NUR 3110

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table? A. The client is aware of spatial relationships to avoid the table. B. The brain is sending impulses to the muscles to avoid the table. C. The cerebellum is responding to impulses from the inner ear. D. The client's muscles are being stretched to walk around the table.

A

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? A. transfer belt B. mechanical lift C. roller sheet D. transfer boards

A

Using proper body mechanics, which motions would the nurse make to move an object? A. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. B. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. C. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. D. The nurse uses the muscles of the back to help provide the power needed in strenuous activities.

A

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. A. moving the bedroom to the ground floor B. placing nightlights in the bathroom and hallways C. removing clutter from the floor D. installing hardwood floors

A B C

Which body system effects would the nurse state as occurring due to immobility? Select all that apply. A. increased risk for renal calculi B. Increased risk for electrolyte imbalance C. increased depth of respiration D. increased cardiac workload E. decreased urinary stasis F. increased rate of respiration

A B D

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? A. supporting the client's back B. under the client's head C. under the client's feet D. in front of the client's abdomen

A.

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? A. Adduction B. Abduction C. Extension D. Circumduction

A.

The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? A. is demonstrating a common gait for the older adult. B. requires a better walking shoe. C. should have an orthopedic consultation. D. requires crutches for mobility.

A.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? A) standing at the top of the bed and having a colleague stand at the bottom of the bed B) positioning a friction-reducing sheet under the client to facilitate movement C) using back muscles to gently and gradually pull the client to the side D) placing the bed in its lowest position to reduce the client's risk for falls

B

In an assessment for proper body alignment of a standing client, which finding is normal? A. The line of gravity is deviated slightly to the left. B. The weight of the body is distributed on the soles and heels. C. The chest is downward and displaced slightly backward. D. The abdominal muscles are held downward and the buttocks upward.

B

The nurse is giving a back massage to a client who is having trouble sleeping. Which nursing actions are performed appropriately? Select all that apply. a. The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. b. The nurse kneads the client's skin using continuous grasping and pinching motions. c. The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks. d. The nurse massages the client's shoulder, entire back, areas over iliac crests, and sacrum with light vertical stroking motions. e. The nurse completes the massage with additional short, stroking movements that eventually become heavier in pressure. f. The nurse applies warmed lotion to client's shoulders, back, and sacral area.

a c f

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? a. administering a muscle relaxer b. placing a small towel under the neck c. positioning the client on the stomach d. contacting the primary care physician

b

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client? a. Corticosteroids b. Opioid analgesics c. Nonopioid analgesics d. NSAIDs

b

A client who is living with chronic pain has received a health care provider's order for TENS. When applying the device to the client's skin, the nurse should do what action? a. Turn on the unit shortly before applying the electrodes to the client's skin. b. Start with the lowest intensity and gradually increase it to the appropriate level. c. Disinfect with chlorhexidine the areas where the electrodes will be applied d. Administer analgesia 30 minutes before beginning a TENS session.

b

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? a. cutaneous pain b. visceral pain c. referred pain d. somatic pain

b

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain? a. decreased respiratory rate b. increased blood pressure c. pupil constriction d. decreased pulse rate

b

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? a. trochanter roll b. bed trapeze c. foot board d. bed cradle

b

A nurse is treating a young boy who is in pain but cannot vocalize this pain. What would be the nurse's best intervention in this situation? a. Ignore the boy's pain if he is not complaining about it. b. Ask the boy to draw a cartoon about the color or shape of his pain. c. Distract the boy so he does not notice his pain. d. Medicate the boy with analgesics to reduce the anxiety of experiencing pain.

b

The majority of the cell's protoplasm is: a. electrolytes. b. water. c. lipids. d. proteins.

b

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? a. the 6-month-old child who is unable to roll over b. the 24-month-old child who is unable to walk unassisted c. the 3-month-old child who is unable to raise the head when prone d. the 18-month-old child who is unable to stack blocks

b

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? a. prone b. Sims' c. supine d. Fowler's

b

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? a. place a trochanter roll under the arms b. place a small pillow under each arm c. instruct the client to place arms on the side rails d. elevate the head of the bed

b

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan? a. Clear pathways for walking in the room and do not rearrange furniture. b. Decrease background noises, as much as possible, before speaking. c. Clearly communicate that the client is expected to perform all the self-care activities he or she can. d. Perform routine oral hygiene.

b

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration? a. requesting hearing aids to help the client receive information b. allowing more time for the processing of the information c. using numerous handouts and detailed education plan d. demonstrating a wide variety of syringes and techniques

b

Which is not a lifespan consideration for sensory perception? a. Preschoolers seek out information using organized play. b. A newborn's sensory perception is very refined. c. School-age children learn to make independent responses based on what is perceived through the senses. d. Toddlers explore their environment by seeing, hearing, touching, tasting, and smelling.

b

Which of the following nonpharmacologic pain relief measures has been found to be effective for soothing agitated newborns and comatose clients? a. imagery b. music c. distraction d. humor

b

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? a. Braden scale b. FLACC scale c. Apgar score d. FACES scale

b FLACC SCALEExplanation:The FLACC Scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES Scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. APGAR score is done at birth to assess how well the baby tolerated the birthing process.

The nurse is caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse? Select all that apply. a. visceral b. somatic c. chronic d. cutaneous e. acute

b c

The nurse prepares to promote the client's comfort using guided imagery. Which actions should the nurse take? Select all that apply. a. Ask the client to focus on tightening and relaxing a particular muscle group. b. Ask the client to concentrate on the details of a pleasant image. Play the client's favorite music in the background. c. Ask the client to imagine oneself in a favorite place. d. Instruct the client how to breathe properly for relaxation. e. Read a book to the client who is postoperative.

b c

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. a. You may smoke cigarettes during the day but not at night. b. Do not drive a vehicle while taking this medication. c. For better absorption, take your pain medication on an empty stomach. d. Keep a diary to record level of pain and time medication is taken. e. You must check with your primary care provider before breast-feeding your infant. f. Client is allowed to have one drink of alcohol each day.

b d e

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? a. Apply the stockings after the client has been sitting up for an hour. b. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. c. Apply the stockings at night when the client is going to bed. d. Avoid the use of powders on the legs before applying stockings.

b.

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find? a. High blood pressure b. Decreased heart rate c. Guarding of the chest area d. Increased respiratory rate

c

A client experiences burning muscle pain at the peak of high intensity physical training for an athletic competition. What is the best explanation for the cause of this occurrence? a. Acetyl-CoA begins the reactions in the citric acid cycle to release carbon dioxide. b. Mitochondria cause oxidation of electrons to create a net increase of ATP. c. Anaerobic glycolysis creates pyruvate, which converts to lactic acid. d. Fatty acids go through the beta-oxidation process to release energy.

c

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system? a. Thorough client education is necessary to prevent overdoses. b. Use of opioid analgesics in a PCA is contraindicated due to the risk of respiratory depression. c. The dose that is delivered when the client activates the machine is preset. d. An antidote is automatically delivered if the client exceeds the recommended dose.

c

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client? a. "We'll be monitoring your use of the system closely, to ensure you don't develop an addiction to your pain medication." b. "I'll have the unit's care aide come check on you every few minutes after I set up the system." c. "The pump is programmed with safeguards to limit the possibility overmedication." d. "If you feel severe pain, either push the button yourself or ask one of your family members to push the button."

c

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client? a. Disturbed Sensory Perception related to client statement of "Get the bugs off my bed, I can feel them crawling on me." b. Disturbed Sensory Perception: Kinesthetic related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." c. Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." d. Disturbed Sensory Perception: Tactile as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me."

c

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? a. "We'll have the nursing assistant watch you while you walk around the unit the first time." b. "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." c. "Your elbows will be slightly bent when you are using your crutches." d. "When your crutches fit right, most of your body weight will be supported by your armpits."

c

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? a. Melatonin b. Serotonin c. Endorphins d. Dopamine

c

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing? a. cutaneous pain b. visceral pain c. neuropathic pain d. chronic pain

c

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? a. Administer a dose of naloxone and report this finding to the primary care provider. b. Discontinue the client's pain medication until his or her level of consciousness improves. c. Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. d. Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours.

c

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as a. "I will call your doctor because you may have loosened sutures when walking." b. "You will need more pain medication as the days progress." c. "Acute pain tends to increase during the day and is called a routine pain response" d. "Your present pain is worse because you had your packing removed."

c

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what? a. "Wearing the TENS unit should not interfere with my daily activities." b. "I may need fewer pain medications with the TENS unit in place." c. "I could use the TENS unit if I feel pain somewhere else on my body." d. "One advantage of the TENS unit is it increases blood flow."

c

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask? a. "Are you receiving chemotherapy?" b. "Do you live by yourself?" c. "Do you work around loud noises at work?" d. "Do you have diabetes?"

c

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention? a. Tell the healthcare provider that the client is unsure of the pain medication taken. b. Call the pharmacy to attempt to identify the pill. c. Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy. d. Document what the client states.

c

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? a. unequal pupil size b. stumbling gait c. decrease in flexibility d. reports of pain in the lower back

c

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain? a. A client with chest pain who is having a myocardial infarction b. A client suspected to have a perforated peptic ulcer c. A client who has a sprained ankle d. A client who has appendicitis

c

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? a. administering a placebo and performing a reassessment of the pain b. judging whether the client is in pain or is just depressed c. reviewing and revising the pain management treatment plan d. beginning pain medications before the pain is too severe

c

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? a. Turn the client from side to side while pushing upward. b. Rock the client back and forth to raise the client up in bed. c. Shift their weight back and forth, from back leg to front leg. d. Shift their weight back and forth from the legs to the back muscles.

c

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate? a. Stop the back massage immediately. b. Apply a warm compress to the area. c. Document the finding. d. Massage the area using lotion.

c

While reviewing the basic information related to hemodialysis, the nurse explains that water molecules move through adjacent phospholipid molecules in the cell membrane by: a. secondary active transport. b. active transport. c. osmosis. d. diffusion. e. vesicular transport.

c

A nurse is performing pain assessments on clients in a physician's office. Which clients would the nurse document as having acute pain? Select all that apply. a. A client who has diabetic neuropathy b. A client who has bladder cancer c. A client who fell and broke an ankle d. a client who is having a myocardial infarction e. A client who has rheumatoid arthritis f. A client who presents with the signs and symptoms of appendicitis

c d f

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain? a. PAINAD Scale b. FLACC Scale c. CRIES Pain Scale d. Wong-Baker

c) CRIES pain scale-CRIES is appropriate for neonates (0-6 months) COMFORT: is used for infants, and adults who are unable to use other scales FLACC: is used for infants and children (2 months-7 years) unable to validate the presence of or quantify the severity of pain The checklist on nonverbal indicators: is appropriate for adult who are unable to validate the presence of or quantify the severity of pain using either r the Numeric rating scale or face scale

A client is admitted to the hospital with reports of severe fatigue, weight gain, and feeling cold all of the time. The client is suspected of having a diagnosis of hypothyroidism and will have several diagnostic tests performed. What type of glandular dysfunction does the nurse suspect this will be? a. Eccrine gland b. Exocrine gland c. Apocrine gland d. Endocrine gland

d

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse? a. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to decrease the risk of severe migraine headaches." b. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to prevent accidental dislodgement of the catheter." c. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to increase the effectiveness of the spinal analgesia." d. "It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

d

A client will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this client? A. Nurses should never assist clients with ambulation without a physical therapist present. B. Clients who are fearful of walking should be told to look at their feet when walking to ensure correct positioning. c. Clients who can lift their legs only 1 to 2 inches off the bed do not have sufficient muscle power to permit walking. d. If an ambulating client whom a nurse is assisting begins to fall, the nurse should slide the client down his own body to the floor, carefully protecting the client's head.

d

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as: a. Therapeutic Touch (TT). b. transcutaneous electrical nerve stimulation (TENS). c. hypnosis. d. biofeedback.

d

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory: a. deprivation. b. adaptation. c. stimulation. d. overload.

d

A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide? a. "I hear that a lot from clients." b. "Your armpits will grow accustomed to the weight in a few days." c. "Fortunately you will only need to be on crutches for a week or two." d. "Try to bear your weight on your hands, not your armpits."

d

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client: a. experiencing chronic pain. b. in the early postoperative period. c. experiencing acute pain. d. in the postoperative stage with occasional pain.

d

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing: a. cutaneous pain. b. neuropathic pain. c. somatic pain. d. visceral pain.

d

A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education? a. "I will bring my favorite music to listen to after my surgery." b. "I will make sure to drink plenty of water so I don't get constipated from the pain medication." c. "I will push my PCA button before I get up to go to the bathroom." d. "I will have my wife push the PCA button when I'm asleep."

d

Besides controlling pain of the postabdominal surgery client with opioids, the nurse suggests to the client that he: a. describe the pain. b. think about the next dose. c. focus on pain relief. d. use distraction.

d

The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next? a. Move the arm across the body as far as possible. b. Move the opposite arm forward to above the head of the client. c. Rotate the lower arm and hand so the palm is up. d. Return the arm to the starting position at the side of the body.

d

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? a. skeletal contractures b. pooling of secretions c. oliguria d. thrombus formation

d

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when the graduate states that back injuries: a. can be prevented with the use of a gait belt. b. are a routine consequence of the job. c. are related to sitting for long periods. d. can occur when uncooperative clients are being repositioned.

d

The nurse manager hears a nurse and a nurse aide talking about a female client who reports pain of 8 out of 10 on a 1-10 scale after a Caesarean birth to deliver twins. The nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug seeking." What is the appropriate nurse manager action? a. Write the nurse up for disciplinary action. c. Continue listening to the conversation before intervening. d. Enter the conversation and tell the nurse and UAP that this type of discussion will not be tolerated. d. Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.

d

The nurse recognizes that which organization requires that employers comply with ergonomic recommendations? a. American Nurses Association (ANA) b. The Joint Commission (TJC) c. National League for Nursing (NLN) d. National Institute for Occupational Safety and Health (NIOSH)

d

When a new mother asks the nurse whether her newborn infant can see her, the best response by the nurse is to tell the mother that her infant: a. can differentiate objects only. b. cannot see for the first 2 weeks. c. can differentiate colors only. d. can see light and dark patterns.

d

Which is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? a. Neuromuscular b. Cardiovascular c. Peripheral Vascular d. Respiratory

d

Which medical client is most likely to be experiencing diffuse pain? a. A client who has been prescribed antibiotics for the treatment of strep throat b. A client who has presented to the emergency department with a stab wound c. A client who is undergoing diagnostic testing for appendicitis d. A client with shingles affecting her entire torso

d

Which of the following is considered to be the most potent neuromodulators? a. Efferent b. Afferent c. Enkephalins d. Endorphins

d

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients? a. The developing neurologic system of children transmits less pain than in older clients. b. Pharmacologic pain relief should be used only as an intervention of last resort. c. A numeric scale should be used to assess pain if the child is older than 5 years of age. d. Pain assessment may require multiple methods in order to ensure accurate pain data.

d

A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate? A. The nurse grabs and holds the client by his arms. B. The nurse discourages the client from helping with the transfer. C. The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight. D. The nurse administers pain medication following the transfer.

C

What is a benefit of regular exercise over time? A) increased work of breathing B) increased risk for blood clots C) decreased heart rate D) decreased venous return

C

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? A. pull the client to the edge of the bed to which the patient will be turning B. push the client to the edge of the bed to which the client will be turning C. move the client to edge of the bed opposite the side that client will be turning D. push the client to the opposite side of the bed

C.

A client arrives in the emergency department reporting an injury to a calf muscle while running. What education will the nurse provide after a diagnosis of muscle strain? Select all that apply. A. Consult a health care provider within 1 week. B. Continue exercising unless there is pain. C. Keep the injured limb elevated. D. Apply heat to the injured area. E. Apply an elastic bandage to the injured area.

C. E.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: A. leans over the walker when walking. B. places the walker far in front when walking. C. steps into the walker when walking. D. uses the sides of the walker to rise from a chair.

C. steps into the walker when walking.

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? A. foot splints B. roller sheets C. foot boards D. trochanter rolls

D.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? A. Place the bed in the highest position. B. Put the chair at the foot of the bed. C. Make sure the bed brakes are unlocked. D. Raise the head of the bed to a sitting position.

D.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? A. A client with a thoracic incision B. A client who has an abdominal incision C. A client who is confined to bed rest D. A client who has leg strength and can cooperate with the movement

D.

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be: A. supported with a narrow base. B. controlled with the upper arm muscles. C. counterbalanced by a horizontal adjustment. D. balanced over the center of gravity.

D.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA? a. The client is actively involved in pain management. b. The client obtains pain relief slowly and steadily. c. The client requires less nursing care. d. The client is able to have long hours of rest.

a

A nurse giving a client a massage notes the presence of a nonblanching reddened area on the client's sacrum. What is the nurse's best action? a. Avoid massaging this area and report the finding to the health care provider. b. Avoid massaging the area and apply a thin layer of a topical antibiotic ointment. c. Massage the area in an attempt to restore adequate circulation. d. Gently massage the region, document the finding, and verbally report it to the health care provider.

a

During range-of-motion exercises, the nurse turns the sole of a client's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions? a. inversion and eversion of the ankle b. dorsiflexion and plantar flexion of the ankle c. internal and external rotation of the ankle d. flexion and extension of the ankle

a

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? a. Examine the effectiveness of the current pain regimen b. Assess the client's serum albumin level c. Educate the client/caregiver about signs of impending death d. Compare the client's current assessment with previous admission assessment

a

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment? a. Respiratory status, oxygen saturation, pain, and sedation level b. Temperature, pedal pulses, and assessment of cranial nerves c. Gastrointestinal status, bowel movements, and urine output d. Heart rate, capillary refill, bowel sounds and pedal pulses

a

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning? a. plantar flexion of the feet b. flexion contracture of the neck c. skin breakdown of the sacrum d. hyperextension of the hips

a

The nurse is preparing the client for the administration of an enema. The nurse will place the client into which position? a. Sims b. Fowler c. supine d. prone

a

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement? a. "I should only take medication when my pain is intense." b. "This will allow me to control my own pain medication." c. "The pump is programmed to limit the chance of overmedicating." d. "I give myself the pain medication by pushing the button."

a

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? a. When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. b. When lifting an object, I will keep my feet shoulder width apart. c. When lifting an object, I will bend at the knees instead of the waist. d. When I lift an object, I will get close to the object being lifted.

a

The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include? a. "Both of your feet should rest on the floor." b, "Cross your legs alternately throughout the day." c. "The upper and lower thighs are your base of support." d. "Keep your knees bent, with the backs of the knees against your chair."

a

Which client is at greatest risk of sensory overload? a. an 88-year-old on a ventilator in an intensive care unit b. a 55-year-old, newly diagnosed with diabetes in a private room in a hospital c. an 8-year-old in isolation in a private room in a hospital d. a 17-year-old on bed rest after a surgical procedure

a

Which situation demonstrates sensory adaptation? a. A client has learned to sleep through the frequent beeping of the intravenous pump. b. A client with hearing loss has learned to communicate using sign language. c. A client with vision loss has begun buying large-print books. d. A client believes their hearing has become more acute since the loss of his vision.

a

Which type of epithelium is found in the lining of blood vessels, lymph nodes, and alveoli of the lungs? a. Simple squamous epithelium b. Transitional epithelium c. Stratified epithelium d. Pseudostratified epithelium

a

The nurse is performing an admission for a client determined to be a high fall risk. What interventions should be a priority for the nurse to employ to provide a safe environment for the client? Select all that apply. a. Use a bed alarm to signal when the client gets up b. Keep all bed rails up at night. c. Use a chair alarm when the client is out of the bed. d. Hold diuretic medications. e. Keep the client's slippers at the bedside for easy reach.

a c

A student nurse is preparing a presentation on pain management. What information regarding nonpharmacologic interventions should he include? Select all that apply. a. Use cold packs for muscle spasms and surgical site pain. b. Dry heat penetrates deeper than moist heat. c. Ice packs should not be left on longer than 20 minutes. d. Distraction is useful for short pain periods. e. Massage can stimulate circulation.

a c d e

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply. a. Consider cultural implications of the perception of pain. b. Delegate pain assessment to the UAP. c. Provide pain medication before activity that may increase pain. d. Infer that the client who does not complain has no pain. e. Assess for pain control 30 minutes after administering an analgesic.

a c e