Fundamentals Coursepoint practice questions - ch. 27 & 33
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? "Put your arm in this sleeve." "Don't put on your shoes yet." "Put on your shirt." "Put your pants on and zip the zipper."
"Put your arm in this sleeve."
Which nurse would be at the highest risk of causing a hazardous situation? A nurse who has placed a client in the bed with three side rails up A nurse who is administering medications to four clients A nurse who is transferred to another unit to assist with care A nurse who has worked 32 hours of overtime this week
A nurse who has worked 32 hours of overtime this week
What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States? American Nurses Asterm-30sociation World Health Organization American Medical Association Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client? Client is in lateral oblique position with arms in functional position and pillow support under the knees. Client is in prone position with arms in functional position and pillow support under the knees. Client is in Sims' position with arms in functional position and pillow support under the knees. Client is in supine position with arms in functional position and pillow support under the knees.
Client is in supine position with arms in functional position and pillow support under the knees.
Which item would alert the home care nurse to a safety hazard threatening a young child? A gated stairway Three blankets in a crib Padded child safety seat Dangling blind cords
Dangling blind cords
A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? Keep the client sedated with tranquilizers. Allow the client to use the bathroom independently. Maintain a high bed position so the client will not attempt to get out unassisted. Involve family members in the client's care.
Involve family members in the client's care.
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priorityrecommendation for this client? Using restraints on the client to prevent a fall Providing a bed that is elevated from the floor Placing the client in a bed with a bed alarm Raising all the side rails of the bed
Placing the client in a bed with a bed alarm
What is the primary role of the nurse in the care of clients who experience domestic violence? Calling the police Serving as a witness in court Identifying health education and counseling measures for the family Providing prompt recognition of the potential or actual threat to safety
Providing prompt recognition of the potential or actual threat to safety
The client is ambulating in the room and walks around a bedside table. What is the bestexplanation for why the client does not bump into the table? The cerebellum is responding to impulses from the inner ear. The brain is sending impulses to the muscles to avoid the table. The client's muscles are being stretched to walk around the table. The client is aware of spatial relationships to avoid the table.
The client is aware of spatial relationships to avoid the table.
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? The nurse should gently slide the client down his or her body to the floor. The nurse should place his or her feet close together with one foot in front of the other. The nurse should grasp the gait belt and pull the client's body backward away from his or her body. The nurse should rock his or her pelvis out on the opposite side of the client.
The nurse should gently slide the client down his or her body to the floor.
In an assessment for proper body alignment of a standing client, which finding is normal? The chest is downward and displaced slightly backward. The line of gravity is deviated slightly to the left. The weight of the body is distributed on the soles and heels. The abdominal muscles are held downward and the buttocks upward.
The weight of the body is distributed on the soles and heels.
A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply. Use filtering software to block objectionable information. Emphasize that everything read online is usually true. Be alert for downloaded files with suffixes that indicate images or pictures. Investigate any public chat rooms used by the children. Keep identifying information posted on the web sites.
Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.
A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? trochanter roll bed trapeze bed cradle foot board
bed trapeze
A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not: improve sleep quality. enhance mood. prevent constipation. decrease appetite.
decrease appetite.
A nurse visits an older adult client at home and assesses the safety of the client's environment. Multiple small rugs are located in the home. Which statement by the nurse is appropriate when addressing the client's safety? "I think you should replace your small rugs with skid-resistant rugs on the floor." "You need to remove the small rugs from your house or you will fall." "I am concerned that the small rugs in your home can be a tripping hazard." "Your home needs to be a safe environment as older adults have a tendency to fall."
"I am concerned that the small rugs in your home can be a tripping hazard."
A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting? "I try to rest between periods of lifting." "I stand with my feet apart so I have a better stance when I lift." "I bend with my knees when I pick up boxes." "I hold the boxes away from my body so I don't drop them on my feet."
"I hold the boxes away from my body so I don't drop them on my feet."
A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? "The chin strap on the helmet should be adjusted to fit loosely so that it does not choke the child." "Any helmet is appropriate for bicycle riding because all children should wear helmets when riding." "Parents are effective role models for children when they also wear helmets while riding." "Young children secured in a bicycle passenger seat do not have to wear a helmet."
"Parents are effective role models for children when they also wear helmets while riding."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To prevent foot drop." "To prevent the legs from rotating outward." "To preserve the client's functional ability to grasp and pick up objects." "To avoid contractures."
"To prevent the legs from rotating outward."
Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant? "We place our baby in a rear-facing car seat in the front of the car so that we can see him in case he chokes." "We place our baby in a front-facing car seat in the front of the car so that he doesn't cry." "We place our baby in a front-facing car seat in the middle of the back seat of the car." "We place our baby in a rear-facing car seat in the back seat of the car."
"We place our baby in a rear-facing car seat in the back seat of the car."
The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." "I can only allow you to transfer without assistance with a physician's order, so I will help you now." "You are free to move onto the stretcher without assistance, but I will supervise for your safety."
"You are free to move onto the stretcher without assistance, but I will supervise for your safety."
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "When your crutches fit right, most of your body weight will be supported by your armpits." "Your elbows will be slightly bent when you are using your crutches." "We'll have the nursing assistant watch you while you walk around the unit the first time." "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly."
"Your elbows will be slightly bent when you are using your crutches."
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? A client who has leg strength and can cooperate with the movement A client who has an abdominal incision A client who is confined to bed rest A client with a thoracic incision
A client who has leg strength and can cooperate with the movement
The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following? Alert the local fire department. Attempt to extinguish the fire. Activate the fire alarm and notify the appropriate person. Answer all telephone calls and call bells.
Activate the fire alarm and notify the appropriate person.
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason? Primarily protects the client from injury Primarily protects the nurse from injury Acts as a safeguard against legal action by the client Acts to prevent injury to the client and/or nurse
Acts to prevent injury to the client and/or nurse
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? Adduction Circumduction Abduction Extension
Adduction
The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? Ask to examine the client alone in order to speak to her privately. Report the suspicions to to the authorities. Document the observed behaviors in the client's chart. Nothing, as it is none of the nurse's concern.
Ask to examine the client alone in order to speak to her privately.
The older client tells the nurse that the client needs to use the restroom. Which safety intervention must the nurse perform first? Ask a family member to help the client to the restroom. Ask the unlicensed assistive personnel (UAP) to help the client to the restroom. Offer the bedpan to keep the client safe. Assess the need for assistance with ambulation.
Assess the need for assistance with ambulation.
A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priorityassessment when the nurse first sees the client? Assessment of head circumference Assessment of vital signs and respiratory status Evaluation of all of his cranial nerves Initiation of a peripheral intravenous (IV) line for fluid administration
Assessment of vital signs and respiratory status
Which topics should be included in an education plan for preventing falls in the home? Select all that apply. Consider the use of an electronic personal alarm. Use a nightlight. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat. Remove clutter from walkways. Avoid climbing on a chair or table to reach items that are too high.
Avoid climbing on a chair or table to reach items that are too high. Use a nightlight. Remove clutter from walkways. Keep electrical and telephone cords against the wall and out of walkways. Consider the use of a raised toilet seat.
What is the most important safety concept that a nurse should include in the teaching plan for a family with a newborn infant in the household? Include safeguards to prevent falls in the home. Avoid stuffed animals and blankets in the crib. Educate about, and be aware of, signs of risky behaviors. Teach seat belt safety.
Avoid stuffed animals and blankets in the crib
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? Instruct the toddler not to go near the pool. Avoid unattended baths for the toddler. Allow the child to swim with friends. Monitor the activities of the toddler.
Avoid unattended baths for the toddler.
The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply. Quality improvement (QI) Revamping the licensing requirements for foreign-educated nurses Client-centered care Establishment of clinical career ladders Teamwork and collaboration
Client-centered care Teamwork and collaboration Quality improvement (QI)
The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply. Developmental level Mobility Type of health care facility Communication ability Community population
Communication ability Developmental level Mobility
The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment? Provide a pamphlet on maintaining healthy sleep habits Suggest a high-fiber, low-fat diet Restrict consumption of liquids before bedtime Encourage exercise that improves balance and muscle strength
Encourage exercise that improves balance and muscle strength
A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? Remove the restraint at least every 4 hours, or according to facility policy. Apply restraints to the hands or wrists, never to the ankles. Ensure that two fingers can be inserted between the restraint and the client's extremity. Use a quick-release knot to tie the restraint to the side rail.
Ensure that two fingers can be inserted between the restraint and the client's extremity.
A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern? Select all that apply. Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function Perform a 24-hour input and output assessment Ask the client to provide details of the exercise regimen including frequency and type Assess cardiovascular function and blood pressure Evaluate for diabetes mellitus
Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function Assess cardiovascular function and blood pressure Ask the client to provide details of the exercise regimen including frequency and type Evaluate for diabetes mellitus
The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse? Have the client stand without moving to see if the dizziness will pass. Quickly pivot the client into the wheelchair to prevent client fall. Firmly grasp the gait belt and gently lower the client into bed. Apply oxygen 2L via nasal cannula to the client.
Firmly grasp the gait belt and gently lower the client into bed.
A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care? Advise the client to avoid blinking until after the eyes are irrigated. Wash the eyes with a hypertonic solution for at least 30 minutes. Flush the eyes with water for 10 minutes. Flush the eyes with a cool saline solution for a 10-minute period.
Flush the eyes with water for 10 minutes.
When educating families on fire safety in the home, which information is important for the nurse to emphasize? Have a meeting place outside the home in case of fire. Use extension cords to prevent shock. Account for all members and then exit together. Keep a fire extinguisher in a closet.
Have a meeting place outside the home in case of fire.
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? Avoid the use of powders on the legs before applying stockings. Apply the stockings at night when the client is going to bed. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Apply the stockings after the client has been sitting up for an hour.
If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.
One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic? Implement drowning prevention strategies. Require fencing around all pools. Begin swim lessons with toddlers. Educate children in cardiopulmonary resuscitation.
Implement drowning prevention strategies.
The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Initiate use of a bed alarm. Administer the client's sedative as ordered. Put up all four side rails on the bed. Contact the physician for a restraint order.
Initiate use of a bed alarm.
A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply. Support body weight with hands and arms. When climbing stairs, advance the unaffected leg past the crutches, place weight on the crutches, and then advance the affected leg followed by the crutches. Place pressure on the axillae when walking. Prevent crutches from getting closer than 3 inches to the feet. Keep elbows close to sides. When descending stairs, move crutches and the unaffected leg first, followed by the affected leg.
Keep elbows close to sides. Support body weight with hands and arms. When climbing stairs, advance the unaffected leg past the crutches, place weight on the crutches, and then advance the affected leg followed by the crutches.
What best describes the nurse's role in disaster preparedness? Performance of all of the skills such as IV insertion and wound care Administration of all of the medications Counseling the victims and families Multiple roles, including triage and the distribution of resources
Multiple roles, including triage and the distribution of resources
The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action? Apply the waist restraint over the gown and abdominal dressing. Notify the primary care provider and obtain an order for a client sitter. Apply bilateral wrist restraints and secure to the bed frame with a quick-release knot. Call the out-of-state family and ask if they can take turns watching the client.
Notify the primary care provider and obtain an order for a client sitter.
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety? Use an extension cord to provide freedom of movement. Obtain a three-prong grounded plug adapter. Tape the electrical cord of the pump to the floor. Run the electrical cord of the pump under the carpet.
Obtain a three-prong grounded plug adapter.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Place the bed in the highest position. Make sure the bed brakes are unlocked. Raise the head of the bed to a sitting position. Put the chair at the foot of the bed.
Raise the head of the bed to a sitting position.
A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan? Lock all cabinets that contain cleaning supplies. Give warm bottles of formula to the baby. Restrain the baby in a car seat. Keep all pots and pans in lower cabinets.
Restrain the baby in a car seat.
The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings? Risk for Injury related to substance use Risk for Poisoning related to medications in unlocked cabinets Risk for Contamination related to flaking or peeling of paint Risk for Suffocation related to child left unattended in the bathtub
Risk for Poisoning related to medications in unlocked cabinets
The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care? Altered Sensory Perception related to decreased visual acuity Risk for Poisoning related to poor eyesight and the inability to read medication labels Risk for Injury related to substance use Risk for Falls related to immobility
Risk for Poisoning related to poor eyesight and the inability to read medication labels
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? Rock the client back and forth to raise the client up in bed. Shift their weight back and forth from the legs to the back muscles. Shift their weight back and forth, from back leg to front leg. Turn the client from side to side while pushing upward.
Shift their weight back and forth, from back leg to front leg.
Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? Poor judgment Social pressure Past experience Normal rebellion
Social pressure
The nurse is educating parents of toddlers on how to prevent injuries and promote safety for their children. What are age-appropriate safety interventions for this age group? Select all that apply. Provide drug, alcohol, and sexuality education. Childproof the house to ensure that poisonous products and small objects are out of reach. Instruct the child to wear proper safety equipment when riding bicycles or scooters. Do not leave the child alone in the bathtub or near water. Practice emergency evacuation measures with the child. Supervise the child closely to prevent injury.
Supervise the child closely to prevent injury. Childproof the house to ensure that poisonous products and small objects are out of reach. Do not leave the child alone in the bathtub or near water.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Talk with the client's family about taking her home because she is out of control. Sedate her with sleeping pills and leave the restraints on. Take the restraints off, stay with her, and talk gently to her. Leave the restraints on and talk with her, explaining that she must calm down.
Take the restraints off, stay with her, and talk gently to her.
A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? Permit the client to remove the stockings indefinitely and speak to the physician about the necessity of having the client wear them. Tell the client he can remove them for 20 or 30 minutes during this shift. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily.
Tell the client he can remove them for 20 or 30 minutes during this shift.
The client is an active, healthy 2-year-old child. His mother asks a nurse what she can expect developmentally from the boy over the next few years. What is the nurse's best response? The client will regress in fine and gross motor skill development. The client will continue to grow rapidly but gross and fine motor skill acquisition will slow. The client will refine both gross and fine motor skills but longitudinal growth will slow. The client will continue to grow rapidly and will refine both gross and fine motor skills.
The client will continue to grow rapidly and will refine both gross and fine motor skills.
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? CMS may choose to divert clients to other health care facilities in the future. The hospital must bear any costs incurred for treating the client's injury. The hospital will be fined by CMS because the client developed a pressure injury. CMS will bear the hospital's costs if the client chooses to sue the hospital.
The hospital must bear any costs incurred for treating the client's injury.
A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? CMS may choose to divert clients to other health care facilities in the future. The hospital will be fined by CMS because the client developed a pressure injury. The hospital must bear any costs incurred for treating the client's injury. CMS will bear the hospital's costs if the client chooses to sue the hospital.
The hospital must bear any costs incurred for treating the client's injury.
The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include? The importance of consistent seat belt use Avoiding workplace injury The importance of practicing moderation when consuming alcohol Identification of hazards associated with falls
The importance of consistent seat belt use
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities? The nurse should request permission from the client to photograph the bruises. The nurse should notify the primary care physician about the bruises. The nurse should contact the facility's social services department. The nurse should question the client about the source of the bruises.
The nurse should question the client about the source of the bruises.
A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should await results of the x-ray before filing the report. The nurse should make a copy of the safety event report and place it in the client's medical record. The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should include a note on the client's chart that mentions the report.
The nurse should record the incident in the client's medical record and fill out a safety event report separately.
Which type of mobility aid would be most appropriate for a client who has poor balance? a cane with four prongs on the end (quad cane) a single-ended cane with a half-circle handle axillary crutches a single-ended cane with a straight handle
a cane with four prongs on the end (quad cane)
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate? The nurse discourages the client from helping with the transfer. The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight. The nurse administers pain medication following the transfer. The nurse grabs and holds the client by his arms.
The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.
Using proper body mechanics, which motions would the nurse make to move an object? The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? Logrolling will maintain straight alignment when the client is sitting in a chair. Logrolling can be performed by one experienced nurse. It is acceptable to twist the client's head, but not the hips, while logrolling. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? side rails a dose of an antipsychotic a dose of an analgesic a geriatric chair with a tray
a dose of an antipsychotic
The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include? correct placement of booster seats for the car the use of skid-proof mats for the bath tub Use of blankets, pillows, and stuffed animals in the crib safety of guns in the home
Use of blankets, pillows, and stuffed animals in the crib
The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? When lifting an object, I will keep my feet shoulder width apart. When lifting an object, I will bend at the knees instead of the waist. When I lift an object, I will get close to the object being lifted. When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.
When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.
The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate? application of devices that reduce the client's ability to move arms administration of an antipsychotic agent to alter the client's behavior articulating the reason for use of a physical restrictive device to the client's spouse asking the unlicensed assistive personnel (UAP) to sit with the client
administration of an antipsychotic agent to alter the client's behavior
A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply. four side rails up administration of sedation having a parent stay with the child isolation four-point soft restraints
administration of sedation four side rails up having a parent stay with the child
The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client? a 16-year-old pregnant female who has morning sickness a 12-year-old male who sprained his wrist skateboarding a 42-year-old female who is a single mom with a sick child home from school an 84-year-old male with four recent driving violations
an 84-year-old male with four recent driving violations
A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to: play-related injuries. automobile accidents. falls from beds. falls from staircases.
automobile accidents.
Health care workers may be exposed to a common occupational injury such as: carbon monoxide exposure. Intimate Partner Violence (IPV). sensory deprivation. inadvertent needlestick.
inadvertent needlestick.
What is a benefit of regular exercise over time? increased work of breathing increased risk for blood clots decreased heart rate decreased venous return
decreased heart rate
A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to: experimentation with drugs and inhalants. malfunction of a carbon monoxide monitor in the home. the ingestion of substances in the home that contain lead. exposure to toxic fumes in the home.
experimentation with drugs and inhalants.
A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should: document strategies in the client's health record for preventing future incidents. hold a facility-wide meeting to identify strategies for making improvements to the safety of residents. complete an incident report to determine who was primarily responsible for the event. fill out an incident report, with the goal of preventing a similar event in the future.
fill out an incident report, with the goal of preventing a similar event in the future.
A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: decubitus ulcers. pooling of blood. foot drop. blood pressure changes.
foot drop
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? Sims' supine prone Fowler's
fowlers
When educating families on fire safety, it is important to: account for all members and then exit. have a meeting place outside the home. use extension cords to prevent shock. keep a fire extinguisher in a closet.
have a meeting place outside the home.
When moving a client up in bed with the assistance of another caregiver, the nurse should: have the client fold the arms across the chest. elevate the head of the bed. ask another nurse about the plan of care. maintain a pillow under the client's head.
have the client fold the arms across the chest.
Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning? keeping medications in clearly labeled containers hidden sources of lead in the household environment avoiding the use of alternative and complementary therapies alternatives to chemical-based cleaning supplies
keeping medications in clearly labeled containers
When logrolling a client, the nurse should use supportive devices in turning the client in order to: maximize the client's participation. maintain the natural alignment of the client's body. prevent the blood stasis that can lead to skin breakdown. allow the client's leg to rest on the bed.
maintain the natural alignment of the client's body.
The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? push the client to the opposite side of the bed push the client to the edge of the bed to which the client will be turning move the client to edge of the bed opposite the side that client will be turning pull the client to the edge of the bed to which the patient will be turning
move the client to edge of the bed opposite the side that client will be turning
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs together to the nondominant side of the client, with legs together and one foot near the head of the bed. near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed
near the client's hip, with legs shoulder width apart and one foot near the head of the bed
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client? deep vein thrombosis circulatory alterations hypertension orthostatic hypotension
orthostatic hypotension
A nurse is preparing to turn a client who is unable to mobilize independently. Which action bestensures the safety of both the client and the nurse? standing at the top of the bed and having a colleague stand at the bottom of the bed using back muscles to gently and gradually pull the client to the side positioning a friction-reducing sheet under the client to facilitate movement placing the bed in its lowest position to reduce the client's risk for falls
positioning a friction-reducing sheet under the client to facilitate movement
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in the movement of secretions in the respiratory tract increase in circulating fibrinolysin predisposition to renal calculi increased metabolic rate
predisposition to renal calculi
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. removing clutter from the floor installing hardwood floors moving the bedroom to the ground floor placing nightlights in the bathroom and hallways
removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor
The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select? impaired transfer ability risk for disuse syndrome risk for impaired skin integrity impaired physical mobility
risk for impaired skin integrity
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? Sims' supine prone Fowler's
sims
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? Sims' Fowler's prone supine
sims
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: leans over the walker when walking. uses the sides of the walker to rise from a chair. steps into the walker when walking. places the walker far in front when walking.
steps into the walker when walking.
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? lateral prone supine Sims'
supine
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? under the client's head under the client's feet in front of the client's abdomen supporting the client's back
supporting the client's back
The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? the 3-month-old child who is unable to raise the head when prone the 24-month-old child who is unable to walk unassisted the 18-month-old child who is unable to stack blocks the 6-month-old child who is unable to roll over
the 24-month-old child who is unable to walk unassisted
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? skeletal contractures oliguria thrombus formation pooling of secretions
thrombus formation
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is mostappropriate to assist in transferring? roller sheet transfer boards transfer belt mechanical lift
transfer belt
The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care? trapeze bar log rolling pull sheets trochanter rolls
trapeze bar
A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as: athetosis dystonia ataxia tremor
tremor
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? foot splints roller sheets foot boards trochanter rolls
trochanter rolls
