NUR 105

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse?

"Allow me to show you how to use your walker again."

The charge nurse confronts a new nurse about not wearing gloves into a client's room. The client is not on transmission-based precautions. How does the new nurse best respond?

"Can you show me the hospital policy for when to wear gloves?" When there is any doubt, the facility resources should be consulted for verification of existing policies regarding transmission-based and standard precautions. This question prevents the nurse from arguing with the charge nurse, too. Gloves are not required for every client interaction.

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

"Consult with your health care provider about beginning an exercise program." The nurse should advise the client to consult with the health care provider to create a plan for an exercise program. Regular exercise, including cardiovascular exercise, helps maintain strength and flexibility and can help slow bone loss, all of which aid in fall prevention. However, the type of exercise and equipment should be determined by the health care provider or another qualified health care professional, not by the nurse.

The nurse considers applying restraints to an agitated client. Which actions does the nurse take?

"Dim the lights and speak softly about something the client enjoys." The nurse attempts multiple techniques before restraining a person, even when the person is agitated. Among those techniques is providing a calming environment and distraction. The nurse can assess the client for injuries anytime he or she is agitated, but this is not immediately relevant. The client must at least be able to reach the call bell to request assistance and water, if allowed. Family members are not always helpful for someone with agitation, and a family member may find it difficult to accept that level of responsibility.

Which question, used for a pain assessment, would assess a client for the perception of pain?

"Do you find any meaning in your pain?" The question about interference with sleep is related to the degree to which the pain interferes with the client's life. The question about stress relates to the client's use of adaptive mechanisms to cope with the pain. The question about meaning assesses the client's perception of pain, and the question about activity if pain were controlled refers to the outcomes of pain.

The client asks the nurse why the nurse wears a disposable gown every time she enters the client's room. What is the nurse's best response?

"I am required to wear a gown for certain infections that are easily passed to others." The client needs a matter-of-fact response that does not make him or her feel dirty, guilty, or confused. The nurse teaches the client in a direct way that some infections are easier to spread, making additional precautions necessary for everyone's protection. It is dismissive to say it is policy or just that there is a sign on the door, and it is unkind to state that the nurse wears a gown to protect everyone else from the client.

A client asks the nurse "Will you remove that goopy gel stuff off the electrodes before applying them this time?" What is the correct response by the nurse?

"I cannot do that because the gel promotes conduction of the electrical current." The best response by the nurse is that the gel is necessary to promote conduction of the electrical current which is what stimulates the muscles. All other responses are untrue should not be provided to the client.

The new nurse notes a health care provider enter a client's room without the correct personal protective equipment (PPE). What does the nurse say to the health care provider?

"I notice you did not wear the required PPE." It is incorrect to confront the provider in a confrontational or accusatory manner. Once the nurse states that this behavior has been observed, the nurse and provider can have a discussion.

The nurse has just measured an adult client's oral temperature and obtained a result of 102.4°F (39.1°C). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate?

"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

"It is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow."

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

"Let me assess the patches. They may indicate the development of a fungal infection." The yellow or white patches in the oral cavity may indicate a fungal infection called thrush. They are not normal, nor are they the result of ineffective brushing or of drinking whole milk.

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

"Microbial contamination can occur when cleaning the anal area first."

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need?

"Place all four feet of the walker on the ground before stepping forward."

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

"Powder in the genital area can create a medium for bacterial growth."

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse?

"The health care provider will see the client and assess whether the restraint prescription should be renewed." After restraints have been worn for 24 hours, the health care provider who is responsible for the care of the client must see and assess the client before writing a new prescription for the use of restraint or seclusion for the management of violent or self-destructive behavior. The health care provider will indicate that the client should remain in restraints if violent or self-destructive behavior continues. The client must be taken out of restraints before discharge, but the nurse would not know whether the health care provider would continue to renew the prescription for restraints for each 24-hour period until the client's discharge. If tests were needed to determine why the client is violent, the health care provider would have prescribed them before this time.

The nurse is talking with a client who states, "My health care provider wants me to try a TENS [transcutaneous electrical nerve stimulation] unit for my pain. How can electricity decrease my pain?" Which response is most appropriate?

"The mild electrical impulses block the pain signal before it can reach the brain." Transcutaneous electrical nerve stimulation (TENS) is a noninvasive technique for providing pain relief that involves the electrical stimulation of large-diameter nerve fibers to inhibit the transmission of painful impulses carried over small-diameter nerve fibers. Heat therapy, not TENS therapy, generates heat to decrease muscle tension. The machine does not "trick the mind" into believing the pain does not exist. Cold therapy, not TENS therapy, produces numbness and alters tissue sensitivity.

A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review?

"Turning a back to a sterile field maintains the sterility of the field." A sterile field becomes contaminated if the nurse turns his or her back to it. Any item that comes into contact with a sterile field must be sterile. Reaching over a sterile field contaminates the sterile field. Any items below waist level are considered contaminated.

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"Use of special bathing products and avoidance of scrubbing help keep your skin intact."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

"Use the call bell for any needs and wear nonslip footwear." All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching?

"When I eat, I will remove my dentures and place them in a napkin." Clients should be encouraged to wear dentures to assist with eating. Dentures should not be wrapped in a napkin or paper towels, because they may be mistaken for trash. This statement indicates a need for further teaching. Dentures should not be placed in the bedclothes or linens, because they may be lost in the laundry. Storing dentures in cold water prevents warping. Special cleaners may be used to soak dentures and remove remaining food or other debris.

The nurse is presenting an educational inservice about comfort and asks the participants to provide examples of effective comfort measures. Which responses by participants indicate a correct understanding of the concept? Select all that apply.

- "Straightening wrinkled bed linens", - "Administering prescribed analgesic medications", - "Holding a client's hand during an invasive procedure or during times of emotional stress", - "Assisting a client with hygiene needs", - "Keeping the client's environment free from unpleasant odors"

A nurse demonstrates the correct use of hand hygiene using an alcohol-based handrub for which situation? Select all that apply.

- After applying a clean, dry dressing, - After removing gloves, - Before entering a client's room An alcohol-based handrub can be used if hands are not visibly soiled or have not come in contact with blood or body fluids. Appropriate situations would include before entering a client's room, after removing gloves, and after applying a clean, dry dressing. Soap and water should be used before eating and after using the restroom.

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

- An electronic thermometer with a rectal probe -, Water-soluble lubricating gel, - Disposable probe cover

A nurse delivers a tray of food to an older client and sets it on the overbed table. The client shows no interest in the food, however. Which actions should the nurse take? Select all that apply.

- Assess the client for signs of depression., - Consult a dietician if the problem persists., - Ask why the client does not want to eat anything on the tray. The nurse should explore with the client the reason why he does not want to eat anything on the tray. The nurse should assess for psychological factors that impact nutrition. Malnutrition is sometimes found with depression in the older adult population. The nurse and client should mutually develop a plan to address the lack of nutritional intake and consult the dietitian as needed. The nurse should not remove the tray until the reason for the client's not eating is explored. Crackers and ginger ale may be offered and an antiemetic administered if nausea is the reason for the lack of eating, but this is not established.

The nurse is caring for a client who asks to use a bedside commode. Prior to assisting the client, what things are important for the nurse to assess? Select all that apply.

- Check for the presence of drains and IV fluid lines., - Evaluate the client for any functional limitations., - Assess client for weakness or unsteady gait.

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply.

- Choose a walker with wheels on the front legs if you have a faster gait., - Check the walker for signs of damage, frame deformity, or loose or missing parts before use., - Wear nonskid shoes or slippers.

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

- Emesis basin, - Toothpaste, - Toothbrush, - Disposable gloves, - Towel Necessary supplies for tooth brushing include toothpaste, toothbrush, emesis basin, towel, and disposable gloves. The nurse would also include other PPE as needed, a glass of water, and mouth rinse. Lip lubricant is optional but should be offered to the client.

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply.

- Falls - Delirium, - Pressure injuries - Contractures Restraint-free care is the standard of practice and an indicator of quality care in all health care settings. Physical restraints do not prevent falls, and they increase the possibility of serious injury due to a fall. Restraint use in older adults is associated with falls and injurious falls, pressure injuries, and other adverse outcomes. Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, and even death.

Which can lead to an inaccurate tympanic temperature reading? Select all that apply.

- Having slept with one ear against a pillow, - Scarred tympanic membrane, - Ear drainage

A nurse must change the linens on a bed while it is occupied. Which actions should the nurse take? Select all that apply.

- Help the client turn toward the opposite side of the bed and fan-fold soiled lines as close to the client as possible., - Put on gloves before removing soiled linens., - Place a bath blanket over the client. Gloves prevent the spread of microorganisms. The blanket provides warmth and privacy. Having the client roll to the opposite side of the bed makes it easier to remove the soiled linens. The nurse should shift the mattress up to the head of the bed to allow the client more foot room, not shift it down to the foot of the bed. The nurse should not place the soiled linens on the floor or furniture or hold it against the uniform. The floor is heavily contaminated; soiled linen will further contaminate furniture and the nurse's uniform. The nurse should secure the clean top linens under the foot, not head, of the mattress.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply.

- Increase the parent's social interaction., - Ensure the parent engages in regular exercise., - Provide frequent reorientation. The nurse should instruct the adult child to provide frequent reminders of person, place, and time to help keep the client oriented in the environment and decreases the chance that the client will wander. The nurse should also instruct the adult child to ensure the parent engages in regular exercise and to work to increase the parent's social interaction, both of which help clients with dementia channel stress more appropriately. Taking naps frequently does not help to reorient the client with dementia or to channel energies. Changing the parent's routine frequently can disorient a client with dementia and increase the chance that the client will wander.

A nurse is giving a client a back massage. Which actions should the nurse perform? Select all that apply.

- Keep hands in contact with the client's skin at all times., - Observe the client's skin over bony prominences., - Warm the lubricant in the palm of the hand. The nurse should observe the client's skin for reddened or open areas, paying particular attention to the skin over bony prominences. The nurse should warm the lubricant in the palm of the hand, as cold lotion causes chilling and discomfort. The nurse should keep hands in contact with the client's skin at all times, as a firm stroke with continuous contact promotes relaxation. The bed should be raised to the nurse's elbow height, not hip height. The nurse should use light, gliding strokes (effleurage) to apply lotion, not heavy percussive ones, as effleurage relaxes the client and lessens tension. The nurse should complete the massage with additional long, stroking movements that eventually become lighter in pressure, not alternating grasping and compression motions, as the former are soothing and promote relaxation.

Which are basic principles of surgical asepsis? Select all that apply.

- Never turn the back on a sterile field., - Only a sterile object can touch another sterile object., - Avoid talking, coughing, sneezing, or reaching over a sterile field., - Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Never walk away from or turn the back on a sterile field. This prevents possible contamination while the field is out of the worker's view. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. Hold sterile objects above waist level. This will ensure keeping the object within sight and preventing accidental contamination. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile.

The nurse is taking a rectal temperature on a client. The client reports dizziness and then faints. What actions should the nurse take? Select all that apply.

- Notify the health care provider, - Assess the heart rate, - Remove the thermometer probe, - Assess the blood pressure

A nurse is massaging the back of client to relieve pain. In addition to pain relief, the nurse understands that massage has which additional benefits for the client? Select all that apply.

- Promotes general relaxation, - Increases circulation, - Improves sleep quality, - Reduces anxiety Giving a back massage provides an opportunity for the nurse to observe the skin for signs of breakdown. It also promotes general relaxation; improves circulation; decreases pain, symptom distress, and anxiety; improves sleep quality; and provides a means of communicating with the client through the use of touch. Massage does not reduce blood sugar level or fight infection.

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

- Provide privacy while the client removes dentures from the mouth., - Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning., - Use a toothbrush and paste to gently brush all surfaces. Putting paper towels or a washcloth in the sink protects against breakage. The nurse should provide privacy to the client during removal of the dentures, which many people are embarrassed by. A toothbrush and paste are appropriate to clean dentures. Rinsing with normal saline is unnecessary; plain water is fine. Upper dentures should be placed before lower dentures. A toothbrush and paste, not sterile gauze, should be used to clean gums and mucous membranes.

The nurse is educating the client about the benefits of implementing nonpharmacological methods of comfort and pain management. What will the nurse include in the teaching plan? Select all that apply.

- They can lessen the emotional aspects of pain., - They can help promote restful sleep., - They can strengthen client's coping abilities., - They can improve client's sense of control. The benefits of implementing nonpharmacological methods of comfort and pain control include the potential to lessen the emotional aspects of pain, improve the client's sense of control and coping abilities, decrease discomfort, and promote more restful sleep. Decreasing the risk of aspiration is not a benefit of using alternative methods of comfort and pain management.

The nurse is caring for a female client who has used the bedside commode. What things should the nurse document for this client? Select all that apply.

- characteristics of urine and/or stool, - tolerance of activity, - alterations in skin integrity

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply.

- clutter - extension cords - polypharmacy In the home of an older adult, the use of extension cords and clutter in the walkways are environmental hazards that increase the risk of falls in the home. Polypharmacy is common risk in the home of an older adult client. Placing objects in familiar places helps to decrease the risk in the home of an older adult. Using ambulation devices helps to decrease the risk of falls in the home of the older adult.

During measurement of a rectal temperature, the thermometer probe should be inserted about how many inches (centimeters) into the anus in an infant?

1 in (2.5 cm)

The nurse is providing care for a 3-year-old toddler and needs to take the child's temperature rectally. How far should the nurse insert the probe into the rectum?

1 in (2.5 cm)

The nurse is preparing to apply a transcutaneous electrical nerve stimulation (TENS) unit. Place the following steps in the correct order. Use all options.

1)Apply electrodes to the prescribed location. 2)Plug electrodes into the TENS unit. 3)Turn on the TENS unit. 4)Assure that the client can feel the tingling sensation. 5)Adjust the intensity to the prescribed setting. 6)Secure the unit to the client. Application to the proper location enhances the success of the therapy. Plugging the electrodes into the TENS unit completes the electrical circuit necessary to stimulate the nerve fibers. Using the lowest setting at first introduces the client to the sensations. Adjusting the intensity is necessary to provide the proper amount of stimulation.

The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. Use all options.

1)Assist the client into a supine position. 2)Wait 3 to 10 minutes, then measure the client's blood pressure. 3)Assist the client to the sitting position with legs dangling. 4)Wait 1 to 3 minutes, then measure the client's blood pressure. 5)Assist the client to a standing position. 6)Wait 2 to 3 minutes, then measure the client's blood pressure.

The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options.

1)Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. 2)Wrap the cuff around the limb smoothly and snugly and fasten it. 3)Place a small amount of conducting gel over the artery. 4)Place the Doppler tip in the gel and move it around until hearing the pulse. 5)Inflate the cuff while continuing to use the Doppler device on the artery. 6)Note the point on the gauge where the pulse disappears.

The nurse is assisting a client to use progressive muscle relaxation techniques. Place in order, from first to last, the action the nurse will implement. Use all options.

1)Explain procedure and rationale to client. 2)Assist client to a comfortable position. 3)Ask client to focus on a specific muscle group. 4)Instruct client to tighten that muscle group and hold it tight for 5 seconds. 5)Instruct client to totally relax a specific muscle group and concentrate of the sensation. The nurse should first explain the procedure and the rationale for the exercise to client, then assist the client to a comfortable position. Next the nurse should ask the client to focus on a specific muscle group (starting high such as with the jaw and moving down the body). Once the client is focused on a specific muscle group, the nurse will instruct client to tighten that muscle group, hold it tight for 5 to 7 seconds, and then totally relax the muscles and concentrate on the sensation of full relaxation. The nurse would continue to have the client focus, tighten, and relax each muscle group until the whole body has been covered.

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots. The steps for applying a prescribed extremity restraint to a client's ankle are: 1) Explain the rationale for use to the client and family; 2) Pad bony prominences; 3) Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps; 4) Ensure that two fingers fit between the restraint and the client's skin; 5) Position limbs in normal anatomic position; 6) Secure restraints to the bed frame with quick-release knots.

A nurse is preparing to shampoo a client's hair while the client is in bed. Place the steps below in the order that the nurse would perform them? Use all the steps listed.

1)Place a protective pad under the client's head and shoulders after removing the pillow. 2)Fill the pitcher with water at an appropriate temperature. 3)Place the shampoo board under the client's head. 4)Position a drain container underneath the drain of the shampoo board. 5)Put on gloves and give the client a folded washcloth to hold over the forehead. 6)Saturate the client's hair with water from the pitcher. When shampooing a client's hair in bed, the nurse would remove the pillow and place a protective pad under the client's head and shoulders, fill the pitcher with comfortably warm water, have the client lift his or her head and place the shampoo board underneath the client's head. Then the nurse would place a drain container underneath the drain of the shampoo, put on gloves, have the client hold a folded washcloth at the forehead and finally pour a pitcher of warm water slowly over the client's head, making sure that all hair is saturated.

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. Place the following steps in the correct order. Use all options.

1)Remove jewelry 2)Check the product label for the correct amount to use 3)Apply the product 4)Rub the hands together, covering all surfaces of the hands and fingers 5)Ensure that the hands are dry Remove any jewelry. Then the nurse would check the product label for the appropriate amount to use and then apply the product to the palm of one hand. Next, the nurse would rub the hands together covering all the surfaces of the hands and fingers, and between fingers as well as the fingertips and the area beneath the fingernails. Lastly, the nurse would rub the hands together until they are dry (at least 15 seconds).

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

1)Turn on the faucet and adjust the force and temperature of the water. 2)Wet the hands and wrists. 3)Apply soap. 4)Wash the palms and backs of the hands for at least 20 seconds. 5)Pat the hands dry with a paper towel. 6)Turn the faucet off with a paper towel. First, turn on the water and adjust force. Second, wet the hands and wrists. Third, use about 1 teaspoon of liquid soap from the dispenser or rinse a bar of soap and lather thoroughly. Fourth, with firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers, and the knuckles, wrists, and forearms. Continue this friction motion for at least 20 seconds. Fifth, pat the hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Sixth, use another clean towel to turn off the faucet.

Place in correct order the steps for removing a gown. Use all options.

1)Unfasten the ties. 2)Touching only the inside of the gown, pull away from the torso. 3)Keeping hands on the inner surface of the gown, pull gown from arms. 4)Turn gown inside out. 5)Fold or roll the gown into a bundle. 6)Discard the gown. To remove gown: Unfasten ties, if tied, at the neck and back. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the torso. Keeping hands on the inner surface of the gown, pull gown from arms. Turn gown inside out. Fold or roll into a bundle and discard.

A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption?

1. Creatinine 1.9 mg/dL (168 μmol/L) 2. Hemoglobin (Hgb) 11.3 g/dL (113 g/L) 3. Hematocrit (Hct) 56% (0.56) 4. Serum albumin 2.8 g/dL (28 g/L) ANSWER: Serum albumin 2.8 g/dL (28 g/L) Normal serum albumin is 3.3 to 5 g/dL (33 to 50 g/L). Decreased albumin indicates malnutrition or malabsorption. Decreased Hgb indicates anemia. Increased creatinine indicates dehydration. Increased Hct indicates dehydration.

The nurse prepares to obtain a rectal temperature on an adult client. To which distance should the nurse insert the thermometer?

1.5 in (3.75 cm)

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100oF (38oC)

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading?

105oF (40.6oC)

A nurse is preparing to use an alcohol-based handrub for hand hygiene. After applying the appropriate amount of product, the nurse would rub the hands together for at least how long?

15 seconds The nurse would rub the hands together until they are dry, for at least 15 seconds. Drying ensures the antiseptic effect.

The nurse estimates a client's systolic pressure to be 150 mm Hg. When obtaining the client's blood pressure measurement with a sphygmomanometer, the nurse would inflate the cuff to which pressure?

180 mm Hg

The nurse is giving instructions to the client about the procedure for measuring orthostatic hypotension. The nurse explains that for each measurement, the client will have to remain in the position for approximately how long?

3 minutes

The nurse has completed assessing for orthostatic hypotension and documents the results. What results would indicate to the nurse the client is experiencing orthostatic hypotension?

A decrease in systolic pressure >20 mm Hg

A nurse is providing care to several clients who are extremely weak and need to have their hair shampooed while remaining in bed. When gathering the necessary supplies, the nurse would anticipate needing to adapt the shampoo board for the client with which condition?

Acute spinal cord injury

The nurse is preparing to assess a client's temperature rectally. The client is lying supine in bed. What should the nurse do first?

Adjust the bed to a comfortable working height.

The nurse is assisting a client with changing an ostomy appliance. What is the best method of ensuring that the client has understood the procedure and is able to perform it independently?

After performing the first appliance change, observe the client performing the next change.

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

A client tells the nurse that the heartburn she is experiencing is worse when she eats spicy foods. What would the spicy food be considered?

An aggravating factor. An aggravating factor makes the pain occur or increase in intensity. Alleviating factors make the pain go away or lessen. Associated phenomena are factors that consistently relate to the pain. Physiologic responses are physical signs related to the pain, such as a change in vital signs.

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

Apply a thin barrier of skin protectant to the perineal area

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures?

Apply gentle pressure with a 4 × 4 gauze to grasp the denture plate. Applying gentle pressure with a 4 × 4 gauze prevents slippage and discourages the spread of microorganisms. Asking the client to take a deep breath and exhaling and using a tongue blade are not effective for removing denture plates. Sterile gloves are not necessary for providing oral care.

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure?

Apply gentle pressure with a piece of gauze to remove the upper dentures. Providing denture care for a client, the nurse would apply gentle pressure with a piece of gauze to remove the upper dentures, place them in a denture cup, line the sink with a paper towel to prevent breakage when cleaning the dentures with a toothbrush and toothpaste, rinse them, and return the dentures to the client.

A nurse is measuring a client's blood pressure in the right arm and is having difficulty auscultating the sounds. Which would be least appropriate for the nurse to do?

Apply less pressure with the stethoscope.

The nurse provides care to a sedated client with soiled sheets. Which action does the nurse take to move the client?

Ask for help from a staff member. The nurse obtains helps from a fellow staff member so that the client can be properly cleaned and safely turned. The nurse protects the client's alignment and observes personal safe body mechanics. A hydraulic lift is not very useful for the client who is soiled. Placing pillows behind the client's back is done after the client has been cleaned. The nurse should not attempt to clean and position a client without assistance so that the client can be rolled without injury.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate?

Assess for the need to urinate. Client needs should be assessed before considering physical or pharmacologic restraint.

Prior to allowing a client to eat, which action is most important for the nurse to take?

Assess the client's level of consciousness. The most important thing the nurse can do is to ensure the client is alert enough to safely eat without aspirating. Next, ensuring the client is physically able to self-feed and safely swallow is necessary. The client's cultural needs and eye sight are least important.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?

Assess the client's need for fluids and toileting every 2 hours. Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance. According to the UAP Nurse Practice Act, the duties of a UAP do not include performing assessments. The nurse should assist with the client's ADLs but allow the client the independence of performing as many as possible for oneself. The restraints should be secured to a non-movable part of the bed frame, and, thus, not to the side rail.

The nurse is planning to take a client's temperature orally. The nurse enters the room and observes the client drinking a cup of coffee. Which action would be most appropriate?

Assess the client's temperature about 30 minutes after the client has finished drinking the coffee.

After assisting a bed-bound client with oral care, what action does the nurse take?

Assist the client to a comfortable position in the bed. During oral care, the client either sits straight up in the bed or must lean toward the bedside. After completion of oral care for the bed-bound client, the nurse assists the client to a comfortable position. Oral care supplies are recapped or rinsed, stored in a drawer, cabinet, or on a shelf, and reused when needed to avoid unnecessary waste. Inspection of the oral cavity should occur prior to care to minimize oral trauma and to correctly assess for hydration.

The nurse, assessing a client's pain, asks the client if there are any other factors that consistently relate to the pain. What characteristic of the pain is the nurse assessing with this question?

Associated phenomena. When assessing the associated phenomena of a client's pain, the nurse would ask if there are any factors consistently related to the pain. Chronology refers to how the pain develops and progresses. Aggravating factors are factors that make the pain occur or increase in intensity. Alleviating factors are factors that make the pain go away or lessen.

A client has had a nasogastric tube inserted in preparation for tube feedings. When developing the client's plan of care, the nurse would anticipate checking the placement of the tube at which time?

Before administering a medication through the tube The nurse would verify correct placement of the nasogastric tube after the initial insertion, before beginning a feeding or instilling medications or liquids, and at 4-hour intervals during continuous feedings. This ensures that the tip of the tube is situated in the stomach or intestine, preventing inadvertent administration of substances into the wrong place. A misplaced feeding tube in the lungs or pulmonary tissue places the client at risk for aspiration.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures Brushing the dentures is within the scope of practice for the UAP and therefore it is appropriate to delegate this aspect of denture care. Assessment, planning and teaching fall within the scope of practice for the nurse and are not appropriate for delegation to the UAP.

The nurse is assessing the pain of a neonate with altered respirations. Which pain assessment scale would be the best choice for this client?

CRIES pain scale. The CRIES pain scale would be the most appropriate scale to use for neonates. The COMFORT scale is used for infants, children, and adults who are unable to use the Numeric Rating Scale or Wong-Baker Faces pain rating scale. The FLACC scale is used for infants and children (2 months to 7 years) who are unable to validate the presence of or quantify the severity of pain. The Wong-Baker Faces pain rating scale is used for adults and children over three years old.

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

Carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath.

The nurse cleans the client after a bowel movement and notes stool on the gloves. The nurse has not finished cleaning the client. What action should the nurse take?

Change into a new pair of gloves.

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next?

Change into a new pair of sterile gloves. The client must be prepared prior to preparing the catheter kit. The nurse must wear sterile gloves while preparing the sterile tray, because it involves opening sterile supplies. If the nurse then touches a non-sterile surface, like the client's blankets, the sterile gloves must be changed prior to continuing the procedure. The nurse does not need to reposition the kit at this time. The nurse is no longer sterile and cannot proceed with cleaning the client with sterile solution. Only the nurse's gloves are contaminated; the nurse does not need to dispose of the kit.

The nurse is changing the linens for a client who could not be turned on the side due to a surgical incision on the right hip and pain from a fall in the left hip. What nursing intervention would be appropriate for this client?

Change the bed linens from the top to the bottom.

The nurse uses perineal cleansing wipes for the client who has had a bowel movement. Which action does the nurse take?

Change to a clean wipe after each stroke. The nurse changes wipes after each stroke to avoid spreading feces to noncontaminated areas. Wipes are not flushable. Using multiple wipes at one time is wasteful. Wash cloths are harsh to perineal skin and are not used for incontinence care or after bowel movements.

What is most important for the nurse to do when using an automatic electronic device to obtain serial blood pressure readings?

Check that the cuff is deflated completely after the reading.

The nurse is preparing to make a bed occupied by a client who is on bedrest. What is the first action the nurse would take in this procedure?

Check the client's chart.

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?

Check the medical record for the client's prescribed diet. The nurse ensures the client has gotten the correct meal tray. Often a client on a dysphagia diet will have a special diet that includes softer or pureed foods and thickened liquids that aren't available on the regular diet tray. The other actions are not incorrect, but the client may not be on a chopped food diet. Sometimes the client with dysphagia just requires sips between bites, and there is no reason to use foods from the unit's kitchen area. The best action the nurse can take is to ensure the client get the correct meal tray.

A nurse is measuring a client's blood pressure using an electronic device. What is important for the nurse to do to ensure accurate results?

Check to make sure the client's heart rate is regular.

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home. The nurse should recommend that the client's family ensure that walking paths and floors in the home are free of clutter, which is an environmental hazard that increases the risk of falls in the home. Changing routines, taking walks outside, and using the stairs will not reduce the risk of falling in the home.

The nurse is observing a client learning to change the ostomy appliance. Which action by the client would require the nurse to intervene?

Client cuts the opening on the new bag 0.5 in (1.25 cm) larger than the stoma size.

In which client would a back massage be contraindicated?

Client who has a fractured rib A back massage would be contraindicated in a client who has a fractured rib as the massage could accidently dislodge the fracture and cause injury to nearby organs. Back massage is also contraindicated in clients with severe burns because of the risk of disturbing the wounds and in clients who have recently had open heart surgery because of the risk of injury to the new sternal incision. None of the other clients present a contraindication to back massage. Back massage does not present a risk for the client who is ambulatory, experiencing anxiety or has diabetes mellitus. In fact, it could be quite beneficial as it helps the client to relax, and it helps to relieve muscle tension hopefully helping them to rest and sleep better while hospitalized.

What is the best source for the nurse to determine the type of transmission precautions a client needs?

Client's medical record The client's medical record includes the type of precautions to observe and the laboratory reports to verify the organism. The sign on the client's room may be incorrect. Nurses typically ensure the client is on the correct precautions. The assigned nurse updates the charge nurse's report regarding transmission precautions.

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which is an example of this type of intervention?

Closing the client's room door to reduce unnecessary noises A noisy environment, even talking, can be a source of stimuli that causes discomfort; therefore, closing the client's room door is a way to adjust the environment to make it quieter. Assisting the client to change positions or smoothing out wrinkles in the bed linen is implementation of a physical adjustment techniques to promote comfort. Offering the client a book or music is using a technique of distraction to help the client not focus on the discomfort.

The charge nurse notices that when caring for a client, some nurses are wearing personal protective equipment and other nurses are not. Which action would be most appropriate for the nurse to take?

Consult the agency's infection control manual. If there is a question about transmission-based precautions when caring for a client, the nurse should check the agency's infection control manual and the institution's policies about specific illnesses. Then the nurse should review the mode of transmission associated with the specific microorganism causing the illness. Although asking the health care provider about the client's condition and reviewing the medication record can provide additional information, the infection control manual and policies would be most appropriate to use. Checking with other staff nurses on the unit would be inappropriate because their actions could be inconsistent.

A nurse is caring for a client who has been prescribed a clear liquid diet. Which liquid can be included in the client's diet?

Cranberry juice Composed only of clear fluids or foods that become fluid at body temperature and includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, commercially prepared clear liquid supplements. A clear liquid diet requires minimal digestion and leaves minimal residue. Low-fat milk, fruit juices or soup, and juices with fruit pulp (orange and grapefruit) are considered full-liquid diet.

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

Decreasing the incidence of hospital-acquired pneumonia Diligent oral care inhibits the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, hospital-acquired non-ventilator pneumonia and ventilator associated pneumonia. While the other choices are expected outcomes of oral care, preventing respiratory complications is the priority.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which areas of the client's mouth?

Deep in the posterior sublingual pocket

The nurse is obtaining serial blood pressure measurements on a client having hypertension medication adjustment. What assessment is most important for the nurse to perform frequently?

Determine if there is compromised circulation in the limb.

The nurse is assessing a cancer client's pain. The client is unable to point to a specific area of pain; rather, the client moves a hand over the abdomen to indicate the pain. What type of pain is this client experiencing?

Diffuse Diffuse pain covers a large area and cannot be localized. Sharp pain is sticking and intense. Dull pain is not as acute as sharp pain, and shifting pain moves from one area to another.

The nurse has taken a client's temperature using a tympanic thermometer. What should the nurse do next?

Discard the probe cover

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding. The nurse should document this finding after completion of the back massage and client care and report it to the health care provider. The nurse would also position the client to remove any pressure from that area. The nurse should not apply a warm compress or massage the reddened area.

The nurse reads the client's history and notes the client has vascular insufficiency in one upper extremity and both lower extremities. Which device would be most appropriate for assessing the client's blood pressure?

Doppler ultrasound

The nurse is performing hand washing using soap and water after providing client care. The nurse has performed hand hygiene using soap and water. What action would the nurse take next?

Dry the hands with a paper towel. After rinsing the hands, the nurse would dry the hands using paper towels, wiping from the fingertips toward the forearms. Once dry, the nurse would then use another clean paper towel to turn off the water at the faucet to prevent clean hands from coming in contact with the soiled surface. The fingernails are cleaned before the hands are rinsed. The hands are dried using clean paper towel. An alcohol-based sanitizer or hospital-provided lotion can be used after handwashing and drying, if desired.

A person's core body temperature is lowest during which part of the day?

Early morning

When a client cannot be turned on the side, what recommended nursing action would the nurse perform, with assistance from another nurse, to replace the soiled linens once they have been removed?

Ease the clean linens under the client, from the top to the bottom of the bed. The recommended procedure for applying new linens on an occupied bed is to apply the bottom sheet securely to the top of the bed, ease the clean linens under the client from the top to the bottom of the bed, and secure the linens at the bottom of the bed.

The nurse obtains a blood pressure on a client using a Doppler ultrasound device but is unsure if the results are accurate. The nurse plans to repeat the measurement. What step would the nurse take to ensure a correct reading?

Ensure that the cuff is completely deflated before attempting another reading.

The nurse is preparing to measure a client's tympanic temperature. After performing hand hygiene and identifying the client, what would the nurse do next?

Ensure that the thermometer is on and ready.

A client with dysphagia prepares to eat dinner. How does the nurse best help this client?

Ensure the head of the bed is high-Fowler. The nurse must ensure that the client is sitting up well enough to safely eat, whether that is high-Fowler or in the chair. The nurse may assist in setting up the meal tray or play something the client enjoys for background noise. The client with dysphagia should have minimal conversation while eating due to the increased risk of failure to correctly swallow.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency?

Every 1 to 2 hours The nurse would plan on increasing the frequency of client observation and surveillance, conducting client/nursing rounds every 1 to 2 hours. These rounds would include assessing for pain, assisting with toileting, providing client comfort, ensuring that personal items are within reach, and meeting client needs. Client care rounds/nursing rounds improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.

The nurse offers a client, who has been experiencing muscle tension, a back massage. The client responds, "Thank you but that is not necessary." Which action by the nurse is most appropriate at this time?

Explain the benefits of a back massage. Because some clients consider a back massage a luxury, they may be reluctant to accept the nurse's offer, so the best action by the nurse is to explain to the client the many benefits of back massage: specifically, that it helps to relax muscles and decrease tension. If the client still declines, the nurse should accept that answer, then documenting refusal would be appropriate. Back massage is an independent nursing action and would not be part of the health care provider's prescription. Notifying the health care provider and requesting a muscle relaxant is not an appropriate action by the nurse, based solely on the client's refusal of a back massage.

How should the nurse open the bottom sheet when making an unoccupied bed?

Fanfold to the center The nurse would place the bottom sheet with its center fold in the center of the bed, open the sheet and fanfold to the center of the bed. Opening items on the bed reduces strain on the nurse's arms and diminishes the spread of microorganisms. Centering the sheet provides sufficient coverage for both sides of the mattress.

The nurse determines that it would be inappropriate to obtain a tympanic temperature for the client with which problem?

Fluid draining from the ear

After removing the closing clamp on a colostomy appliance, what would be the nurse's next step before emptying the appliance?

Fold the end of the pouch upward, like a cuff.

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens?

Fold the linens in fourths on the bed and then hang them over a clean chair. The nurse would fold reusable bedding, such as a sheet, blanket, or spread, in fourths on the bed and then hang it over a clean chair. Folding the reusable linens saves time and energy when they are replaced on the bed. Folding bedding while it is on the bed reduces strain on the nurse's arms. Having another nurse assist may not be an effective use of time. The overbed table should be reserved for client items. The nurse would want to place the reusable lines on the bed after the client has returned to the bed.

Which item would the nurse remove first when removing personal protective equipment?

Gloves When removing personal protective equipment (PPE), the first item to be removed is the gloves. If the gown is tied in the front, the nurse unties the gown first and then removes the gloves. The face shield is removed next, followed by the gown, and lastly the mask.

The nurse is required to wear a gown, gloves, goggles, and mask as personal protective equipment (PPE) when caring for an assigned client. What should the nurse put on first?

Gown When using personal protective equipment (PPE), the nurse would put on the gown first. Then the nurse would then put on the mask and goggles, and lastly the gloves.

The nurse, assessing a client for pain, looks for behavioral responses to the pain. Which is an example of a behavioral response?

Grimacing Facial grimaces are a behavioral response to pain. Anxiety, fear, and depression are affective responses to pain.

How would the nurse remove the top linens when making an occupied bed?

Have the client hold onto the bath blanket and reach under it to remove the linens.

The nurse is assessing a client for orthostatic hypotension and is obtaining the blood pressure while the client is sitting at the edge of the bed with the feet dangling. The client states, "I'm feeling a bit dizzy." The client is pale and beginning to perspire. What should the nurse do first?

Have the client lie down in the bed.

The unlicensed assistive personnel (UAP) measures the client's axillary temperature shortly after the client has taken a shower. The temperature is lower than the client's previous baseline. What should the UAP do next?

Have the nurse retake the temperature.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?

Health care-associated infection This infection is best described as a health care-associated infection. A health care-associated infection is an infection not present on admission to health care agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

Heat the entire package in the microwave, following the manufacturer's recommendation.

When measuring a client's axillary temperature, the nurse would position the thermometer at which location?

In the center of the axilla

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. When applying the product, the nurse would place the product at which location?

In the palm of one hand The proper procedure for using an alcohol-based handrub is to apply the appropriate amount of product to the palm of one hand. This helps to ensure that the product will cover all the surfaces when the product is rubbed in. The nurse would rub the hands together, covering all surfaces of hands and fingers, between fingers as well as the fingertips and the area beneath the fingernails. It would be inappropriate to apply the product to each fingertip, on the back of the hand, or between each finger.

When using a Doppler to obtain a client's blood pressure, which action does the nurse take?

Inflate the cuff until the pulse disappears.

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted?

Insert the fist between the restraint and the client. The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

Where should the nurse roll soiled linens when removing them from an unoccupied bed?

Inside the bottom sheet The nurse should snugly roll all the soiled linen inside the bottom sheet and place it directly into the hamper to help prevent the spread of microorganisms. The floor is heavily contaminated, and soiled linens would further contaminate the furniture. Rolling the used lines inside the top sheet is not efficient.

How should the nurse teach the client who is ambulating with a cane?

Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

When assessing a client's pain, what characteristic of pain does the nurse assess using a pain rating scale?

Intensity For clients who can self-report about their pain, the nurse uses a pain rating scale to assess the intensity of the pain. The intensity is the degree (amount) of pain experienced.

When taking an axillary temperature, the nurse exposes only the axilla area. What reasons does the nurse tell the client? Select all that apply.

It maintains the client's dignity., It keeps the client warm.

The nurse is preparing to change the linens from the top to the bottom for a client who cannot be turned on the side. Which accurately describes a recommended step in this procedure when removing the soiled linens?

Keep the blanket in place over the client to provide privacy and remove the top sheet. To change the linens in an occupied bed when the client cannot be turned on the side, the nurse would first cover the client with a bath blanket and remove the top linens. Then, the nurse would help the client up to a sitting position in the bed (as tolerated), roll the soiled linens from the top of the bed until they meet the client's backside, and remove the soiled sheets by working them out from under the client down to the foot of the bed.

When washing the hands with soap and water what is an appropriate action for the nurse to perform?

Keep the hands below the elbows. The nurse keeps the hands lower than the elbows to allow water to flow toward fingertips. When hand washing, the nurse washes jewelry, usually restricted to only a wedding band, before starting; jewelry can harbor microorganisms and contaminants. Next, the nurse would turn on the water, apply soap to the hands, and rub it in using a circular motion. After thoroughly cleaning the hands, the nurse would then clean under the nails. The nurse does not lean on the sink as this can lead to contamination.

The nurse is making a bed occupied by a client. How would the nurse position the client when loosening bottom bed linens?

Lying on one side

The nurse making an occupied bed. Under which body part of the client would the nurse place the drawsheet?

Midsection

A client rates pain on a numeric pain scale at a "5" out of 10. What type of pain is this client experiencing?

Moderate On a numeric rating scale, no pain is rated as 0, mild pain is rated as 1 to 3, moderate pain is 4 to 6, severe pain is 7 to 9, and a 10 is pain as bad as it gets.

When assessing a client, the nurse may identify which physiologic response to pain?

Muscle tension and rigidity. Physiologic responses to pain are involuntary responses, such as increased blood pressure, and muscle tension and rigidity. The other examples are behavioral or voluntary responses.

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint?

Pad bony prominences. Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. The nurse should remove PPE after applying the restraint.

The nurse will assess the client for orthostatic hypotension. What symptoms would alert the nurse that the client is experiencing hypotension? Select all that apply.

Pallor, Diaphoresis, Dizziness

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?

Perform a circulation check and offer toileting and hydration. Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids. Restraints are not used on an as needed basis but are used for a 24-hour period with breaks only for basic needs, like toileting. Even if the client suddenly seems calm, removal of the restraints is not permitted. Once this is done, a new prescription must be obtained and there are legal issues to consider. Bargaining with the client for restraint removal is not an acceptable nursing action. Restraint use is a safety measure, not a punishment.

The nurse prepares to wear personal protective equipment (PPE) when entering a client's room. What action does the nurse take first?

Perform hand hygiene. The nurse must perform hand hygiene before putting on gloves, just like any other time. The nurse does not want to introduce additional infectious organisms to this client. The client's door, for most isolation types, can be opened after PPE is on. Though often done incorrectly, when gowning it is important to ensure the gown covers the back and front of the nurse. As the nurse is dressing in PPE it is wise to double check that the correct transmission precautions are being observed and that each piece of equipment needed is being worn by the nurse. The nurse would not be wrong if wearing more than is required but would not want to wear less than is needed.

When changing a client's ostomy appliance, the nurse finds that feces continue to flow from the stoma, making applying the new appliance difficult. What would be the recommended action when this occurs?

Place a piece of gauze over the stoma to absorb the drainage.

The nurse is assisting the client with transfer to a bedside commode. After the client stands and pivots, what should the nurse instruct the client to do next?

Place hands on the armrests prior to sitting down.

The nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply.

Protective pads, Linen, Bath blanket, Towels, Gown

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action?

Provide client comfort The main purpose for changing the linens on a client's bed is to provide client comfort. Tidying up the room, preparing for visitors, and removing soiled linens are also benefits of this action, but the main objective is to make the client comfortable and free of skin alterations due to wrinkled linens.

The nurse is assessing a client's pain and asks the client, "What words would you use to describe your pain?" What characteristic of pain is the nurse assessing with this question?

Quality The nurse assesses the quality of pain by asking the client to describe it. The location of pain is assessed by asking the client where the pain is being experienced. Duration refers to how long the client has been experiencing the pain. The pain intensity is assessed with a pain rating scale.

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube?

Radiographic confirmation of position Radiographic (x-ray) examination is the only reliable method to determine accurate tube placement. In the absence of an x-ray, pH testing is predicative of correct placement. Although visualization of aspirated contents can help confirm correct placement of the tube, this method is not as reliable as an x-ray.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height.

When making an occupied bed, the nurse positions and tucks in the bottom linens on one side of the bed. What would be the nurse's next action?

Raise the side rail.

The nurse is providing care to a client who has a low platelet and white blood cell count. When assessing the client's temperature, which method would method would be contraindicated?

Rectal

The charge nurse observes a new nurse not wearing personal protective equipment (PPE) entering and exiting a client's room. The client is on transmission-based precautions. What is the charge nurse's best response?

Reinforce teaching that transmission-based precautions must be observed. The new nurse may have forgotten, missed the signs, or some other honest error. The charge nurse first offers teaching to the new nurse immediately to prevent further potential harm. An incident report should not be necessary and is not an immediate action. The manager may need to be involved if the issue persists.

The nurse notes that a health care provider failed to observe transmission precautions in a client's room and is entering another client's room. What is the nurse's next action?

Remind the health care provider about the transmission precautions. It is best to directly and immediately address the issue with the health care provider. The nurse may suggest that additional precautions are taken prior to entering the client's room, but really can't insist, and hand hygiene is expected for every client. The charge nurse or supervisor can intervene, following the chain of command, if the health care provider does not take corrective action.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action?

Remove gloves, unless indicated for transmission precautions. After placing the soiled linens in the laundry hamper, the nurse would remove gloves, unless indicated for transmission precautions, and then place the bottom sheet with its center fold in the middle of the bed. This can be done without gloves, because the linens are clean. If the mattress is soiled, it should be cleaned according to facility policy. Scrubbing the mattress with antimicrobial cleanser is not necessary.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

Remove the antiembolism stockings before the bath.

The patient states that she feels nauseated and cannot eat:

Remove the tray from the patient's room. Explore with the patient the desirability of eating small amounts of foods or liquids, such as crackers or ginger ale, if the patient's diet permits. Administer antiemetic as prescribed, and encourage patient to retry small amounts of food after medication has had time to take effect.

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

Retract the foreskin when washing the prepuce of adolescents and older.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place.

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

Scrotum

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

Sitting at the edge of the bed To prevent aspiration, it is best to assist the client to a sitting position. If the client is unable to sit, the side-lying position is also acceptable. The other options would place the client at risk for aspiration.

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?

Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Talking during eating increases the risk of aspiration for a client who has dysphagia. Arranging food on the plate in a clock face pattern is a strategy appropriate for a client who is visually impaired. Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration. Allow enough time for the client to adequately chew and swallow the food. The client may need to rest for short periods during eating.

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

Start with cleanest areas and end with most soiled areas.

Which situation would require the nurse to contact the health care provider when changing an ostomy appliance?

Stoma appears brown in color.

A nurse aspirates a small amount of fluid from a client's nasogastric tube. The nurse determines that the tube is in the intestines based on the aspirate being which color?

Straw-colored Gastric fluid can be green with particles, off-white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden yellow color. Also, intestinal aspirate may be greenish brown if stained with bile. Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus.

Which includes practices used to render and keep objects and areas free from microorganisms?

Surgical asepsis This statement describes surgical asepsis, or sterile technique. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Hand hygiene is a type of medical asepsis specific to the hands and includes hand washing and use of alcohol-based handrubs.

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take?

Take a few steps around the table to pick up the additional supplies. The nurse can step around the edge of the table, without turning his or her back on the sterile field, to gather the remaining supplies. Reaching across the current sterile field would be a reason to discard all the supplies and the field due to contamination. The table does not need to be completely covered with sterile drapes.

After inserting a nasogastric tube, what should the nurse do to ensure that the tube is properly placed in the client?

Test the pH of aspirated content. Current research demonstrates that the use of pH is predictive of correct placement of a nasogastric tube. The pH of gastric contents is acidic (less than 5.5). If the client is taking an acid-inhibiting agent, the range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher, indicating the tube is beyond the stomach. The pH of respiratory fluid is 6.0 or higher. An x-ray can also be used to check placement of the tube, as well as aspirating the gastric contents and checking them for color and consistency. A feeling of fullness will not confirm tube placement. An ultrasound is not used for confirmation of tube placement.

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

The UAP begins cleansing from the anus toward the pubic bone.

The nurse performs hand hygiene using an alcohol-based handrub after exiting a client's room. The nurse does not touch another surface or client until what has occurred?

The antiseptic has evaporated from the skin. Although products may vary, typically the nurse would apply the antiseptic to the palm of the hand, covering all surfaces of the hands and fingers. The nurse would continue to rub until the antiseptic until it evaporates from the hand. Hand hygiene is not documented. Thirty seconds may not be enough time for the solution to dry. Hands are not dried with a paper towel after using the alcohol-based handrub.

The client is experiencing a neuromuscular condition with frequent tremors. The nurse determines to manually check the client's blood pressure instead of using the electronic blood pressure machine. What is the rationale behind the nurse's decision?

The blood pressure machine would not be accurate.

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

The client continually tries to move from head of the bed toward the foot of the bed. Research suggests that waist restraints pose the same risks for asphyxial death as vest restraints. When the client is very mobile in the bed or chair, the risk for asphyxiation increases. The nurse should pad skin and bony prominences that will be covered by the restraint to reduce friction and pressure to skin and underlying tissue. Restraints ground a client's center of gravity, thus helping to prevent injuries and falls such as rolling off a stretcher or falling out of bed. Because the nurse should be following the removal schedule (every 2 hours), the client is at less risk for incontinence and dehydration because these needs are being met every 2 hours.

The nurse is observing a client apply the TENS unit. Which action by the client indicates that further teaching is needed?

The client places the electrodes about 1 in (2.5c m) apart from each other. Further teaching is indicated when the client places the electrodes only 1 in (2.5 cm) apart. The electrodes should be placed at least 2 in (5 cm) apart to reduce the risk of burns. When the electrodes are placed too close together the risk of skin burns is increased. All other answers are correct and appropriate actions to take when applying a TENS unit.

The nurse is teaching proper cane use to a client who has had ankle surgery. The client has been cleared to begin bearing weight on the affected leg. What outcome would be unexpected?

The client reports increased strength in the weaker leg.

What should the nurse teach the client about climbing stairs with a cane?

The client should advance the stronger leg up the stair first, followed by the cane and weaker leg.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

The nurse has taught a client how to change the ostomy bag. How would the clamp be placed to demonstrate that the client understood the directions?

The curve of the clamp would follow the curve of the client's body.

The nurse is teaching the unlicensed assistive personnel (UAP) the proper technique to take an axillary temperature. Where would the nurse teach the UAP to place the probe?

The deepest area of the axilla

The nurse is wearing a gown as part of using personal protective equipment and is preparing to put on clean disposable gloves. Which placement indicates that the nurse has put on the gloves properly?

The glove ends extend to cover the gown's cuffs. When properly applied, the edges of the gloves should extend to cover the cuffs of the gown so that there is no visible skin exposed.

When preparing to measure orthostatic hypotension, the nurse should place the bed in which position?

The lowest position

The nurse determines that the sterile field has been contaminated when which action occurs?

The nurse turns his or her back to the field. A sterile field becomes compromised if the nurse turns away from it, if it drops below waist level, if an object falls onto or outside of the 1-in (2.5-cm) border of the field, or if the nurse reaches over the sterile field.

A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching?

The students wash their hands for 15 seconds prior to drying them. Hand washing is done for about 20 seconds, followed by a focus on the fingernails prior to rinsing off the soap. When performing hand washing, the water temperature should be warm to the touch. The hands should be kept lower than the elbows at all times to allow water to flow to the fingertips. Firm rubbing and a circular motion promotes friction that helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of the knuckles, on the palms and backs of the hands, and on the wrists and forearms.

The nurse wears personal protective equipment (PPE) when entering the client's room. What is the nurse's goal in wearing PPE?

To prevent infection transmission The nurse's goal is to prevent infection transmission, including from other clients to this client and from this client to other clients. The nurse does not necessarily have an infection. The nurse is adhering to policy, but that is not the goal of using PPE during client care. The gown protects the nurse's other clients from an infectious organism, but the goal is not prevention of infection in the nurse, though that is a desirable outcome.

Personal protective equipment (PPE) is used in health care facilities for primarily which reason?

To protect both the staff and clients from becoming infected by one another PPE protects both the staff from clients and the clients from staff. Although the use of PPE provides some protection for the hospital from legal liability, this is not the primary reason it is used.

The nurse is caring for a client who has a prescription for strict intake and output measurements. The client wants to use the bedside commode. What is most important for the nurse to instruct the client?

Toilet tissue should not be placed in the commode as it may affect accurate measurement.

The nurse removes personal protective equipment after caring for a client on transmission-based precautions. Which action by the nurse is correct?

Touch the inside of the gown and pull it away from the torso. The outside of the equipment is considered contaminated. Removal follows a prescriptive sequence. Most personal equipment is removed at the door of the client's room. The contaminated glove grasps the other contaminated glove for removal. The nurse's clean hand reaches under the other glove for removal. Goggles are removed by holding the earpieces. Clean hands touch the inside of the gown for removal, pulling away from the torso. Roll these items up, inside out, for disposal. Grasp ties on mask on respirator for removal after leaving the room.

When taking a tympanic temperature on a client, the nurse should place the thermometer into the client's ear at what angle?

Toward the jawline

A client using a TENS unit reports uncomfortable muscles twitching to the nurse. The nurse is planning to reposition the electrodes of the TENS unit. What should the nurse do first?

Turn the unit off. When planning to remove and reposition the electrodes, the nurse should first turn the TENS unit off. Then remove the electrodes, inspect, clean, and dry the skin and apply the electrodes in the new position, then turn the unit back on at a low setting increasing the intensity as indicated.

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

Uncover only the area being cleaned.

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

Underneath the breasts and in between skin folds

The nurse is wearing a gown and gloves as part of using personal protective equipment. The gown is tied in the front at the waist and at the neck. Which action would the nurse take first?

Unfasten the gown at the waist. When removing personal protective equipment, a gown that is tied in the front at the waist is unfastened first because the front of the gown, including the waist ties, are considered contaminated. The nurse would then remove the gloves, one at a time, so that one glove is contained within the other. After discarding the gloves, the nurse would then untie the gown at the neck and back.

The nurse is removing a gown after providing care to a client. Which action would the nurse take first?

Unfasten the ties at the neck and back. When removing a gown, the nurse first unfastens the ties at the neck and back, and then allows the gown to fall away from the shoulders. Touching only the inside of the gown, the nurse pulls the gown away from the torso. Keeping the hands on the inner surface of the gown, the nurse pulls the gown from the arms, turns it inside out, and folds or rolls it into a bundle to be discarded.

When obtaining a tympanic temperature of an adult client, the nurse would pull the pinna in which direction?

Up and back.

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply.

Use a night light., Remove clutter from walkways., Avoid climbing on a chair or table to reach items that are too high to reach., Keep electrical and telephone cords against the wall and out of walkways. A teaching plan for fall prevention in the home should include the recommendations: avoid climbing on a chair or table to reach items that are too high to reach; use a night light; remove clutter from walkways; and keep electrical and telephone cords against the wall and out of walkways. Considering the use of an electronic personal alarm would not help prevent a fall, but it may be used to help alert others to the fact that one has fallen.

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?

Use a safety monitoring device. A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance. Restraining the client takes away independence and can increase agitation and confusion. Asking a family member to sit with the client may help calm the client, but inappropriately transfers the nurse's responsibility to the family member. Checking on the client every 30 minutes is insufficient, because the client could fall and sustain injury during the unobserved intervals.

The nurse is providing care to a client who has had a left modified radical mastectomy 2 days ago. The woman also has an intravenous line inserted in the right antecubital space. Which would be most appropriate when assessing this client's blood pressure?

Use either the client's right or left thigh to obtain the blood pressure.

A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain?

Use of nonpharmacologic methods can diminish the emotional component of pain. Nonpharmacologic methods of pain management can diminish the emotional components of pain, strengthen coping abilities, give clients a sense of control, contribute to pain relief, decrease fatigue, and promote sleep. Although it is true that nonpharmacologic methods do not require a health care provider's prescription, it is not the best rationale for their use. Many nonpharmacologic methods are more expensive than pain medications, especially if nursing staff are needed to implement the methods. Nonpharmacologic interventions lessen the emotional impact of pain but may not diminish the sensation of pain. A combined approach is often most effective.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers.

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing?

Using a rubbing, circular motion When washing the hands with soap and water, the nurse would use a rubbing circular motion to wash the palms and back of the hands, each finger, the areas between the fingers and knuckles, and the wrists and forearms. Throughout the process, the nurse would keep the hands lower than the elbows to allow water to flow toward the fingertips. The nurse would wash to at least 1 in (2.5 cm) above the level of contamination or to 1 in (2.5 cm) above the wrists. When drying the hands, the fingers are dried first and the nurse then moves upward toward the forearms.

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first?

Warm the cap in the microwave.

The nurse prepares to obtain a rectal temperature on an adult client. What lubricant should the nurse prepare for the thermometer probe?

Water soluble lubricant

The nurse prepares to enter a client's room where goggles are required but are not available. Which action by the nurse is best?

Wear a face shield as part of the protective equipment. The nurse would not delay care due to a lack of goggles. The acceptable alternate is a face shield, which is a mask with a clear plastic covering for the eyes. If goggles are needed, the nurse would not enter the room without eye covering unless there was an emergent reason to do so. However, it is not correct to delay care until goggles can be obtained. This can take quite a long time. Even if the goggles can be supplied soon, the nurse can easily locate and use a face shield.

A client's blood pressure is very low and the nurse needs to asses it using a Doppler. To get an accurate reading the nurse would inflate the cuff to what level on the manometer?

Where the pulse disappears

The nurse is caring for a female client who has used a bedside commode. The client requires assistance with personal care after voiding. How should the nurse assist the client with personal hygiene?

Wipe using one stroke from the pubic area toward the anal area.

The nurse is teaching a class on vital signs to a group of new unlicensed assistive personnel (UAP). What should the nurse teach the UAP about the proper use of an electronic blood pressure machine when taking vital signs on an adult client? Select all that apply.

Wrap the cuff around the arm snugly , Line up the artery mark with limb artery , Select an adult setting on the machine

A client who is recovering from surgery is beginning to ambulate. This client is strong enough to walk without assistance but has poor balance. Which type of mobility aid would be most appropriate for this client?

answer: A cane with four prongs on the end (quad cane) The quad cane provides a wide base of support and thus is recommended for clients with poor balance. A single-ended cane with a half-circle handle is recommended for clients requiring minimal support and for those who will be using stairs frequently. A single-ended cane with a straight handle is recommended for clients with hand weakness because the handgrip is easier to hold but is not recommended for clients with poor balance. A walker with four fixed legs must be completely lifted off of the floor between steps and is not recommended for clients with poor balance.

The nurse is collecting supplies to change the ostomy appliance of a client who has an ileostomy following surgery for a tumor. What items would the nurse prepare to wash around the stoma?

basin of warm water

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment?

cognitive function level

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

every 60 minutes If a client who is at high risk for falls has no access to an activated bed or chair alarm, a nurse should observe the client every 60 minutes. Unless the client is on one-to-one observation, every 30 minutes is too frequent. Once a shift, or at 2- or 4-hour intervals, is too infrequent.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

extremity restraint The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.

The client has decreased strength in the left leg. How should the nurse instruct the client to hold a cane for assistance?

on the right side

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

the alternative measures attempted before applying the restraints Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

tip of the penis

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate?

tying the restraint behind the chair The nurse should run the restraint under the arm rests and tie it behind the chair. Tying the restraint out of the client's reach promotes security. Tying the restraint to the side rail or in the front of the chair would allow the client to untie the restraint. Tying the restraint under the chair would not provide the nurse with swift access to the quick-release knot.

The nurse is teaching a client about emptying an ostomy appliance. How would the nurse instruct the client to hold the appliance when removing the closing clamp?

upward

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?

waiting outside of the closed bathroom door while the client uses the toilet To prevent falls for a client who is at high risk for falls, the nurse should not wait outside the closed bathroom door but should remain with the client in the bathroom and assist the client in toileting. The other actions are appropriate measures for a client who is at high risk for falls and would not require the charge nurse to intervene.

The nurse is teaching a client how to empty an ostomy appliance. How often would the nurse recommend the appliance be emptied?

when bag is one-third to one-half full

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms?

wiping down the handles of the walker once the client has returned to bed