fundamentals

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?" - therapeutic response validates feelings of agitation

A nurse isREINFORCING teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"sit on the toilet 30 mins. after eating a meal" - retraining

a nurse is instructing an assistive personnel (AP) about proper hand hygiene. which of the following statements by the AP indicates an understanding of the teaching?

"there are times i should use soap and water rather than an alcohol based hand rub to clean my hands"

A nurse is collecting data for the health history of a client who is postop. and has PARALYTIC ileus. Which of the following findings should the nurse expect?

ABSENT bowel sounds with distension

A nurse is COLLECTING DATA for a client who has decreased circulation in his left leg. Which of the following ACTIONS should the nurse take first?

Evaluate pedal pulses.

A nurse is receiving a client from the PACU who is postop. following abdominal surgery. Which of the following ACTIONS should the nurse take to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher - prevents the client from falling to the floor by not allowing cart or bed to move away

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. which of the following ACTIONS by the newly licensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy care -cotton ball particles can be aspirated in tracgeostomy opening may cause tracheal abscess

A nurse is obtaining the blood pressure in a clients lower extremity. Which of the following actions should the nurse take?

Place the b;adder of the cuff over the posterior aspect of the thigh .

A nurse is REINFORCING TEACHING with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change - client involvement

A nurse is caring for a child who is postop. following a tonisillectomy. which of the following actions should the nurse take?

administer analgesics to the child on a routine schedule throughout the day and night

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse DOCUMENT?

pericardial friction rub - scratching sound

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. AT which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

second intercostal space to the right of the sternum