K&E - February
The nurse is preparing to shampoo the hair of a client confined to bed. What items would the nurse assemble? Select all that apply. A. Comb and brush B. Bath blanket C. Plastic sheet or pad D. Curved basin E. Washcloth
A. Comb and brush B. Bath blanket C. Plastic sheet or pad E. Washcloth
Steps involved in eliminating urine:
1st The stretch receptors transmit impulses to the spinal cord. 2nd Impulses are transmitted to the voiding center at the second to fourth sacral vertebrae. 3rd The internal sphincter relaxes. 4th The urge to void takes place. 5thThe brain relaxes the external sphincter muscle and urination occurs. 6th If time and place are inappropriate, the voiding reflex subsides. 7th The bladder then becomes more filled, and the reflex is stimulated again.
The nurse is caring for a client who had heart bypass surgery yesterday, is unable to get out of bed, and is drowsy from pain medication. What is the most appropriate type of bath for this client? A. A complete bed bath B. A self-help bed bath C. A partial bath D. A therapeutic bath
A. A complete bed bath
During the admission interview, the client abruptly left in haste, explaining to the nurse that he suddenly needed to urinate. Which factors would indicate the presence of urinary urgency? Select all that apply. A. A large amount of urine in the bladder B. Dehydration C. Psychological stress D. Kidney contractions E. Poor internal sphincter control
A. A large amount of urine in the bladder C. Psychological stress
The nurse uses an anatomy poster to help motivate a client to change a habit of ignoring the urge to urinate, which increases the risk of urinary tract infections. The nurse points to the pubic bone as a marker, saying that a full bladder's upper edge is located at what point? A. Above the pubic bone B. Even with the pubic bone C. To one side of the pubic bone D. Below the pubic bone
A. Above the pubic bone
When performing eye care for a client who is comatose, what actions by the nurse would be most appropriate? Select all that apply. A. Administer moist compresses to cover eyes every 2 to 4 hr. B. Instill artificial tears into the lower lids. C. Clean eyes with cotton balls and saline solution, wiping from inner to outer canthus. D. Use sterile technique and sterile equipment. E. Tape the eyes closed with silk tape.
A. Administer moist compresses to cover eyes every 2 to 4 hr. B. Instill artificial tears into the lower lids. C. Clean eyes with cotton balls and saline solution, wiping from inner to outer canthus.
The nurse is caring for a client who has been on long-term bedrest. How does the nurse promote normal bowel elimination? Select all that apply. A. Assisting the client to flex knees and rest weight on back and heels B. Assisting the client to lift the shoulders off the bed when positioning on a bedpan C. Positioning the client on a bedpan in a semi-Fowler position D. Providing fluid intake between 2 to 3 L a day E. Providing isometric exercises
A. Assisting the client to flex knees and rest weight on back and heels C. Positioning the client on a bedpan in a semi-Fowler position D. Providing fluid intake between 2 to 3 L a day E. Providing isometric exercises
The nurse is educating a client who is donating a kidney to his sibling. However, the client is concerned about possible scarring to several tattoos on his back. Before answering questions about the surgical site, the nurse refers to the location of the kidneys as which of the following? Select all that apply. A. Behind the peritoneum B. In the upper abdominal cavity C. To the right and left of the vertebral column D. In front of the peritoneum E. In the lower abdominal cavity
A. Behind the peritoneum B. In the upper abdominal cavity C. To the right and left of the vertebral column
Your client, Mrs. Brown, has been identified with several pathological conditions that affect the quantity and quality of the urine she produces. Which set of pathological conditions is most likely to be associated with Mrs. Brown? A. Congenital urinary anomalies, gout, diabetes mellitus, and connective tissue disorders B. Urinary tract infection, hypertension, cataracts, and gastroesophageal reflux disease C. Hypertension, gout, and open-angle glaucoma D. Diabetes mellitus, Addison disease, and Cushing disease
A. Congenital urinary anomalies, gout, diabetes mellitus, and connective tissue disorders
Mr. Warner is a 72-year-old male. The nurse is educating Mr. Warner, his wife, and his daughter about normal changes that go along with aging which place an elderly person at risk for impaired skin integrity. Which of the following expected changes that go along with aging place Mr. Warner at higher risk for skin breakdown? A. Diminished pain perception B. Increased oil production by the sebaceous glands C. Increased skin elasticity D. Increased lean body mass
A. Diminished pain perception
The newly admitted male client has severe mobility problems. The client has not asked for assistance to go to the bathroom. What conditions would alert the nurse to the possibility of urinary retention? Select all that apply. A. Has a distended bladder, displaced to one side of his midline B. Has a firm bladder upon palpation by the nurse C. Complains of a burning sensation upon urination D. Has a history of an enlarged prostate E. Used a urinal, into which he urinated a large amount of amber-colored urine
A. Has a distended bladder, displaced to one side of his midline B. Has a firm bladder upon palpation by the nurse D. Has a history of an enlarged prostate
It is important for you as the nurse to complete an assessment of any client prior to initiating hygiene care. Which of the following should be included in the prehygiene skin assessment? Select all that apply. A. Identify any skin problems (e.g., skin reactions or allergic responses). B. Assess the client's ability and desire to participate in hygiene care for the skin. C. Give a pain shot (pain medication) prior to helping the client get into the shower. D. Assess the client's skin care practices and preferences. E. Ask if the client needs soap, shampoo and conditioner, or oral care products.
A. Identify any skin problems (e.g., skin reactions or allergic responses). B. Assess the client's ability and desire to participate in hygiene care for the skin. D. Assess the client's skin care practices and preferences.
Mrs. Welsh is an 84-year-old woman who is unable to ambulate and has been losing weight for the past 2 months. She has a red nonblanchable area on her left hip. Based on the nurse's assessment, which of the following are priorities for Mrs. Welsh? A. Keep her off her left hip; reposition her every 2 hr (prevent further breakdown). B. Treat her stage II pressure ulcer. C. Needs specific nursing interventions to prevent skin breakdown. D. Teach the importance of good nutrition; encourage her to eat five to six small meals/day. E. Massage the nonblanchable area on her left hip.
A. Keep her off her left hip; reposition her every 2 hr (prevent further breakdown). D. Teach the importance of good nutrition; encourage her to eat five to six small meals/day.
You are planning short- and long-term goals for Ms. Kline, the 17-year-old female with a fractured left radius who asked to take a shower. When you assessed her, you learned that she received a pain medication (intramuscular) and is feeling "a bit dizzy and lightheaded." Which of the following goals would be appropriate for this nursing diagnostic statement: Potential for fall or injury risk factor: side effects of pain medication (dizziness, lightheadedness)? Select all that apply. A. Ms. Kline will verbalize why it is not safe to shower when she feels dizzy and lightheaded. B. Ms. Kline will not aspirate when she is feeling dizzy and lightheaded. C. Ms. Kline will not take any more pain shots if she wants to shower. D. Ms. Kline will not incur any injuries while in the hospital. E. Ms. Kline will not fall while in the hospital.
A. Ms. Kline will verbalize why it is not safe to shower when she feels dizzy and lightheaded. D. Ms. Kline will not incur any injuries while in the hospital. E. Ms. Kline will not fall while in the hospital.
The nurse is developing a plan of care for a female client, Ms. Sate, who has a stage II pressure ulcer. Which of the following is an appropriate goal for Ms. Sate? A. Promote wound healing by secondary intention B. Prevent impaired skin integrity C. Apply appropriate devices on the bed to keep joints mobile D. Maintain skin integrity
A. Promote wound healing by secondary intention
As a nurse, which of the following actions can you implement to enhance your client's ability to void? Select all that apply. A. Provide privacy. B. Have patient lie down. C. Help with comfortable positioning. D. Provide sound of running water. E. Allow sufficient time.
A. Provide privacy. C. Help with comfortable positioning. D. Provide sound of running water. E. Allow sufficient time.
Ms. Peterson has slid down toward the foot of her bed and is unable to move herself back up in the bed. You call the nursing assistant to help you move her back up to the top of the bed. If you try to move Ms. Peterson by yourself, you will slide her body up, and her body weight (and moisture on the skin) will cause the skin on her sacrum to stick to the linens and not move while the underlying tissues and muscles do move. This movement may cause _________ on her sacrum and deep tissues. A. Shearing force B. Pressure C. Friction D. An abrasion
A. Shearing force
Mr. Thompson, a 53-year-old African American client with chronic uncontrolled hypertension, was admitted to the hospital after a massive stroke, which has left him immobile and unable to complete any activities of daily living (ADLs) (e.g. eating, bathing, toileting, transferring) independently. Which of the following are critical components of the assessments the nurse will complete on Mr. Thompson? Select all that apply. A. Skin integrity, especially over bony prominences and common pressure areas B. Continence (fecal and urinary) C. His ability to independently move from the bed to the chair or to the wheelchair D. Mental status and his ability to report pain or discomfort E. Level of nutrition and intake of protein, carbohydrates, fluids, vitamins, and other nutrition-related issues
A. Skin integrity, especially over bony prominences and common pressure areas B. Continence (fecal and urinary) D. Mental status and his ability to report pain or discomfort E. Level of nutrition and intake of protein, carbohydrates, fluids, vitamins, and other nutrition-related issues
You are the nurse caring for a female client who is experiencing urinary incontinence. What information should you share with her? Select all that apply. A. Stress can cause chronic urinary incontinence. B. Conditions that contribute to urinary incontinence include infections, medications, and restricted mobility. C. Women are more likely to experience urinary incontinence due to a long urethra. D. Transient urinary incontinence is not reversible. E. Urinary incontinence is a loss of bladder control.
A. Stress can cause chronic urinary incontinence. B. Conditions that contribute to urinary incontinence include infections, medications, and restricted mobility. E. Urinary incontinence is a loss of bladder control.
The nurse is caring for a 4-year-old child. When providing hygienic care, what can the nurse expect? A. The child to be able to brush her teeth, with a little encouragement B. The child to need complete assistance to brush her teeth C. The child to independently think of brushing her teeth in the morning D. Arguments about using toothpaste
A. The child to be able to brush her teeth, with a little encouragement
The night nurse has been assigned to four older adult clients with urinary difficulties. Which client presents the highest priority for further assessment by the nurse? A. The client who voids less than 30 mL per hour B. The client with urinary urgency C. The client with nocturia D. The client who complains of urinary frequency
A. The client who voids less than 30 mL per hour
You are assisting a student nurse as she plans her goals for the nursing outcome of achieving normal patterns in urinary elimination. Which of the following are appropriate goals? Select all that apply. A. The nurse or student will assist with application of any urinary devices for the client. B. The client will have signs and symptoms of a urinary tract infection. C. The client will maintain adequate fluid balance. D. The client will be dependent in toileting. E. The client's electrolytes will be within normal limits.
A. The nurse or student will assist with application of any urinary devices for the client. C. The client will maintain adequate fluid balance. E. The client's electrolytes will be within normal limits.
Mr. Johnson, an 89-year-old male, lives with his daughter and her family. Which of the following changes commonly associated with aging, if present in Mr. Johnson, may indicate a greater risk for skin breakdown? Select all that apply. A. Thinning of the epidermis and decreased skin elasticity B. Digestive and metabolic issues (the prevalence of gastrointestinal problems rises with age) C. Changes in hearing (50% of those 85 and older have hearing loss) D. Decreased pain sensation E. Loss of lean body mass and a decrease in venous and arterial blood flow
A. Thinning of the epidermis and decreased skin elasticity D. Decreased pain sensation E. Loss of lean body mass and a decrease in venous and arterial blood flow
A nurse is preparing a discharge plan for a client with a risk of skin breakdown. What would the nurse include in the discharge plan? Select all that apply. A. Turn and reposition at least every 2 hour. B. Position to prevent pressure on bony prominences. C. Diet should be adequate in fluids, protein, vitamins B and C, iron, and calories. D. If persistent redness occurs, apply lotion to the area. E. Massage the bony prominences.
A. Turn and reposition at least every 2 hour. B. Position to prevent pressure on bony prominences. C. Diet should be adequate in fluids, protein, vitamins B and C, iron, and calories.
As the nurse, you are teaching your client about urinary urgency. Which concepts should you address in your teaching? Select all that apply. A. Urgency is related to the irritation of the trigone and urethra. B. Urgency is not related to psychological stress. C. Poor external sphincter control produces symptoms of urgency. D. Urgency is a strong and sudden sensation to urinate. E. Urgency does not always occur when there is a large amount of urine in the bladder.
A. Urgency is related to the irritation of the trigone and urethra. C. Poor external sphincter control produces symptoms of urgency. D. Urgency is a strong and sudden sensation to urinate.
The nurse is caring for a female client who was admitted to the hospital and has informed the staff that she is a practicing Muslim. What would the nurse ask to determine appropriate interventions to care for a client of this culture? A. "Are there any restrictions as to who can assist you with bathing?" B. "Do you have adequate finances?" C. "Do you have modern bathing facilities in your home?" D. "Do you have restrictions as to guests using a bathroom in your home?"
A. "Are there any restrictions as to who can assist you with bathing?"
Mr. Roberts needs to apply a cold compress to a wound on his knee. The nurse is teaching Mr. Roberts and his wife about the benefits of cold, how to apply cold treatment, and for what conditions cold is useful. Which of the following responses indicates Mr. Roberts understood the teaching provided? Select all that apply. A. "Putting ice on my knee will help decrease the swelling." B. "Ice helps to decrease pain; it definitely helped while I was in the hospital." C. "If I see that my knee becomes inflamed and red, using ice will help relieve it." D. "Cold therapy is the best bet for joint stiffness and muscle spasms." E. "Ice increases circulation to the area better than heat."
A. "Putting ice on my knee will help decrease the swelling." B. "Ice helps to decrease pain; it definitely helped while I was in the hospital." C. "If I see that my knee becomes inflamed and red, using ice will help relieve it."
The nurse predicts that the client admitted with a fever of unknown origin will need what additional intervention? A. As-needed (prn) care B. Morning care C. Early morning care D. Hour of sleep (HS) care
A. As-needed (prn) care
The home care nurse made a visit to the apartment of a client with an indwelling catheter. The client reported no sensation of needing to urinate. The nurse will educate the client to realize that this situation is which of the following? A. Permanent, while the indwelling catheter is in place B. Unexpected, requiring close monitoring C. Temporary, until the client gets used to the indwelling catheter D. An emergency, calling for the immediate removal of the indwelling catheter
A. Permanent, while the indwelling catheter is in place
Mr. Jones is a 63-year-old man who is admitted for renal calculi. He is asking some basic questions about how his kidneys function. Which of the following is accurate for you as his nurse to share? A. "Mr. Jones, you have 2 kidneys, which are located on the right and left of the vertebral column. The kidneys contain nephrons that remove wastes from approximately 550 mL of blood per minute. Once your urine is formed, it is transported by peristalsis through your ureters and you produce urine.close double quote" B. "Mr. Jones, you have 2 kidneys, which are located on the right and left of the vertebral column. The kidneys contain nephrons, which remove wastes from approximately 1,200 mL of blood per minute. Once your urine is formed, it is transported by peristalsis through your ureters and you produce urine.close double quote" C. "Mr. Jones, you have 3 kidneyslong dash—2 on the right and 1 on the left of your vertebral column. The kidneys contain nephrons, which remove wastes from approximately 1,200 mL of blood per minute. Once your urine is formed, it is transported by peristalsis through your ureters.close double quote" D. "Mr. Jones, you have 1 kidney located on the right side of your vertebral column. The kidneys contain nephrons, which remove wastes from approximately 1,200 mL of blood per minute. Once your urine is formed, it is transported by peristalsis through your ureters.close double quote
B. "Mr. Jones, you have 2 kidneys, which are located on the right and left of the vertebral column. The kidneys contain nephrons, which remove wastes from approximately 1,200 mL of blood per minute. Once your urine is formed, it is transported by peristalsis through your ureters and you produce urine.close double quote"
You as the nurse are teaching your client Ms. Phelps, age 67, about her diagnosis, which is impaired urinary function with symptoms of urinary frequency and nocturia. What information do you need to share with her to assure she understands her diagnosis? A. "Ms. Phelps, your condition may give you symptoms of complete incontinence, and you will have skin breakdown.close double quote" B. "Ms. Phelps, your condition may give you symptoms of urinary retention, urgency, frequency, or incontinence. It does increase with age, and you may be prone to skin breakdown.close double quote" C. "Ms. Phelps, your condition may give you infrequent symptoms of urinary retention and urgency.close double quote" D. "Ms. Phelps, your condition may give you symptoms of urinary retention, urgency, frequency or incontinence. It does not increase with age, but you will see a decline with increasing age.close double quote
B. "Ms. Phelps, your condition may give you symptoms of urinary retention, urgency, frequency, or incontinence. It does increase with age, and you may be prone to skin breakdown.close double quote"
Ms. Green is a 68-year-old female. Her sister, who is also her caregiver, reports that Ms. Green's skin has been increasingly dry and flaky. The sister asks the nurse to recommend care for the skin changes. She says she has been using powder to keep the skin dry and smelling clean. What products should the nurse recommend to address the dry skin? A. Soap and water daily on the skin during bathing B. A moisturizing lotion or cream C. Continue to use the powder D. An alcohol-based spray
B. A moisturizing lotion or cream
Ms. Klein, a 58-year-old client, is being discharged home after undergoing an appendectomy. While she was in the hospital, her wound became infected and she had to go back to surgery for debridement. She will need to complete dressing changes at home. The nurse can educate Ms. Klein and her husband to promote wound healing by teaching them to: A. Reposition Ms. Klein in bed every 2 hour. B. Aggressively integrate the principles of asepsis into wound care at home. C. Aggressively cleanse the wound, irrigating with normal saline four times/day. D. Use soap and water to cleanse the wound, followed by irrigation with normal saline.
B. Aggressively integrate the principles of asepsis into wound care at home.
The nurse is assisting a client with a bath. What action by the nurse would be most appropriate? A. Insist that the client perform autonomously as much as possible. B. Assess the skin and psychosocial status. C. Perform a complete physical assessment. D. Involve the family in assisting.
B. Assess the skin and psychosocial status.
The nurse is evaluating why a wound is not healing. Which medication, taken by the client, can delay wound healing? A. Esomeprazole (Nexium) B. Dexamethasone (Decadron) C. Nebivolol (Bystolic) D. Digoxin (Lanoxin)
B. Dexamethasone (Decadron)
The nurse inspects a client's hearing aid after the client complains of difficulty hearing. If the client still has difficulty hearing, what would be the nurse's next action? A. Clean the hearing aid with alcohol. B. Ensure that the ear canal is not blocked with wax. C. Take the battery out of the hearing aid. D. Ensure that the earmold is properly attached to the receiver.
B. Ensure that the ear canal is not blocked with wax.
A client is complaining of stiffness and arthritic pain in the hands. Which application should the nurse expect to be included in the treatment plan? A. Ice glove B. Heat pack C. Cool, moist compresses D. Cold pack
B. Heat pack
Ms. Adams is a 48-year-old female. She is being discharged after undergoing a hysterectomy. Her wound dehisced (when a surgical wound bursts or splits open along the suture line), and she had to go back to surgery to have the wound repaired. She will be going home tomorrow. The nurse will teach her and her partner (Sue) how to complete dressing changes at home. Which of the following will they need to learn and/or review to promote continued healing of the wound? Select all that apply. A. How to prevent pressure ulcers B. Importance of hand hygiene and principles of asepsis with dressing changes C. Signs and symptoms of wound infection D. Nutritional support, that is, the need for adequate protein, carbohydrates, and vitamins E. Need for increased fluid intake
B. Importance of hand hygiene and principles of asepsis with dressing changes C. Signs and symptoms of wound infection D. Nutritional support, that is, the need for adequate protein, carbohydrates, and vitamins E. Need for increased fluid intake
You as the nurse are doing your urinary assessment on Mr. Slater. It is vital that you interview him and perform a complete assessment. Which of the following actions are part of a complete urinary assessment? Select all that apply. A. Measure the client's urinary output for 12 hr only. B. Inspect the skin for edema that could be indicative of impaired renal function. C. Inspect the urethral meatus for swelling, discharge, and inflammation. D. Do not percuss the bladder during assessment. E. After the client has voided, measure the client's bladder with a bladder scanner to determine any residual urine in the bladder.
B. Inspect the skin for edema that could be indicative of impaired renal function. C. Inspect the urethral meatus for swelling, discharge, and inflammation. E. After the client has voided, measure the client's bladder with a bladder scanner to determine any residual urine in the bladder.
The nurse discussed ways to handle the problem of the client's transient urinary incontinence with the caregiver spouse. The spouse asked for an explanation about possible causes. Possible causes the nurse could discuss include which of the following? A. Restricted mobility and pain B. Medications and an infection C. Medications and immunizations D. An infection and dehydration
B. Medications and an infection
In taking care of Mrs. Smith, you are to review her medications, fluids, and food intake to see which are affecting her urinary elimination. Which factors should you consider? Select all that apply. A. It is not necessary to have your patient void prior to medication administration of antidepressants, opioids, or anticholinergic medications. B. Mrs. Smith is taking antihistamine medications. C. Mrs. Smith had red beets with her dinner last night. D. Mrs. Smith regularly drinks a glass of red wine with dinner. E. The amount of food or fluid ingested directly correlates with urine output.
B. Mrs. Smith is taking antihistamine medications. C. Mrs. Smith had red beets with her dinner last night. D. Mrs. Smith regularly drinks a glass of red wine with dinner. E. The amount of food or fluid ingested directly correlates with urine output.
The home care nurse performs continuous bladder irrigation on the client. While setting up the equipment, how would the nurse describe the function of each of the catheter's lumens? Select all that apply. A. One lumen of the catheter is not attached, to allow for overflow. B. One lumen of the catheter is attached to a drainage bag. C. One lumen of the catheter is attached to the irrigation solution. D. One lumen of the catheter is kept clamped and opened for instillation of medication. E. One lumen of the catheter is attached to the balloon port.
B. One lumen of the catheter is attached to a drainage bag. C. One lumen of the catheter is attached to the irrigation solution. E. One lumen of the catheter is attached to the balloon port.
Your client, Paul Jenkins, is a 27-year-old male admitted for an emergency appendectomy. He says he has many skin allergies and sensitivities. Which of the following skin- and hygiene-related nursing interventions is appropriate for this client? A. Cleanse the skin with soap and dry well; then apply antiperspirant. B. Provide the client with (utilize) hypoallergenic soaps and lotions. C. Provide frequent skin care and linen changes. D. Apply lotion frequently and limit bathing to one to two times per week.
B. Provide the client with (utilize) hypoallergenic soaps and lotions.
The nurse is caring for a client with a treated wound. What would the nurse be looking for as she assesses the wound? A. Location and extent of tissue damage B. Redness and swelling C. A foreign object D. How the wound is immobilized
B. Redness and swelling
You are completing an admission assessment of your client, Ms. Dean, who is 31 years old. You note an open area on the skin over her left trochanter that measures 2 cm by 2 cm. The open area is a deep crater with undermining of adjacent tissue. There is no exposure of bone, muscle, or tendons. Based on this assessment data, the nurse determines this pressure ulcer is a: A. Stage I pressure ulcer B. Stage III pressure ulcer C. Stage II pressure ulcer D. Stage IV pressure ulcer
B. Stage III pressure ulcer
Mr. Richards, a 51-year-old client who is confined to a wheelchair, has a large wound on his sacrum with full thickness tissue loss; bone, tendons, and muscle are exposed; eschar is present on the lower half and proximal edges of the wound. What stage is this ulcer? A. Stage I B. Stage IV C. Stage III D. Stage II
B. Stage IV
What important points should you as the nurse teach your client with regard to a neurogenic bladder? A. The client should be aware that she has a rigid bladder. B. The client should be aware that she will not be able to feel bladder fullness and will not be able to contract the bladder sphincters. C. The client should be aware that she has a flaccid, nondistended bladder. D. The client should be aware that the bladder is spastic with voluntary elimination of urine.
B. The client should be aware that she will not be able to feel bladder fullness and will not be able to contract the bladder sphincters.
In the evaluation phase of the nursing process you must determine whether the client's goals related to urinary elimination have been met. Which of the following are expected outcomes that would indicate that his goals have been met? A. Acid-base balance is not met, and the client consumes no acidic foods to promote good urine output. B. The output of urine is comparable to intake of fluids, and the client is able to completely empty the bladder. C. The client's medications will have no impact on the urinary output. D. The client has no need for further assessment for maintaining healthy urinary habits.
B. The output of urine is comparable to intake of fluids, and the client is able to completely empty the bladder.
You are going to give Mrs. Smith a bath. The type of bath you are going to give usually lasts 20-30 min and is often used when a client has inflamed, itchy, or dry skin; hives; sunburn; chafing; poison ivy or oak; eczema; or skin irritation. The temperature is usually between 100° and 115°F (37.8° to 46.1°C). This type of bath relieves emotional tension, stress, and general aches and pains. It is also used to treat a variety of skin disorders involving large areas of the skin. What type of bath is described here? A. Towel bath B. Therapeutic bath C. Cleansing bath D. Tub bath
B. Therapeutic bath
You are planning to teach a female client, Ms. Brown, about pelvic floor structures. What must you include in your teaching? A. The male urethra is 20 cm long and allows for the passage of urine. B. The vagina, urethra, and rectum pass through the pelvic floor. It consists of muscles and ligaments. C. The vagina and urethra pass through the pelvis to the rectum. D. The vagina and urethra form a slinglike formation through the pelvic floor.
B. The vagina, urethra, and rectum pass through the pelvic floor. It consists of muscles and ligaments.
The nurse is teaching the client with a new descending colostomy the basic purposes of the appliance. What information should the nurse include? Select all that apply. A. To protect the stoma from stool B. To control odor C. To collect liquid stool D. To protect the skin from stool E. To collect stool
B. To control odor D. To protect the skin from stool E. To collect stool
The nurse reminds the client who has undergone a cystoscopy to report any problems with urination. The client reports difficulty urinating, with some pink-tinged urine. Which possible problems could that include? Select all that apply. A. Kidney bleeding B. Urinary bleeding C. Kidney stones D. Urinary retention E. Vaginal infection
B. Urinary bleeding D. Urinary retention
The nurse determines that the client on a bladder training program has met expected outcomes when the client does what? Select all that apply. A. Uses a condom catheter B. Voids on a timetable C. Postpones urination, depending on the frequency of urges-to-void D. Drinks a large glass of water before bedtime E. Voids each time there is an urge
B. Voids on a timetable C. Postpones urination, depending on the frequency of urges-to-void
The nurse is supervising an unlicensed assistive personnel (UAP) who is providing a bed bath for the client. Prior to starting the bath, the nurse checks the water temperature. What is the appropriate temperature to provide comfort and not present a risk for burning the client? A. 110degrees° to 125degrees°F B. 90degrees° to 100degrees°F C. 100degrees° to 115degrees°F D. 125degrees° to 135degrees°F
C. 100degrees° to 115degrees°F
Ms. Small was admitted for an emergency appendectomy 2 days ago. She no longer has a dressing, and the wound is exposed to air. The nurse is assessing her abdomen. Which of the following will the nurse include in the wound assessment? Select all that apply. A. Any other injuries such as fractures, internal bleeding, abscess? B. Is there a dressing? If yes, check for drainage amount, color, odor, and use of drains. C. Appearance of the wound: Is it healing, size, drainage, swelling, redness? D. Are the wound edges well approximated? E. Inspect for presence of foul odor (from wound) and assess for pain.
C. Appearance of the wound: Is it healing, size, drainage, swelling, redness? D. Are the wound edges well approximated? E. Inspect for presence of foul odor (from wound) and assess for pain.
The nurse instructed the client about providing a urine specimen. After the nurse finished, the client asked the nurse, "how is urine made by the body?" What physiological process produces urine? A. Bladder sphincter muscle contractions B. Peristalsis of the ureters C. Kidney filtration D. Stretching of bladder stretch receptors
C. Kidney filtration
Your client, Andrea Kline, a 17-year-old female admitted with a fractured left radius, has asked if she can take a shower. Which of the following require priority status before allowing her to get into the shower? Select all that apply. A. Assess her teeth and mouth, and her ability to eat and swallow. B. Assess her hair for potential problems such as dandruff, ticks, brittleness, and texture. C. Assess her current health status (e.g., weakness, lightheadedness, dizziness, pain). D. Assess her skin, particularly around the fracture area (wound) on her left arm. E. Assess steadiness, mobility, and ability to shower independently and safely.
C. Assess her current health status (e.g., weakness, lightheadedness, dizziness, pain). D. Assess her skin, particularly around the fracture area (wound) on her left arm. E. Assess steadiness, mobility, and ability to shower independently and safely.
A nurse is evaluating skin care needs. Which client poses the greatest risk for skin breakdown? A. A 36-year-old with coronary artery disease B. An 18-month-old with bronchitis C. A 74-year-old with a diagnosis of diabetes D. A 20-year-old with a urinary tract infection
C. A 74-year-old with a diagnosis of diabetes
In the implementation phase of the nursing process, which of the following are appropriate actions to prevent urinary tract infections? Select all that apply. A. Decrease fluid intake. B. Wear tight clothing. C. Cleanse the perineum from front to back. D. Wear cotton undergarments. E. Avoid use of shower gels and bubble baths.
C. Cleanse the perineum from front to back. D. Wear cotton undergarments. E. Avoid use of shower gels and bubble baths.
You are completing a hair assessment and general interview with Ms. Chin. You ask her if she has ever been diagnosed with thyroid disease. She seems confused and asks why you are asking her this question. Which of the following explanations is correct? A. When the body is in crisis, the hair cells can shut down and redirect energy elsewhere. B. Thyroid disease is considered a nutritional disease and can cause hair loss. C. Hair loss can be attributed to hyperthyroidism or hypothyroidism. D. Thyroid medication causes the hair to fall out.
C. Hair loss can be attributed to hyperthyroidism or hypothyroidism.
The nurse is reviewing the record of a client who is at risk for skin breakdown. Which lab data would be of particular concern to the nurse who is concerned with skin integrity? A. Potassium level of 4.0 mEq/L B. Albumin level of 4.0 g/dL C. Hemoglobin level of 10.2 g/dL D. Leukocyte level of 6,000
C. Hemoglobin level of 10.2 g/dL
The nurse is assessing the extent of tunneling of a pressure ulcer on a client admitted to the wound care unit. Which assessment technique is appropriate? A. Apply sterile gloves and insert a gloved index finger until the full extent of the tunneling is reached. B. Use a ruler to measure the glossy appearance of the skin area involved. C. Insert a sterile cotton-tipped applicator to measure the involved area. D. Rotate a tongue blade into the tunneled area until resistance is met.
C. Insert a sterile cotton-tipped applicator to measure the involved area.
Mr. Skinner, a 33-year-old, fell when he was skiing and broke his left tibia, requiring surgery to correct the fracture. He tells the nurse he wants to learn, what he needs to do to heal efficiently and quickly so that he can return home because he does not have health insurance. The nurse will implement nursing interventions to help maintain skin integrity and promote wound healing. Which of the following interventions does not promote wound healing? A. Maintain skin hygiene and prevent contamination of the wound. B. Encourage Mr. Skinner to drink at least 2,500 mL of fluids each day. C. Keep head of the bed no higher than 30 degrees to prevent shearing, and also prevent friction. D. Teach about nutrition and make sure he eats adequate protein, vitamins, and zinc.
C. Keep head of the bed no higher than 30 degrees to prevent shearing, and also prevent friction.
The 75-year-old client had a stroke 2 weeks ago that resulted in paralysis of the client's left side. What actions by the nurse would be most appropriate? Select all that apply. A. Allow the client to bathe herself. B. Give the client a total bed bath. C. Place the water, soap, towels, and other equipment within reach on the client's right side. D. Perform back care. E. Help the client bathe the right side.
C. Place the water, soap, towels, and other equipment within reach on the client's right side. D. Perform back care. E. Help the client bathe the right side.
The data gathered during the nursing history relative to hygiene practices enables the nurse to conduct what intervention? A. Apply the general guidelines for skin care while providing a bath. B. Evaluate the client's understanding of the instructions provided. C. Predict the client's needs and type of bath best suited for the client. D. Determine the effectiveness of the hygiene practices.
C. Predict the client's needs and type of bath best suited for the client.
The nurse is providing a bed bath to an unconscious older adult client. During the bath, the nurse notices flaky, dry, and silvery lesions on the client's knees and ankles. The nurse suspects that these are signs of what condition? A. Hirsutism B. Ammonia dermatitis C. Psoriatic lesions D. Abrasion
C. Psoriatic lesions
The nurse sees a health care provider order to apply a hydrocolloid dressing to a client with an infected pressure ulcer. Which is the most appropriate nursing action? A. Apply a transparent dressing to the area instead of the hydrocolloid. B. Implement the dressing change procedure as ordered. C. Question the health care provider's order. D. Administer pain medication prior to applying the hydrocolloid dressing.
C. Question the health care provider's order.
The nurse teaches the client that the process of urination is stimulated by which of the following? A. The urethra B. The pelvic floor C. Stretch receptors in the bladder wall D. The ureters
C. Stretch receptors in the bladder wall
Ms. Kline is a 17-year-old girl with a fractured radius who has asked if she can take a shower. When you ask her how she is feeling, she says "dizzy and lightheaded," and she thinks it is because of the pain medication she received 30 min ago. Which of the following nursing interventions would be critical and appropriate regarding her request based on how she is feeling and will contribute to accomplishing the following goal: Ms. Kline will not incur any injuries while in the hospital? A. Encourage the client to push through the dizziness and lightheadedness while showering. B. Assist the client while she is in the shower. C. Teach the client and her family about why she needs to remain in bed when feeling dizzy and lightheaded. D. Do not give the client any pain medications (will prevent dizzy and lightheaded feelings).
C. Teach the client and her family about why she needs to remain in bed when feeling dizzy and lightheaded.
The nurse is developing a care plan to prevent skin breakdown. Which body fluid does the nurse recognize as the least likely to cause skin excoriation? A. Excessive saliva B. Gastric juices C. Tears D. Perspiration
C. Tears
The nurse is caring for a client who has swallowing problems. The health care provider has considered both nasogastric (NG) and nasoenteric tubes for nutritional assistance to the client. The client's spouse asks the nurse about the difference between these two tubes. Which statements are appropriate responses? Select all that apply. A. A nasogastric tube reaches down into the upper small intestine. B. A nasogastric tube is used when enteral feeding is expected to be long term. C. The main candidates for nasoenteric tubes are clients at risk for aspiration. D. A nasoenteric tube is longer than a nasogastric tube. E. The nasogastric tube can be used for other purposes besides providing nutrition. The nasoenteric tube can be used only for providing nutrition.
C. The main candidates for nasoenteric tubes are clients at risk for aspiration. D. A nasoenteric tube is longer than a nasogastric tube. E. The nasogastric tube can be used for other purposes besides providing nutrition. The nasoenteric tube can be used only for providing nutrition.
The client's family members were concerned about their older parents' urinary elimination difficulties. The home care nurse educated the caregivers about some ways to help. What intervention would be included? A. Restricting fluids B. Regularly monitoring the parents while they are in the bathroom C. Turning on the cold water tap in the bathroom sink D. Insisting that the older parents relax
C. Turning on the cold water tap in the bathroom sink
Your 66-year-old client asks why her bladder always feels full. What physiology must you understand to explain the process of the bladder feeling pressure? Select all that apply. A. The stretch receptors are stimulated when 500 mL of urine is in the bladder. B. Sensory nerves in the bladder are called retracting receptors. C. When the bladder is full, it extends above the symphysis pubis and can reach the umbilicus. D. If the bladder is full, it will stimulate the nerves to give the client the sensation to void. E. The bladder feels pressure when it is holding between 300 and 600 mL of urine.
C. When the bladder is full, it extends above the symphysis pubis and can reach the umbilicus. D. If the bladder is full, it will stimulate the nerves to give the client the sensation to void. E. The bladder feels pressure when it is holding between 300 and 600 mL of urine.
A client sustained a right-wrist strain following a fall. Prior to applying the order ACE wrap, the nurse notes a superficial abrasion. Which nursing asessment should be completed prior to applying the ACE wrap? A. Pain on a scale from 1 to 10 B. Adequacy of the circulation in the right arm C. Wound drainage D. Client's ability to reapply the dressing
C. Wound drainage
You have just finished antibiotics for a urinary tract infection (UTI). You are currently caring for six medically complex patients on a renal unit. One of your clients has to have all paperwork done prior to going down for surgery. What is your best health care practice should you have the urge to eliminate? A. You may be experiencing some anxiety and muscle tension, but it will not delay your ability to void. B. Ignore the urge. Tension from your client assignment may impair your ability to void, but this will pass. You will be able to void later with no risk for a urinary tract infection. C. You should not ignore the urge to eliminate. Many nurses ignore this urge, placing themselves at risk for development of a urinary tract infection. D. It is important that you continue with fluids and foods with high sodium content to keep your urinary tract flushed properly.
C. You should not ignore the urge to eliminate. Many nurses ignore this urge, placing themselves at risk for development of a urinary tract infection.
The nurse has performed client teaching on how to cleanse a wound. Which statement by the client indicates further instruction is necessary? A. "I should avoid drying the wound after I clean it." B. "If the wound appears clean, I will not have to clean it each time I change the dressing." C. "I should cleanse the wound with a cotton pad." D. "I should clean in an outward direction."
C. "I should cleanse the wound with a cotton pad."
The nurse anticipates that her healthy adult clients with normal renal function will produce which of the following? A. 1,000 mL of urine per day B. 2,500 mL of urine per day C. 1,500 mL of urine per day D. 500 mL of urine per day
C. 1,500 mL of urine per day
The nurse assesses the skin of a newly admitted client. Findings include a 3 cm area with partial thickness dermis loss on the client's sacral area. Which documentation is an accurate description of the assessment? A. A stage I ulcer 3 cm in diameter on sacral region B. Stage III pressure ulcer noted on sacrum C. A stage IV ulceration 3 cm on sacral area D. 3 cm stage II pressure ulcer sacral area
D. 3 cm stage II pressure ulcer sacral area
The nurse providing foot care to a client with diabetes would provide what intervention? A. Soak the feet for at least 45 min to soften the toenails. B. Use the client's personal toenail clippers to trim the toenails. C. Teach the client how to perform self-care for calluses. D. Blot the foot gently with the towel to dry it thoroughly, particularly between the toes.
D. Blot the foot gently with the towel to dry it thoroughly, particularly between the toes.
The client has been taught nutrition needs for healthy skin. Which client diet selection best indicates to the nurse that understanding has taken place? A. A Caesar salad, broth, and a chocolate chip cookie B. Hamburger patty, green leafy salad with dressing, and steamed broccoli C. A bowl of chili, crackers, and a baked potato D. Boiled potatoes, steamed green beans, baked chicken, and fruit
D. Boiled potatoes, steamed green beans, baked chicken, and fruit
The nurse is explaining the stages of pressure ulcers to a group of new RNs. Which area of the body is most likely to develop a stage III ulcer? A. Ankle B. Patella C. Sacrum D. Buttocks
D. Buttocks
The nurse educated a client about ways to reduce a genetic risk of developing hypertension. The nurse listed foods with high sodium content. In addition to affecting blood pressure, these items have what effect on the urinary system? A. Cause bladder spasms B. Increase urine output C. Irritate the urethra D. Decrease urine output
D. Decrease urine output
Ms. Wilson is too weak to move herself in bed; she is immobile. Why is immobility a dangerous condition? A. Her skin and underlying tissues may become compressed over time, especially between a bone and the skin surface. B. Because she has little body fat, the pressure of her weight may cause ulcers to develop on bony prominences. C. Immobility causes damage to blood vessels and deep tissues in those areas that adhere to the bed linens. D. Immobility causes pressure on skin surfaces, leading to poor circulation and oxygenation of tissues, and eventually to skin breakdown (ulceration).
D. Immobility causes pressure on skin surfaces, leading to poor circulation and oxygenation of tissues, and eventually to skin breakdown (ulceration).
When you assess Ms. Kline (the 17-year-old female with a fractured left radius who asked to take a shower), you learn that she received pain medication (intramuscular) less than 1 hr ago, and she says she is "a bit dizzy and lightheaded." Which of the following nursing diagnostic statements is most appropriate for her at this time? A. Pain (scaled at "3"/10; 0 = no pain, 10 = worst pain) related to edema in left arm B. Change in skin integrity (open wound) related to wound on left arm C. Potential for aspiration risk factor: dizziness and lightheadedness D. Potential for fall or injury risk factor: side effects of pain medication (dizziness, lightheadedness)
D. Potential for fall or injury risk factor: side effects of pain medication (dizziness, lightheadedness)
The client informs the nurse that his hearing aid is uncomfortable. After checking the hearing aid and inspecting the client's ear, the nurse notices that the cerumen is visible in the auricle. How does the nurse remove the cerumen? A. Position a cotton-tipped applicator behind the cerumen and lift the cerumen out. B. Instruct the client to use a toothpick and remove the cerumen. C. Retract the auricle down and forward, and remove the cerumen. D. Retract the auricle up and back, and remove the cerumen.
D. Retract the auricle up and back, and remove the cerumen.
Adults have two ureters that come off the kidneys. What are the sizes of most adult ureters? A. The adult ureters are 27 to 30 cm long and 1.25 cm in diameter. B. The adult ureters are 20 to 25 cm long and 2.25 cm in diameter. C. The adult ureters are 25 to 30 cm long and 2.25 cm in diameter. D. The adult ureters are 25 to 30 cm long and 1.25 cm in diameter.
D. The adult ureters are 25 to 30 cm long and 1.25 cm in diameter.
The nurse performing a continuous bladder irrigation adjusts the flow rate of the irrigant based on what factor? A. The amount of discomfort reported by the client B. The type and number of medications taken by the client C. The client's report of daily fluid intake D. The color of the urine output
D. The color of the urine output
The nurse is caring for an emaciated older adult client who is immobile and is experiencing frequent watery stools. Which technique would the nurse use to protect the client's skin integrity? A. Place the client in Fowler's position in bed. B. Use a firm, circular motion to cleanse the sacral area. C. Wipe the soiled skin firmly with a towel. D. Use a gel and foam combination mattress.
D. Use a gel and foam combination mattress.
When providing foot care to your diabetic client, Ms. Chin, which of the following would be considered appropriate nursing care? A. Soak her feet in warm, soapy water for at least 45 min before trimming her toenails. B. Trim her toenails using the nail clippers she brought with her to the hospital. C. Teach the client how to perform self-care for the calluses she has on her feet. D. Wash the feet and dry well, especially between the toes.
D. Wash the feet and dry well, especially between the toes.
You are providing ear care for Mr. Connors and notice some cerumen partially blocking the ear canal. When is it appropriate for you, the nurse, to use a cotton-tipped applicator (Q-Tip) when performing ear care for the client? A. You can give the Q-Tip to the client to use, but you should not ever use one. B. If you see excess cerumen, it is acceptable to use a Q-Tip in the ears. C. If the client uses hearing aids, it is acceptable to use a Q-Tip in his ears. D. You should never use a cotton-tipped applicator for ear care.
D. You should never use a cotton-tipped applicator for ear care.
Suzy, your 4-year-old client, needs to take a bath prior to surgery. Suzy says she does not want to take a bath and begins to cry. Her parents have shared with you that she loves to take bubble baths. Which of the following is the most appropriate action to take? A. You direct the nursing assistant to bathe Suzy even though the child refuses and cries. B. You are busy and tell Suzy that she must take a bath; you carry her, crying, to the bathtub. C. You call the health care provider to inform her that Suzy is refusing to take the ordered bath. D. You tell Suzy that you have some bubbles for her bath and that it will be fun.
D. You tell Suzy that you have some bubbles for her bath and that it will be fun.
You are seeing Ms. Daniels, age 54, who had a urinary tract infection (UTI) last month. She states that she is "having to go all the time." How will you best respond to Ms. Daniels? A. "Ms. Daniels, you are not experiencing urinary frequency at this time. But if it gets worse, we will see you again." B. "Ms. Daniels, you are experiencing urinary frequency. It is normal for you to have occasional episodes of frequency." C. "Ms. Daniels, you are still getting over your UTI from last month. We will revisit the issue if your condition gets worse." D. "Ms. Daniels, you are experiencing urinary frequency. We will check your patterns to see why you have altered urinary elimination and offer suggestions."
D. "Ms. Daniels, you are experiencing urinary frequency. We will check your patterns to see why you have altered urinary elimination and offer suggestions."
An older adult client asks why the home health nurse suggested a bath every other day instead of daily. What would be the most appropriate response by the nurse? A. "At your age, reduced activity means that the need for a bath lessens." B. "Older people can have accidents while bathing, so when you lessen the number of baths you also lessen the possibility of accidents." C. "It can be tiring to take a bath every day at your age." D. "Too-frequent bathing causes dryness of the skin, and as people grow older, they produce less lubricant called sebum."
D. "Too-frequent bathing causes dryness of the skin, and as people grow older, they produce less lubricant called sebum."
The orthopedic nurse educator is preparing a post-conference seminar on osteomyelitis for a group of nurses. Which client is identified to have the greatest risk of developing this condition? A. 35-year-old paraplegic with tissue loss extending through the muscle B. 22-year-old with gastroenteritis and redness in the perianal area C. 50-year-old with paralysis and redness on the sacrum D. 60-year-old with full-thickness tissue loss and subcutaneous fat visible
A. 35-year-old paraplegic with tissue loss extending through the muscle
The nurse has admitted a new client to the unit. What question would best assist the nurse in assessing the client's skin care practices and concerns? Select all that apply. A. "How often do you floss your teeth?close double quote" B. "Do you experience any skin reactions or allergic responses?" C."Have you experienced any skin eruptions, redness, or dryness?" D. "Do you bathe or shower?" E. "Do you have any mobility concerns?"
B. "Do you experience any skin reactions or allergic responses?" C."Have you experienced any skin eruptions, redness, or dryness?" D. "Do you bathe or shower?" E. "Do you have any mobility concerns?"
