nur 111 exam 2

which assessment findings would the nurse consider as abnormal? select all that apply a. joint crepitation b. muscular atrophy c. muscle strength of 5 d. tenderness of the spine e. full range of join motion

a, b, d

the nurse is obtaining a health history from the newly admitted client who has chronic pain in the right knee. which would the nurse include in the pain assessment? select all that apply a. pain history, including location, intensity, and quality of pain b. clients purposeful body movement in arranging the papers on the bedside table c. pain pattern, including precipitating and alleviating factors d. vital signs, such as increased blood pressure and heart rate e. the clients family statement about increases in pain with ambulation.

a, c

the nurse is taking care of a client who has chronic back pain. which nursing considerations would be made when determining the clients plan of care? select all that apply. a. ask the client about the acceptable level of pain b. eliminate all activities that precipitate the pain c. administer the pain medications regularly around the clock d. use a different pain scale each time to promote patient education e. assess the clients pain every 15 minutes

a, c

proper techniques of abdominal assessment: a. i will note the position of the umbilicus b. i will inspect the surface motion of abdomen c. i will assess bowel motility by auscultation d. i was palpate to assess for any abdominal tenderness

b,a,c,d

an older adult is having urinary incontinence. which nursing interventions would help the client? select all that apply. a. provide nutritional support b. provide voiding opportunities c. avoid indwelling catheterization d. provide beverages and snacks frequently e. promote measures to prevent skin breakdown

b,c,e

which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? a. answer the clients call light immediately to prevent incontinence b. check the clients buttocks at least every two hours and clean after incontinence c. place a waterproof pad under client to prevent soiling the linens d. offer toileting every two hours to prevent incontinence

b.

which statement made by the nurse will be most significant when teaching strategies to reduce the risk for developing antibiotic resistant infections? a. wash your hands frequently with warm soapy water b. do not skip any prescribed doses of antibiotics c. do not save unfinished antibiotics for later use d. do not stop taking the antibiotics when you feel better

b.

which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? select all that apply a. switch positions every 4 hours b. use a heating pad for the first 24 hours c. apply for 30 min intervals d. place ice pack directly to injury site e. take ibuprofen every 4 hours prn

c

a client is scheduled for discharge after surgery. the medical record indicates that the client has not had a bowel movement since before surgery, which was four days ago. which prescribed medication will the nurse administer to ensure a bowel movement before discharge? a. lactulose b. docusate sodium c. bisacodyl suppository d. psyllium

c.

a health care provider prescribed bisacodyl for a client with constipation. the nurse explains to the client that this medication acts by which mechanism? a,. producing bulk b. softening feces c. lubricating feces d. stimulating peristalsis

d

an older adult is accustomed to taking enemas periodically to avoid constipation is admitted to a long term care facility and is bedbound. which nursing action would be included in the initial plan of care to prevent the client from developing constipation? a. arrange to have enemas prescribed for the client b. obtain a prescription for a daily laxative for the client c. place a commode by the bedside to facilitate defecation d. offer a large glass of prune juice with warm water each morning

d

during administration of an enema, the client experiences intestinal cramps. which action would the nurse take? a. discontinue the procedure b. instill the fluid a slower rate c. lower the height of the container d. stop the fluid until cramps subside

d.

the nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. when would the nurse assess the symptomatic quadrant? a. first b. second c. third d. last

d.

what is the sequence of techniques used while assessing the abdomen? a. inspection b. palpation c. percussion d. auscultation

a, d, c, b

the nurse instructs a client about safety measures and precautions when taking care of a pressure ulcer. during a follow up visit, the nurse finds increased tissue necrosis with damaged capillary beds. which actions by the client would the nurse expect are the reason for the clients condition? select all that apply a. massaging the reddened skin areas b. placing pillows between two bony surfaces c. using a donut shaped pillows for pressure relief d. keeping head of bed below 30 degrees e. using a bed pillow under the ankles to keep heels off the bed surface

a,c

which evidence based nursing intervention links to reducing CAUTIs in clients requiring long term indwelling catheters? a. perform catheter care once a day b. replace the catheter on a routine basis c. administer cranberry tablets three times a day d. administer prophylactic antibiotics

a

which factor would the nurse assess in a client reporting constipation? a. diet b. fluid intake c. use of laxatives d. date of last bowel movement e. use of opioid pain medications

a,b,c,d,e

an older adult in acute care has a risk of skin breakdown. which interventions are beneficial to the client? select all that apply a. providing thorough skin care b. reducing shear forces and friction c. providing beverages and snacks frequently d. using a support surface base all the time e. avoiding pressure with proper positioning

a,b,e

the RN asks a client to rate their pain on a scale of 0-10. then instructs the nursing student to perform a physical assessment. which steps by the nursing student would be included in a physical assessment for pain? select all that apply a. palpating for tenderness b. observing nonverbal cues c. inspecting any areas of discomfort d. noticing if the pain is localized or radiates e. noticing if the client gives nonverbal signs of pain

a,c

an emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods. the family blames the nurses and threatens to sue. which is considered when determining the source of blame for the pressure ulcer? a. the client should have been turned regularly b. older clients frequently develop pressure ulcers c. the nurse is not responsible to a clients family d. nurses should respect a clients right to not be moved

a.

when providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? a .avoid massaging the clients legs b. frequently reposition the client on a scheduled basis c. increase the fiber content in the clients food d. encourage the client to participate in weight bearing exercises

b.

soft swishing sounds of breathing are heard when the nurse auscultates a clients chest. which term would be used when documenting this assessment finding? a. fine crackles b. adventitious sounds c. vesicular breath sounds d. diminished breath sounds

c.

when the nurse auscultates a clients lungs and hears fine, high pitched, popping sounds in the left lower lung as the client inhales, how would the finding be documented? a. vesicular sounds b. coarse rhonchi c. inspiratory crackles d. bronchial breath sounds

c.

which intervention is most beneficial in preventing a CAUTI in a postoperative client? a. pouring warm water over perineum b. ensuring the patency of the catheter c. removing the catheter within 24 hours d. cleaning the catheter insertion site

c.

which term would the nurse use to document a client experiencing urinary incontinence via involuntary loss of small amounts (25-35mL) of urine from an overdistended bladder? a. urge incontinence b. stress incontinence c. overflow incontinence d. functional incontinence

c.

which action will the nurse take to prevent skin breakdown for a client who is on bed rest? a. massage the bony prominences b. promote range of motion activities c. maintain a sheepskin pad under the client d. encourage the client to move in bed as much as possible

d.