NUR 204

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

Acupuncture. The nurse should inform the client that shingles or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is admitting a client who is having an exacerbation of HF. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process.

A nurse on a med-srug unit is caring for a client who has a new rx for wrist restraints. Which of the following action should the nurse take?

Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries. The first action the nurse should take when using nursing process is to assess the client for injuries.

A nurse is caring for a client who is post-op and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority for the nurse is to determine why the client is refusing the treatment.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amt of irrigation used from the client's urine output. The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Taking a sip of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while I'm laying in bed." Listening to music is effective non-pharmacological intervention for the management of mild pain

A nurse is talking with an older adult who is contemplating retirement. The client states "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse take?

"Let's talk about how the change in your job status will affect you." This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.

A nurse in a long term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance.

1. Obtain the pronouncement of death from the provider 2. Remove tubes and indwelling lines. 3. Wash the client's body 4. Ask the client's family members if they would like to view the body 5. Place a name tag on the body

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Abd cramping. This client has hyponatremia, which is low sodium level. Manifestations include abd cramping, weakness, confusion, lethargy, headache and nausea.

A nurse is caring for a client who is post-op. When the nurse prepares to change her dressing, she says "every-time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures the client's safety, health, and rights. Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures client's safety, health, and rights including the right to privacy, confidentiality and refusal of care.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply Intermittent suction when withdrawing the catheter. The nurse should apply intermittent suctions during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a controlled substance.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Assist the client with a partial bath Measure the client's BP after the nurse administers an antihypertensive med. Use a communication board to ask what the client wants for lunch

A nurse is admitting a new client. Which of the following actions should the nurse take while preforming medication reconciliation?

Compare the client's home meds with the providers rx. The nurse should compare home meds with providers rx when performing med reconciliation.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care of when within 1 m (3 ft) of the client who has a disorder requiring droplet precautions.

A nurse is caring for a child who has a rx for blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue. Nurse should examine their own personal values about the issue in question in order to provide care that is without bias.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

Is your pain sharp or dull? Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area. An allogeneic stem cell stem cell transplant compromises the client's immune system, greatly increasing risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is caring for a client who is post-op following a knee arthroplasty and requires the use of high-length sequential compression sleeves. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves. The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the the sleeves and the legs can inhibit circulation when the sleeves inflate.

A nurse is caring for a client who is post-op and is exhibiting signs of hemmorhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 minutes and to report back in 1 hour. Which of the following actions should the nurse take next?

Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Place a client who has TB in a room with negative-pressure airflow. A client who has TB requires airborne precautions, which would include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position. The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

Pupil Clarity Visual Fields Visual Acuity Could pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because client cannot see items in their path clearly. The nurse should use a finger to test the client's peripheral vision by moving the finger-out of range and then back into visual field to determine when the client sees the finger. Clients who have a visual fields impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. The nurse should use a snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they may not see objects in their path and trip over them or bump into them and fall.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. The client is at risk for dysrhythmias.

A nurse is caring for a client who has terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hours The nurse should turn the client at least once every 2 hours to break up the secretions in the client's lungs and prevents noisy respirations.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors. Covers protect client's airway from cold air, dust, and other airborne particles.

A nurse is education a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ER and I had difficulty breathing?" Which of the following responses should the nurse make?

We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

Wear a gown when caring for the client. The nurse should implement contact precautions for a client who has shigella to prevent the transmission of bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces.