NUR 204 ATI Physiological Integrity

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take?

-Check for personal items when changing the bed linens -Keep the bath water temperture between 43.3C (110F) and 46.1C (115F) -Shave the client's hair in the direction of the hair growth

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect?

-Contractures of the extremities -Crackles in the lungs -Pressure ulcers

A nurse is providing postmortem care for an adult client. Which of the following actions should the nurse take?

-Determine whether the client will have an autopsy. -Cover the body with a clean sheet and place the arms outside of the sheet. -Give the client's personal belongings to the family.

A nurse is teaching a client who has a new second-degree ankle sprain. Which of the following instructions should the nurse include in the teaching?

-Elevate the affected ankle above the level of the heart. -Apply a heating pad intermittently to the affected ankle after 48 hr. -Wrap the affected ankle with an elasticized compression bandage. -Apply intermittent ice to the affected ankle for the first 48 hr.

A nurse is caring for a client who is recovering from a CVA. Which of the following information should the nurse include when teaching family members about repositioning the client?

-Remove pillows prior to repositioning. -Elevate the bed to waist height. -Stand with feet wide apart. -Face the direction of movement when positioning the client.

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indication a therapeutic response?

-The shoulders droop. -The facial muscles relax. -The pulse is within the expected range.

A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expects?

-Sudden attacks of sleep -Hallucinations at the onset of sleep

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain.

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?

Discard unused formula after 8 hr.

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication the the client needs further teaching?

"I have a set of my brother's crutches in my basement I can also use."

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take?

-Offer the client a back rub -Remind the client to use incisional splinting -Identify the client's pain level -Change the client's position

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

Yogurt

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown.

Apply a moisture barrier ointment to the client's skin.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30mins at a time.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Gait belt

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A nurse is assessing a client for pitting edema and noted an indentation of 6mm (0.25in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

A nurse on a medical unit is assessing 4 clients for urinary retention. Which of the following clients have manifestations of urinary retention?

A client who reports urinary frequency.

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain.

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?

Aspirate the client's stomach contents.

A nurse is caring for a client who experienced a lacerated spleen and has been on bed rest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safely of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Check the stockings for wrinkles.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the med-surg unit with and NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working.

A nurse is providing healthcare for a client. Which of the following actions should the nurse take?

Clean under the nail within orange stick.

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

Cleanse the top of the can of formula with an alcohol wipe.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increased dietary intake of raw vegetables.

A nurse is caring for a client who is receiving heat applications using a aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red.

A nurse in a long term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinenec. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hr.

A nurse is teaching a client about how to use her new hearing aids. Which of the following statement should the nurse identify as an indication that the client needs further instruction?

"I will clean the hearing aids with alcohol wipes."

A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?

"I will monitor my husband for tilting his head forward when he swallows."

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will no longer have a glass of wine before bedtime."

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

"I'll apply ice to my ankle today and tomorrow."

A nurse is teaching in older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

"When walking, move your left foot forward first."

A nurse is providing palliative care to the client whose partner asks why music therapy might help her. Which of the following responses should the nurse make?

-"Music therapy can help her verbally express emotions. -"Music therapy works as a distraction and can help alleviate her pain." -"Music therapy can help facilitate movement in some clients who have mobility limitations."

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating?

-A client who has had a cerebrovascular accident -A client who is 4 hr postoperative following a leg amputation with general anesthesia -A client who has had radiation therapy for head and neck cancer

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

-Broth -Grape juice -Lemon gelatin

A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow.

1. Make sure the provider has certified the client's death. 2. Verify the client's organ and tissue donation status. 3. Remove medical equipment from the client. 4. Cleanse the body while adhering to body fluid precautions. 5. Attach identification tags to the body.

A nurse should teach which of the following clients requiring crutched about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg

A nurse is caring for a client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?

Active range-of-motion exercises of the left leg

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Albumin

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?

Auscultate breath sounds at least every 2 hr.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction.

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for the problem, when she should document as which of the following disorders?

Bruxism

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

Determine if the client can bear weight

A nurse is planning care for a client who has a decreased LOC. The client is receiving continuous enteral feedings via a gastronomy tube due to the inability to swallow. Which of the the following is the priority action by the nurse.

Elevate the head of the client's bed 30° to 45°.

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

Encourage the client to hold her breath when feeling the urge to urinate.

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the clients to have>

Grape juice.

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The cleint's current weight bearing status

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Hold the cane on the right side to provide support for the weaker leg.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Hold the container of solution 30cm (12in) above the anus.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion.

A nurse in the clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?

Use a new cosmetic pad with each limited application of makeup.

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space.

A nurses is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following intervention should the nurse used to help maintain the integrity of the clients skin?

Use a transfer device to lift the client up in bed.

A nurse is assessing a client who has a required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Performs active ROM exercises of all extremities.

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Provide the client with a diet high in protein.

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Self-report of pain.

A nurse is administering cold therapy application client. Which of the following manifestations should the nurse identify as an indication for discontinuing the applicationDue to systemic response?

Shivering

A nurse removes an indwelling urinary catheter that an older adult client had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate.

A nurse is caring for a client who is postoperative. The nurse should base her pain management intervention primarily on which of the following methods of determining the intensity of the clients pain?

The client's self-report of pain severity.

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

The nurse allows the client to rest in a supine position during feeding.

A nurse os caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse is providing oral care for a client who is immobile. Which of the following action should the nurse take?

Turn the client on his side before starting oral care.

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should the client to the toilet at which of the following times?

When the client has the urge to defecate