastric residuals greater than 250 mL Rational 1 - The nurse should hold the feeding if the gastric residual exceeds 250 mL after two consecutive residual checks to reduce the client's risk of aspirating gastric contents. Some facility policies require intervention if a single residual exceeds 100 mL. 2 - The nurse should change the bag and tubing every 24 hr to reduce the risk for bacterial growth. Changing the bag more often is not cost-effective. 3 - The nurse should flush the tube with water or sterile water every 4 hr to maintain tube patency. 4 - The nurse should ensure the formula is at room temperature before administering to reduce the risk for gastric discomfort.

A nurse is reinforcing teaching with a client who has a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following information should the nurse include in the teaching. 1 - Place the electrodes near the pain site 2 - The TENS unit has one constant frequency 3 - The TENS creates a sharp burning sensation when turned on 4 - The electrodes can be placed over hair

1 - Place the electrodes near the pain site Rational 1 - The nurse should instruct the client to place the electrodes near or on the pain site to produce analgesia at the peripheral neuroreceptors. 2 - The nurse should instruct the client that the TENS unit has various frequencies to produce analgesia at the peripheral neuroreceptors. 3 - The nurse should instruct the client that the TENS unit creates a tingling sensation, which produces analgesia at the peripheral neuroreceptors. 4 - The nurse should instruct the client to remove hair from the site before attaching the electrodes. This will ensure effective contact between the unit and the client's skin, as well as sufficient stimulation.

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? 1 - Precontemplation 2 - Preparation 3 - Maintenance 4 - Action

1 - Precontemplation Rational 1 - Precontemplation - According to the stages of health behavior change, precontemplation is the first stage the client will experience. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. 2 - Preparation - According to the stages of health behavior change, preparation is not the first stage the client will experience. In this stage, the client plans to make minor changes to behavior. 3 - Maintenance- According to the stages of health behavior change, maintenance is not the first stage the client will experience. In this stage, the client sustains changes to behavior. 4 - Action - According to the stages of health behavior change, action is not the first stage the client will experience. In this stage, the client actively changes behavior.

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? 1 - Young adults should receive a dental assessment every 6 months 2 - Young adult males should have a testicular examination every 5 years 3 - Young adult females should have a routine physical examination every 4 years 4 - Young adults should receive a tuberculosis skin test every 3 years.

1 - Young adults should receive a dental assessment every 6 months Rational 1 - The nurse should include the recommendation for young adults to receive a dental assessment twice per year. 2 - Young adult males should have a testicular examination annually. 3 - Young adult females should have a routine physical examination every 1 to 3 years. 4 - Young adults who have an increased risk of exposure should receive a tuberculosis skin test every 2 years.

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? 1 - "Why are you angry about taking insulin?" 2 - "Don't worry. Diabetes runs in my family as well." 3 - "I see that you are angry. Let's sit down and talk." 4 - "You should take insulin, because it reduces the risk for complications."

3 - "I see that you are angry. Let's sit down and talk." Rational 1 - This response is probing and might make the client defensive. 2 - This response is unwarranted reassurance and dismisses the client's feelings. 3 - This is an example of the therapeutic communication technique of offering self. It provides an opportunity for the nurse to understand the reason for the client's anger and provides a means for further communication. 4 - This response is judgmental, ignores the client's anger, and does not encourage her to discuss her feelings.

A nurse is collecting data from a client who is menopausal. Which of the following statements indicates that the nurse should screen the client for depression? 1 - "Everything is fine. I started a glass blowing class this week." 2 - "I am really not old enough to be going through menopause." 3 - "My family doesn't need me anymore. I've failed them in so many ways." 4 - "I am only 50 and my children treat me like I am old."

3 - "My family doesn't need me anymore. I've failed them in so many ways." Rational 1 - This statement is an example of an expected response to menopause. Instead of allowing menopausal symptoms to restrict her activities, this client is expanding her social interactions and embracing a new skill. 2- This statement indicates denial or a lack of knowledge about menopause, but it does not indicate depression. 3 - This statement indicates feelings of hopelessness and powerlessness, which are indications of depression 4 - This statement can indicate a lack of communication within the family, but it does not indicate depression. The nurse should assess family dynamics to promote relationships.

A client who had a recent below-the-knee amputation says, "I don't know how I can continue to live my life without my leg." Which of the following responses should the nurse make? 1 - "You can have a prosthesis after you recovery has progressed." 2 - "I am so sorry. I know I would hate to lose my leg." 3 - "Tell me what concerns you have about your future." 4 - "Your focus right now should be on recovering from surgery."

3 - "Tell me what concerns you have about your future." Rational 1 - This response changes the subject and is dismissive of the client's concerns. 2 - This response is sympathetic rather than empathetic. It places emphasis on the nurse's feelings rather than those of the client. 3 - This response is therapeutic because it is open-ended, nonjudgmental, and allows the client to further express emotions about the amputation. 4 - This response is judgmental and is dismissive of the client's concerns. It also gives an unsolicited opinion.

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching. 1 - "We will make sure she eats three meals a day." 2 - "We will decrease her pain medication if she gets too drowsy." 3 - "We will keep her room cool to help her breathe better." 4 - "We will make sure to provide oral care twice a day."

3 - "We will keep her room cool to help her breathe better." Rational 1 - Clients who are dying might have decreased appetites due to the disease process and medication side effects. Clients should not be forced to eat. 2 - Clients who are dying should be provided enough pain medication to promote comfort. Moderate increases in the client's pain medication will not hasten death. 3 - Clients who are dying will have thick secretions and decreased muscle tone, which can make breathing more difficult. Keeping the air in the room cool will ease the work of breathing. 4 - Clients who are dying will require oral care at least every 2 to 4 hr to keep the oral mucosa moisturized and prevent lesions.

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires action by the nurse. 1 - "I don't understand why everyone is so worried about me." 2 - "I don't know if I'll ever find someone who wants to marry me." 3 - "When I look at myself in the mirror, I don't know if I can go on." 4 - "I feel like the doctor pressured me into having the mastectomy."

3 - "When I look at myself in the mirror, I don't know if I can go on." Rational 1 - This statement reflects the client's denial of her situation. It is important to ensure that the client has an accurate understanding of her condition; however, another statement requires immediate action 2- This statement reflects the client's concerns about future intimacy. It is important to acknowledge the client's need for intimacy; however, another statement requires immediate action. 3 - This statement shows sadness and a decreased initiative. The greatest risk to this client is injury from suicidal ideation. Therefore, the priority action is for the nurse to immediately contact the client's provider regarding this statement. 4 - This statement reflects the client's anger at her situation. It is important to acknowledge the client's feelings; however, another statement requires immediate action.

A nurse is caring for a female client who has urinary incontinence. Which of the following action should the nurse take? 1 - Instruct the client to perform the Valsalva maneuver during urinary urges 2 - Cleanse the client's labia minora before cleansing the labia majora 3 - Apply a moisture skin barrier to the client's perineal area 4 - Implement a toiling schedule for the client with 4 hr intervals

3 - Apply a moisture skin barrier to the client's perineal area Rational 1 - The nurse should instruct the client to take deep breaths and perform pelvic exercises when she feels the urge to urinate. These actions can help prevent incontinence; however, performing the Valsalva maneuver will not. 2 - When providing skin care, the nurse should cleanse the perineal area from most clean to least clean. Therefore, the nurse should first cleanse the labia majora followed by the labia minora. The labia minora is considered the less clean area as it tends to collect secretions, which can result in bacterial growth and skin breakdown. 3 - The nurse should apply a moisture barrier, which can prevent urine from causing skin breakdown. The nurse should provide perineal care at the end of the client's bath and after each incontinent episode using mild cleansers and applying a skin barrier to keep moisture off the skin. 4 - The nurse should implement a toileting schedule with intervals of 2 to 3 hr. Waiting for 4 hr before toileting can result in incontinence.

A nurse is caring for a client who is alert and in a long-term care facility. Which of the following actions should the nurse take to protect the client's privacy 1 - Place the laboratory results on the bedside table while ambulating the client 2 - Give report about the client's status while standing in the hallway 3 - Ask the client before discussing his condition when the family is present 4 - Place a message board in the client's room to post vital sign values

3 - Ask the client before discussing his condition when the family is present Rational 1 - Placing laboratory results on the bedside table unattended can violate the client's privacy by allowing visitors or staff members not caring for the client to view this information. 2 - Giving report about the client in a location where others might hear can violate the client's privacy. 3 - As long as the client agrees, the nurse may share health information with the client's family. The nurse may share information with whomever the client designates even when the client is not present. 4 - Posting client health care information in the client's room can violate the client's privacy by allowing anyone who enters the room to view this information.

A nurse is assisting with the admission of a client who has brough her medications to the facility. Which of the following actions should the nurse take? 1 - Allow the client to continue taking the medications as she did at home 2 - Take the medications from the client and discard them 3 - Compare the medications the provider has prescribed with the client's medications from home 4 - Place the medications in the medication cart and administer them as the client took them at home

3 - Compare the medications the provider has prescribed with the client's medications from home Rational 1 - Allowing the client to self-administer her medications as she did at home poses a risk for overdose and interactions when taken with medications that the provider prescribes during hospitalization. During changes in the level of care, the provider often changes prescriptions, and the client needs to follow the most recent plan of care. 2 - Each facility has policies and procedures for handling the client's possessions, including medications. Discarding the medications the client purchased shows a lack of respect for the client's personal property. 3 - During admission, the nurse should compare the medications that the provider has prescribed with the medications that the client is taking at home to decrease the risk of medication error. The nurse should include this information in the client's medical record as a resource for other health care personnel. 4 - Administering the medications as the client took them at home might cause harm to the client since the provider often updates the treatment plan at admission to an acute facility. The nurse should not dispense medications from the client's home supply because she cannot validate that the medication and dose are correct as labeled.

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? 1 - Replace the NG tube 2 - Place the client in Sim's position 3 - Decease the rate of the feeding 4 - Check the client's blood glucose

3 - Decease the rate of the feeding Rational 1 - The nurse should replace the NG tube if the client demonstrates indications of tube displacement, such as coughing and vomiting. The findings for this client do not indicate tube displacement. 2 - The nurse should maintain a client who is receiving continuous NG tube feedings in a position with the head of the bed elevated 30° to 45° to prevent aspiration of the formula 3 - .The nurse should expect to hear bowel sounds every 5 to 35 seconds. This audio clip indicates hypermotility because there are greater than 40 bowel sounds per min. Hypermotility leads to diarrhea and is an indication of intolerance to the enteral feeding. Therefore, the nurse should slow the rate of the feeding to promote the client's tolerance of the feeding. 4 - The nurse should check the blood glucose if the client demonstrates indications of hyperglycemia such as headache and confusion. The client can develop hyperglycemia when receiving continuous NG tube feedings. The findings for this client do not indicate the presence of hyperglycemia.

A nurse is caring for a client who is refusing medical treatment. Which of the following actins should the nurse take? 1 - Explain the negative consequences of the refusal 2 - Discuss with the client's partner why the treatment is necessary 3 - Document the client's refusal of the treatment 4 - Try to convince the client that the treatment is needed.

3 - Document the client's refusal of the treatment Rational 1 - The provider is responsible for explaining the negative consequences of the client's refusal. 2 - Consulting with the client's partner can be a violation of the client's privacy. 3 - The nurse is responsible for notifying the provider when a client refuses a treatment or procedure and documenting the client's decision. 4 - The nurse should ensure that the client has been fully informed. However, the client has the right to refuse treatment.

A charge nurse is reinforcing teaching with an assistive personnel(AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? 1- Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds 2 - Use an adhesive oximetry probe for a client who has a latex allergy 3 - Remove polish from the client's fingernail before applying the oximetry probe 4 - Lubricate the tip of the oximetry probe

3 - Remove polish from the client's fingernail before applying the oximetry probe Rational 1 - The nurse should instruct the AP to select an alternate site to place the probe if the capillary refill is greater than 2 seconds because of the inability of the sensor to detect a pulsating vascular bed to produce a reading. 2- The nurse should instruct the AP not to apply an adhesive oximetry probe on the client who has a latex allergy because it can cause an anaphylactic reaction. 3 - The nurse should instruct the AP to remove the client's fingernail polish on at least one finger before placing the probe on that finger because the sensor needs to detect a pulsating vascular bed to produce a reading. 4 - The nurse should instruct the AP to ensure that the site is free of moisture and has adequate circulation to obtain an accurate reading.

A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? 1 - Give the paper to a member of the client's family 2 - Place the paper in a receptacle at the nurse's station 3 - Shred the paper in a secure container 4 - Discard the paper at home

3 - Shred the paper in a secure container Rational 1 - Giving a paper that contains written client information to a member of the client's family can be a violation of the client's privacy and HIPAA guidelines. 2 - Placing the paper in a receptacle at the nurse's station puts the client's private information at risk for a violation of privacy and HIPAA guidelines. 3 - The nurse should shred any written information in a secure container after use to protect the client's privacy and adhere to HIPAA guidelines. 4 - Taking written client information home is a violation of the client's privacy and HIPAA guidelines.

A nurse is reinforcing teaching with an older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep. 1 - The need for sleep diminishes with age 2 - Older adults have longer rapid eye movement (REM) periods 3 - Sleep patterns change with age 4 - Sleep apnea decreases with age

3 - Sleep patterns change with age Rational 1 - Although older adults often have difficulty falling asleep, the amount of sleep required does not change with age. 2 - Older adults have a shortened period of REM sleep, and they sleep less soundly. 3 -The circadian sleep-wake cycle changes with age. Older adults tend to have difficulty falling asleep, wake frequently during the night, and nap during the day. 4 - The risk for sleep apnea increases with age due to a decrease in upper-airway muscle activity and the resulting impairment of the patency of the pharynx.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? 1 - The client has smooth, brown, irregular lesions on the back of each hand. 2 - The client has glossy, white circles around the periphery of the corneas 3 - The client reports urinary incontinence 4 - The client reports a decreased sense of taste

3 - The client reports urinary incontinence Rational 1 - Smooth, brown, irregular lesions on the backs of the hands of an older adult are an expected age-related physical change. 2 - Glossy, white circles around the periphery of the corneas, known as arcus senilis, are an expected age-related physical change. 3 - Urinary incontinence is not an expected age-related change. Aging, menopause, and prostatic enlargement are risk factors for urinary incontinence; therefore, the nurse should report this finding to the provider. Urinary incontinence might be manageable with treatment. 4 - A decreased sense of taste is an expected age-related physical change.

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? 1 - Close the fire doors on the unit 2 - Use a fire extinguisher to put out the fire 3 - Evacuate clients from the area 4 - Pull the lever on the fire alarm box

3, 4, 1, 2 3 - Evacuate clients from the area 4 - Pull the lever on the fire alarm box 1 - Close the fire doors on the unit 2 - Use a fire extinguisher to put out the fire Rational The first action the nurse should take when using the RACE protocol is to "rescue" or evacuate the clients from the area to prevent harm. For the next step, "alarm," the nurse should activate the facility fire alarm and call to report the fire to the facility emergency extension. For the third step, "confine," the nurse should close the unit fire doors to prevent the fire from spreading. For the final step, "extinguish," the nurse should use a fire extinguisher to put out the fire by aiming the nozzle at the base of the fire and using a sweeping motion.

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? 1 - "Keep your knees in a locked position when standing for prolonged periods." 2 - "Bend at the waist when lifting a heavy object." 3 - "Keep your feet close together when lifting a heavy object." 4 - "When lifting a heavy object, keep it close to your body."

4 - "When lifting a heavy object, keep it close to your body." Rational 1 - The nurse should instruct the client to avoid standing for a long period of time. If the client cannot avoid it, he should place one foot on a stool to minimize stress on the back. 2 - The nurse should instruct the client to keep his back straight and bend at the knees when lifting a heavy object. 3 - The nurse should instruct the client to maintain a wide base of support by keeping his feet far apart when lifting a heavy object 4 - The nurse should instruct the client to keep the object as close to his body as possible to increase stability and decrease back strain when lifting a heavy object.

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrate an understanding of the teaching? 1 - 1 cup of cantaloupe 2 - 1 large baked potato 3 - 4 oz of banana chips 4 - 1 cup of applesauce

4 - 1 cup of applesauce Rational 1 - The nurse should recommend that the client choose a different food that contains less potassium. One cup of cantaloupe contains 473 mg of potassium 2 - The nurse should recommend that the client choose a different food that contains less potassium. One large baked potato contains 1,630 mg of potassium 3 - The nurse should recommend that the client choose a different food that contains less potassium. Four ounces of banana chips contains 608 mg of potassium. 4 - The nurse determines that applesauce is the best food choice because 1 cup of applesauce contains 184 mg of potassium per serving. Therefore, the client's food choice of applesauce demonstrates an understanding of the teaching.

A nurse is reviewing the vital sings of four clients. Which of the following findings requires further data collection by the nurse? 1 - A client who has a respiratory rate of 12/min 2 - A client who has a blood pressure of 110/74 mm Hg 3 - A client who has a temperature of 37.3°C (99.2° F) 4 - A client who has a pulse of 110/min

4 - A client who has a pulse of 110/min Rational 1 - This client's respiratory rate is within the expected reference range. Therefore, the nurse does not need to collect further data. 2 - This client's blood pressure is within the expected reference range. Therefore, the nurse does not need to collect further data. 3 - This client's temperature is within the expected reference range. Therefore, the nurse does not need to collect further data. 4 - This client's heart rate is above the expected reference range. Therefore, the nurse should collect further data to determine the cause of the tachycardia.

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? 1 - Provide an artificial voice box 2 - Avoid using facial gestures 3 - Speak to the client in a louder voice 4 - Ask the client close-ended questions

4 - Ask the client close-ended questions Rationals 1 - The nurse should provide an artificial voice box for a client who had a laryngectomy. 2 - The nurse should use facial gestures when communicating with the client to assist the client in understanding the context of the conversation. 3 - The nurse should use a normal voice when speaking with the client. Speaking loudly can cause the client distress. 4 - Clients who have aphasia can have difficulty forming words. Therefore, the nurse should ask the client questions that can be answered with a "yes" or "no" because the client can respond to these close-ended questions by shaking or nodding her head.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? 1 - Ensure a client can use crutches before discharge 2 - Check a client's ability to swallow following a stroke 3 - Obtain a client's pain rating prior to physical therapy 4 - Assist a client to get out of bed after a breathing treatment

4 - Assist a client to get out of bed after a breathing treatment Rational 1 - Ensuring a client can use crutches is a form of evaluation of care and is outside an AP's range of function. 2 - Checking to see if a client can swallow following a stroke is a form of data collection and is outside an AP's range of function. 3 - Obtaining a client's pain rating is a form of data collection and is outside an AP's range of function. 4 - The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's range of function.

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? 1 - Confidentiality 2 - Nonmaleficence 3 - Accountability 4 - Autonomy

4 - Autonomy Rational 1 - Confidentiality is an ethical principle that refers to protecting a client's right to privacy. 2 - Nonmaleficence is an ethical principle that refers to the avoidance of causing harm. 3 - Accountability is an ethical principle that refers to taking responsibility for one's actions. 4 - Autonomy is an ethical principle that refers to protecting a client's independence and right to make decisions about care.

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that they client has fluid volume excess? 1 - Urine specific gravity 1.015 2 - Hematocrit 42% 3 - Urine pH 6.5 4 - BUN 8 mg/dL

4 - BUN 8 mg/dL Rational 1 - A urine specific gravity of 1.015 is within the expected reference range. With fluid volume excess, the nurse should expect the urine specific gravity to be below the expected reference range due to dilution of the urine. 2 - A hematocrit of 42% is within the expected reference range. With fluid volume excess, the nurse should expect the client's hematocrit to be below the expected reference range due to hemodilution. 3 - A urine pH of 6.5 is within the expected reference range. Hydration status does not affect pH levels. 4 - A BUN of 8 mg/dL is below the expected reference range. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution.

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? 1 - Show the assistive personnel where to apply the medication 2 - Ask the client when the previous nurse last applied the medication 3 - Identify the client by comparing the medication administration record with the client's room number 4 - Compare the label of the medication container with the medication administration record three times.

4 - Compare the label of the medication container with the medication administration record three times. Rational 1 - The nurse should not delegate any part of the medication administration process to an assistive personnel because this action requires the use of nursing judgment. 2 - The nurse should check the medication administration record to determine when the last dose was administered. 3- The client's room number is not an acceptable identifier when administering medications. 4 - When preparing medication from a bottle or container, the nurse should compare the label of the medication container with the medication administration record three times to ensure it is the correct medication.

A nurse is reinforcing teaching with a client about using guided imagery. Which of the following actions should the nurse take? 1 - Instruct the client to alternately tighten and relax muscles 2 - Evaluate the client's energy field 3 - Attach electronic sensors to the client prior to beginning therapy 4 - Direct the client to visualize tension leaving the body

4 - Direct the client to visualize tension leaving the body Rational 1- The nurse should instruct the client to alternately tighten and relax muscles when reinforcing teaching about progressive relaxation. 2 - The nurse should evaluate the client's energy field when providing therapeutic touch therapy to identify areas of energy obstruction. Therapeutic touch, healing touch, and Reiki involve energy field manipulation and require special training. 3 - The nurse should attach electronic sensors to the client prior to beginning biofeedback therapy to provide information regarding physiologic changes related to the client's internal well-being. 4 -The nurse should direct the client to visualize tension leaving the body during exhalation while using guided imagery. Guided imagery uses mental images to assist the client in relaxation through the use of abdominal breathing.

A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? 1 - Using hand sanitizer to cleanse her hands of spilled food from a client's meal tray 2 - Setting aside her gown for future use in the room of a client who has a wound infection 3 - Removing her gloves after exiting a client's room 4 - Donning a mask to measure the vital signs for a client who has pertussis

4 - Donning a mask to measure the vital signs for a client who has pertussis Rational 1 - The AP should wash her hands with soap and running water whenever they are visibly soiled, such as when food has been spilled on them. 2 - The AP should don a new gown each time she enters the room because a gown is a single-use item. 3 - The AP should remove her gloves before leaving a client's room. 4 - Caring for clients who have pertussis requires droplet precautions. Therefore, the AP should wear a mask when within 1 m (3.3 feet) of the client.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? 1 - Support the client's head with a pillow that maintains cervical flexion 2 - Position the client's shoulders off the pillow for internal rotation 3 - Place the client's arms at his side to keep his elbows extended 4 - Internally rotate the client's hips by using a trochanter roll

4 - Internally rotate the client's hips by using a trochanter roll Rational 1 - The nurse should position the client's head on a pillow that does not cause cervical flexion when the client is supine. 2 - The nurse should support the client's shoulders with a pillow or blanket to prevent internal rotation of the shoulders when the client is supine. 3 - The nurse should position the client's elbows in a flexed position on pillows when the client is supine. 4 - The nurse should internally rotate the client's hips by using a trochanter roll when the client is supine to prevent external rotation of the hips.

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? 1 - Nasal cannula 2 - Simple face mask 3 - Venturi mask 4 - Nonrebreather mask

4 - Nonrebreather mask Rational 1 - A nasal cannula provides a low oxygen concentration. 2 - A simple face mask can be adjusted for short-term delivery of low to medium oxygen concentration. 3 - A Venturi mask can be adjusted to provide a consistent lower oxygen concentration. 4 - A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? 1 - Bone pain 2 - Drowsiness 3 - Bowel hypomotility 4 - Positive Chvostek's sing

4 - Positive Chvostek's sing Rational 1 - The nurse should identify bone pain as a finding associated with hypercalcemia. 2 - The nurse should identify drowsiness as a finding associated with hypermagnesemia. 3 - The nurse should identify decreased bowel motility as a finding associated with hypokalemia. 4 - To elicit Chvostek's sign, the nurse should tap the client's facial nerve near the ear. If the client's facial muscles contract, the sign is positive, indicating low serum magnesium or calcium level

A nurse is reinforcing preoperative teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? 1 - Ask a family member who speaks the client's primary language to interpret 2 - Plan a long teaching session initially to introduce the necessary material 3 - Provide the least important information first 4 - Provide handouts written in the client's primary language

4 - Provide handouts written in the client's primary language Rational 1 - The nurse should request a certified interpreter to deliver the instructions to the client. The nurse should not ask the client's family members to interpret because they are not trained in medical terminology. 2 - The nurse should plan teaching sessions that are short in length to promote learning 3 - The nurse should provide the most important information first while the client is receptive to learning. 4 - The nurse should provide handouts that are easy to read in the client's primary language to promote learning.

A nurse is reinforcing teaching with an older adult client about oral hygiene. Which of the following instructions should the nurse include in the teaching. 1 - Use a firm-bristled toothbrush 2 - Use lemon-glycerin sponges between meals for dry mouth 3 - Replace her toothbrush eve 6 months 4 - Replace her toothbrush following an illness

4 - Replace her toothbrush following an illness Rational 1 - The nurse should instruct the client to use a rounded, soft-bristled toothbrush to stimulate gum regeneration and prevent bleeding. 2 - The nurse should instruct the client to avoid lemon-glycerin sponges for dry mouth because they dry the mucous membranes and erode tooth enamel. 3 - The nurse should instruct the client to replace her toothbrush every 3 months to decrease the risk for acquiring an infection. 4 - The nurse should instruct the client to replace her toothbrush following an illness to decrease the risk for reacquiring an infection.

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number)

1820 mL

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? 1 - Restrict the client's visitors to the immediate family 2 - Assign the client to a negative-pressure airflow room 3 - Discard personal protective equipment outside the client's room 4 - Have the client wear a HEPA mask during transportation throughout the facility

2 - Assign the client to a negative-pressure airflow room Rational 1 - The nurse does not need to restrict visitors, but should ensure that they follow airborne precaution guidelines. 2 - The nurse should assign the client to a negative-pressure airflow room to ensure that the air from the client's room is not circulated throughout the facility. 3 - The nurse should remove personal protective equipment before leaving the client's room to prevent the spread of bacteria outside the room. 4 - The nurse should have the client wear a surgical mask whenever she leaves her room to prevent transmitting bacteria to others.

A nurse is using Maslow's hierarchy of needs is assisting with discharge planning for a client. Which of the following actives should the nurse recommend as a priority for this client. 1 - Volunteer at the local food pantry 2 - Attend an exercise program 3 - Find an enjoyable hobby 4 - Support environmental conservation

2 - Attend an exercise program Rational 1 - According to Maslow's hierarchy of needs, volunteering at the local food pantry helps fulfill the client's self-esteem needs. Therefore, another activity is the priority. 2 - When using Maslow's hierarchy of needs, the nurse determines the priority activity is to fulfill the client's physiological needs for activity, Therefore, the nurse should recommend exercise and help the client select a suitable exercise program. 3 - According to Maslow's hierarchy of needs, finding an enjoyable hobby helps fulfill the client's self-esteem needs. Therefore, another activity is the priority. 4 - According to Maslow's hierarchy of needs, supporting environmental conservation helps fulfill the client's self-actualization needs. Therefore, another activity is the priority.

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refused to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles. 1 - Automony 2 - Beneficence 3 - Justice 4 - Nonmaleficence

2 - Beneficence Rational 1 - The nurse is not demonstrating autonomy. The nurse is attempting to compromise, rather than simply accepting the client's refusal of the medication. 2 - The nurse is demonstrating beneficence by acting in the client's best interest to make it possible for the client to swallow the medication. 3 - Justice refers to fairness in client care. A nurse demonstrates fairness by dividing his time among assigned clients to ensure all clients have their needs met. 4 - Nonmaleficence means to avoid harm or injury to the client. This situation does not involve a choice among potentially painful interventions.

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? 1 - Body regulation of heat and cold increases with age 2 - Circulation becomes less efficient with age 3 - Increased metabolic rate occurs with age, increasing body temperature 4 - Sweat gland actives sis increased with age

2 - Circulation becomes less efficient with age Rational 1 - Older adults have a decreased ability to regulate body temperature due to poor control of vasoconstriction and vasodilation. Older adults also have a reduced ability to shiver to increase body temperature. 2 - Older adults have an increased sensitivity to temperature extremes due to decreased cardiac output. Poor cardiac output leads to less efficient circulation of blood to the tissues. 3 - Older adults have a decreased body temperature due to decrease in metabolic rate. 4 - Older adults will have a decrease in sweat gland activity, which affects body temperature regulation.

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? 1 - Check for capillary refill proximally to the elastic bandages every 12 hr 2 - Compare the client's pedal pulses bilaterally every 4 hr 3 - Place the client's legs in a dependent position for 30 min before applying the elastic bandages 4 - Remove the elastic bandages every other day to inspect the skin

2 - Compare the client's pedal pulses bilaterally every 4 hr Rational 1 - The nurse should check capillary refill distally every 4 hr for a client who has elastic bandages on his lower extremities. 2 - The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on his lower extremities. 3 - The nurse should elevate the client's legs for at least 20 min before applying the elastic bandages. 4 - The nurse should remove the elastic bandages daily to inspect for skin breakdown.

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following as indications that the client has fluid volume deficit? Select all 1 - Full Bounding Pulse 2 - Decreased skin turgor 3 - Moist crackles in the lungs 4 - Orthostatic hypotension 5 - Flat neck veins

2 - Decreased skin turgor 4 - Orthostatic hypotension 5 - Flat neck veins Rational Full bounding pulse is incorrect. A full bounding pulse indicates fluid volume excess. The nurse should expect a weak peripheral pulse in a client who has fluid volume deficit. Decreased skin turgor is correct. Poor skin turgor indicates fluid volume deficit. Moist crackles in the lungs is incorrect. Moist crackles in the lungs indicate fluid volume excess. The nurse should expect clear lungs in a client who has fluid volume deficit. Orthostatic hypotension is correct. Orthostatic hypotension indicates fluid volume deficit. Flat neck veins is correct. Flat neck veins indicate fluid volume deficit.

A nurse is palpating the pulse located on top of a client's foot. Which of the following pulses should the nurse document that she is palpating? 1 - Posterior tibial 2 - Dorsalis pedis 3 - Popliteal 4 - Femoral

2 - Dorsalis pedis Rational 1 - The posterior tibial pulses are located on the inner side of the ankle below the medial malleolus. 2 - The nurse should document palpating the dorsalis pedis pulse on the top of the foot. 3 - The popliteal pulses are located behind the knees. 4 - The femoral pulses are located below the inguinal ligament in the groin area.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? 1 - Empty the urine drainage bag every 12 hr 2 - Drain urine from the tubing before ambulation 3 - Use clean technique for urine specimen collection 4 - Use clean technique for urine specimen collection 5 - Hang the urine drainage bag at the level of the bladder.

2 - Drain urine from the tubing before ambulation Rational 1 - The nurse should empty the drainage bag whenever it is half full. 2 - Draining urine from the tubing before ambulation will prevent backflow of urine into the bladder. 3 - The nurse should use sterile technique to collect specimens from the drainage system to prevent contamination. 4 - The nurse should hang the drainage bag below the level of the client's bladder to prevent backflow of urine into the bladder.

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to the included in the plan of care? 1 - Place the client in a room with another client who has pharyngitis 2 - Ensure that the client wears a surgical mask during transportation throughout the facility 3 - Limit the client's family member visitations to 30 min 4 - Provide the client a room with negative-pressure airflow of six air exchanges per hr

2 - Ensure that the client wears a surgical mask during transportation throughout the facility Rational 1 - Many organisms can cause pharyngitis; therefore, the nurse should only place the client in a room with another client who has a positive throat culture for streptococci to prevent bacterial transmission. 2 - Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room. 3 - There are no restrictions on the time visitors may spend with a client who has a positive throat culture for streptococci. 4 - The nurse should provide a room with negative-pressure airflow for clients who require airborne precautions.

A nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. Which of the following is a priority modification that the nurse should include. 1 - Alarm clock that shakes the bed 2 - Flashing smoke alarm 3 - Low-pitched buzzer doorbell 4 - Telephone with an amplified receiver

2 - Flashing smoke alarm Rational 1 - An alarm clock that shakes the bed is an effective waking tool for a client who has hearing loss because he can feel the vibrations rather than having to hear the alarm. However, another modification is the priority. 2 - The greatest risk to the client's safety is injury from a fire. Therefore, the priority modification is to install flashing smoke alarms because this allows the client to see when the alarm is activated rather than having to hear it. 3 - A doorbell with a low-pitched buzzer is an effective tool for a client who has a partial hearing loss because, with sensorineural hearing loss, low-pitched sounds are easier to hear than high-pitched sounds. However, another modification is the priority. 4 - A telephone with an amplified receiver is an effective tool for a client who has a partial hearing loss because it can help him hear during a telephone conversation. However, another modification is the priority.

A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching? 1 - Carbon monoxide gas smells like rotten eggs 2 - Headache is a manifestation of carbon monoxide poisoning 3 - A pulse oximeter is used to diagnose carbon monoxide poisoning 4 - Dusky mucous membranes are an early indication of carbon monoxide poisoning

2 - Headache is a manifestation of carbon monoxide poisoning Rational 1 - The nurse should instruct that carbon monoxide is a clear, odorless gas. 2 - The nurse should instruct that headache, dizziness, and weakness are manifestations of carbon monoxide poisoning. 3 - The nurse should instruct that a pulse oximeter is used to measure oxygen saturation and cannot diagnose carbon monoxide poisoning. 4 - The nurse should instruct that cherry-red mucous membranes are an indication of carbon monoxide poisoning.

A client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? 1 - Keep the conversation moving by asking about his family 2 - Let the client know that he is available and willing to listen 3 - Ask if the client understands what to expect in the advanced stages of the illness. 4 - Ask the client's visitors to not say anything about the advanced disease

2 - Let the client know that he is available and willing to listen Rational 1 - Changing the subject reflects a lack of empathy for the client's feelings and a disregard for the client's needs. 2 - Active listening conveys the nurse's respect and acceptance for the client's feelings and gives the client an opportunity to express his thoughts and needs. 3 - Asking the client for an explanation about his illness can reflect lack of empathy for the client's feelings. The client's words indicate that he needs help in coping with his situation. 4 - Interfering with the visitors' relationship with the client in this way suggests that the nurse is controlling the situation and blocking communication of the client's feelings and needs to his family and friends.

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? 1 - Isopropyl alcohol 2 - Mild soap 3 - Chlorhexidine 4 - Triclosan

2 - Mild soap Rational 1 - Isopropyl alcohol is an active ingredient in the alcohol-based cleansing solutions nurses use to perform hand hygiene when in contact with bacteria, fungi, and viruses. However, alcohol does not kill C. difficile. 2 - The CDC recommends using soap and water for handwashing when caring for clients who have a C. difficile infection. C. difficile is a spore-forming bacterium that is difficult to kill with disinfectants 3 - Chlorhexidine solution is effective against bacteria and viruses. However, this solution does not kill the spores of C. difficile. 4 - Triclosan is effective against some bacteria. However, this solution does not kill the spores of C. difficile.

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actins should the nurse include in the plan. 1 - Check that the restraint is tied to a fixed frame of the bed 2 - Pad bony prominences of the wrist 3 - Remove the restraint every 4 hr to allow movement 4 - Tie the restraint with a knot that will tighten when pulled

2 - Pad bony prominences of the wrist Rational 1 - The nurse should tie the restraint to the part of the bedframe that moves when raising or lowering the head of the bed. The restraint should not be tied to the siderails or the immovable part of the bedframe. 2 - The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client's skin. 3 - The nurse should remove the restraint every 2 hr. 4 - A knot that tightens when pulled could injure the client. The nurse should use a quick-release knot or buckle to secure the restraint.

A nurse in a long-term care facility is contributing to the plan of care for a client who is at risk for pressure ulcers. Which of the following recommendations should the nurse include in the plan? 1 - Complete a Braden scale at the first indication of pressure ulcer formation 2 - Perform a thorough skin inspection each day 3 - Gently massage skin over bony prominence 4 - Place a dehumidifier in the client's room

2 - Perform a thorough skin inspection each day Rational 1 - The nurse should complete the Braden scale prior to pressure ulcer formation to determine the client's risk for skin breakdown. 2 - The nurse should perform a thorough skin inspection, including all bony prominences, each day. This daily inspection helps ensure that prompt treatment is provided for any indications of pressure ulcer formation. 3 - Evidence-based practice indicates that massaging the skin over bony prominences increases the client's risk for pressure ulcer formation. 4 - A low-humidity environment increases the dryness of skin and the risk for pressure ulcer formation.

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? 1 - Stand facing the center of the bed at the client's side 2 - Place feet apart with the foot nearest the head of the client's bed in front of the other foot 3 - Keep knees and hips straight while bending at the waist towards the client 4 - Encourage the client to keep his legs straight and remain still

2 - Place feet apart with the foot nearest the head of the client's bed in front of the other foot Rational 1- The nurse should face the head of the bed. Facing the direction of movement prevents twisting of the nurse's body while moving the client 2 - Placing the feet apart provides a wide base of support, which improves balance. Forward-backward stance enables the nurse to shift his weight as the client moves up in bed. 3 - The nurse should flex his knees and hips, bringing his forearms close to the level of the bed. This position brings the nurse's center of gravity closer to the client and enables the nurse to use his thigh muscles instead of his back muscles to move the client. 4 - The nurse should encourage the client to flex his knees with his feet flat on the bed and assist with movement up in bed, which reduces the workload for the nurse.