Quiz 2 Funds

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take a directed plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax

A nurse is caring for a client who has right sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

Apply a protective boot to the right ankle

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction?

Body image changes

A nurse is assessing a client who has 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? A. Needs assistance raising her legs B. Demonstrate mild dyspnea when eating breakfast C. Performs active range-of-motion (ROM) of all extremities D. Develops fatigue when assisting with morning hygiene care

C

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnea of the ears B. Dorsal surface of the hand C. Conjuctivae D. Dorsal surface of the foor

C

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take? A. Provide support by holding the clients arm B. Lean the client toward the wall C. Lower the client to the floor D. Assume a narrow base of support

C

A nurse is caring for a client who experienced a lacerated spleen and has 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? A. An upper resp infection B. Pulmonary edema C. Atelectasis D. Delayed gastric emptying

C

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first? A. Apply a vest restraint on the client B. Place the client in bed with two side rails raised C. Place a seat alarm in the clients chair D. Adminster lorazepam the client

C

A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an interventions should the nurse complete?

Pinch up a fold of skin to check for turgor

A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse ass scoliosis screening?

Preadolescence /adolescent

A nurse is caring for a client who is receiving heat applications using an 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 at an extended care facility is instructing a class of AP about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the AP about the clients use of cane?

When the client moves, he should move the cane forward first

A nurse is teaching an older adult client who has left sided weakness how to use a cane

When walking move your left foot forward first

A nurse is assisting with the admission of a client to an implant unit. Which of the following sources of information should the nurse rely for accurate information about the client?

Client concerns

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 reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? A. Increased insulin production B. Decreased RBC production C. Decreased sodium excretion D. Increased calcium exertion

D

A nurse is caring for a client who has fallen whie getting out of bed and states"I'm ok" i guess i should have called for help to the bathroom. After assessing the client, the nurse notify the provider. Which of the following documentation should the nurse include in the clients medical record? A. There were no injuries sustained B. An incident report was completed C. An incident report was forwarded to risk management D. The provider was notified

D

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? A. Trochanter roll B. Sheepskin heel pad C. Abduction pillow D. Footboard

D

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the clients level of strength? A. Ask the client how strong she feels today B. Ask the client to touch her finger to her nose C.Palpate the client's pedal pulses D. Ask the client to push her feet against the nurse's palms

D

A nurse is preparing a community presentation about repetitive motion injuries. Which of the following occupations should the nurse identify as increasing a client's risk for carpal tunnel syndrome? A. Truck driver B. Nursing assistant C. Elementary school teacher D. Assembly line worker

D

A nurse is providing discharge teaching for a client who requires home oxygen. Which is indication for further teaching? A. I will be able to tell how much ox I'm receiving by looking at th eflowmeter B. I should call my doctor if i find it harder to concentrate C. I will make sure my visitors smoke outside D. I will wear synthetic clothing and woolen socks when using my oxygen

D

A nurse is providing teaching to a assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?

I will tie a restraints to the portion of the bed that moves when the head of the bed is moved

A nurse is providing discharge teaching for a client who requires home 02. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I will wear synthetic clothing and woolen socks when using my 02

A nurse is performing a mental status examination (MSE) on a client who has dementia. Which of the following components should the nurse include? (Select all that apply) A. Grooming B. Long term memory C. Support system D. Affect E. Presence of pain

A, B, D

A nurse is helping an older adult 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 safety if the client, which of the following actions should the nurse take? A. Check that the client lifts the walker and then places it down in front of her B. Walk in front of the client to guide her in moving the walker C. Have the client move on leg forward with the walker D. Make sure that the upper bar of the walker is level with the client's waist

A

A nurse is performing a neurological assessment for a client who had head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? A. Instruct the client to look up and down without moving his head B. Observe the client's ability to smile and frown as part of an evaluation C. Have the client stand with his eyes closed and touch his nose D. Ask the client to shrug his shoulders against passive resistance

A

A nurse is preparing to transfer a client from a bed to chair. Which of the following actions should the nurse take first? A. Determine if the client can bear any weight B. Place a transfer belt on the client C. Position the bed at an appropriate height D. Assist the client to a seated position

A

A nurse is providing nail care for a client. Which of the following actions should the nurse take? A. Clean under the nail with an orange stick B. File the nails in a rounded shape C. Push the cuticles back with a metal nail file D. Trim the nails at the lateral corners

A

A nurse needs to lift a box in a supply room. Which of the following actions should the nurse take to prevent an injury due to lifting? A. Keep the box close to his body as he lifts B. Stand with his feet close together when lifting C. Bend at the waist to pick up the box D. Twist when placing the box to his side

A

a charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses station?

A client who sustained a head injury and is having periods of confusion

A nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning of the client (Select all that apply) A. Remove pillows prior to repositioning B. Elevate the bed to waist height C. Position the client toward the edge of the bed on the side the client will face after turning D. Stand with feet wide apart E. Face the direction of movement when positioning the client

A, B

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (select all that apply) A. Grooming B. Long term memory C. Support system D. Affect E. Presence of pain

A, B, C, E

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply) A. Blot the perineal area dry after cleansing B. Clean the perineal area from front to back C. Perform hand hygiene before and after voiding D. Apply ice packs to the perineal area several times daily E. Wash the perineal area using a squeez bottle of warm water after each voiding

A, B, C, E

A nurse is assessing a client who has Bells Palsy. Which of the following findings should the nurse expect? (Select all that apply) A. Muscle distortion B. Pain behind the ears C. Hearing loss D. Facial twitching E. Impaired taste

A, B, D

A nurse at an extended care facility is instructing a class f AP about a client use of assitive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients use of the cane? A. When the client moves, he should move the cane forward first B. The client should hold the cane on the weak side of his body C. The grip should be level with the clients waist D. The client should first move the strong leg, then the weak one

A

A nurse is assessing a client at a follow up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? A. The client faces the direction of movement when sliding an object across the floor B. When pushing an object, the client moves his front foot backward C. When moving an object to one side, the client puts his weight on his heels D. The client stands with his feet close together when lifting an object

A

A nurse is assisting an older adult who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? A. Gait belt B. Jack harness C. Four-wheel walker D. Cane

A

A nurse is assesing a client who has bell palsy. Which of the following findings should the nurse expect? (Select all that apply) A. Muscle distortion B. Pain behind the ear C. Hearing loss D. Facial twitching E. Impaired taste

ALL

The nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Airway patency

A nurse in a providers office is caring for a client who reports pruritus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders? A. Alopecia B. Contact dermatitis C. Perdiculosis D. Tines pedis

B

A nurse is assesing a client with pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the clients edema? A. 4+ B. 3+ C. 2+ D. 1+

B

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 stocking for wrinkles

A nurse is auscultating breath sounds of a client who has asthma. When the client exhales, the nurses hears continuous high pitched squeaking sounds. the nurse should document this as which of the following breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

D

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? A. Clamps th NG tube during ausculattion B. Performs auscultating between meals C. Auscultates bowel sounds for 3 to 5 min D. Palpates the abdomen prior to performing auscultation

D

A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? A. Keep artificial nails trimmed B. Use alcohol based rubs before administering eye drops C. Wash hands with alcohol based hand rubs for c-diff patients D. Use chlorehidine to wash hands if the client is immunosupressed

D

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority? A. Lock the doors to the unit and secure windows so they cannot be opened B. Provide the client with plastic eating utensils for meals C. Remove any object from the clients environment that could be used for self harm D. Assign a staff member to stay with the client at all times

D

A nurse in a 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? A. Use friction rub when washing the affected area B. Use an oil based soap to wash affected areas daily C. Express the larger comedones periodically D. Use a new cosmetic pad with each limited application of makeup

D

A nurse is assessing a clients abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

A nurse is caring for an older adult client who states, I am afraid to fall while walking to the bathrrom at night. Which of the following should the nurse do?

Leave a nightlight in the room

What is tinea pedis?

Scaling and redness between the clients toes

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear anti embolism stockings during and after the procedure. When the client asks what the stocking do, which of the following responses should the nurse make?

They improve your circulation to keep blood from pooling in your legs

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

Turn the client on his side before starting oral care

A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following info should the charge nurse include in the teaching?

Use chlorhexidine to wash hands if the client is immunosuppressed

A nurse is preparing to transfer a client who has left sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take?

Use gait belt to stand and pivot the client

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve III? A. Ask the client to read a Snellen chart B. Listen to the clients speech C. Ask the client to identify scented aromas D. Ask the client to clench his teeth

A

A nurse is assessing a clients cardiovascular system. TO palpate for unexpected pulsations in the pulmonary area, at which anatomical location should the nurse place her fingers? A. The left second inter-coastal muscle B. The right second inter-coastal muscle C. The left fifth inter-caostal space D. The left fifth inter-caostal space at the mid-clavicular line

A

A nurse is auscultating a client's heart sounds and hears an extra sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. the fourth heart sound (S4) B. A friction rub C. The third heart sound (S3) D. A split second heart sound S2

A

A nurse is auscultating a clients lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breath deeply and cough B. Instruct the client to limit fluid to less than 2,000 ml/daily C. Prepare to admister antibiotics D. Place the client on bed rest semi fowlers

A

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? A. Report of exposure to a skin irritant B. Denial of pruritus C. systemic symptoms including elevated temp D. Report of generalized joint discomfort

A

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? A. Auscultate breath sounds at least every 2 hr B. Perform range-of-motion (OM) exercises at least two or three times daily C. Make sure the client has an intake of 2,000 or 3,000 mL of fluid per day D. Apply antiembolic stockings

A

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching? A. O only need to catheterize myself twice every day B. I carry a water bottle with me because I drink a lot of water C. I sue a suppository every night to have a bowel movement D. I do wheelchair exercises while watching tv

A

A nurse is prepasring an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? A. Explain to the client what is about to happen B. Make sure the room temp is cool C. Provide music as an environmental distraction D. Inform the client that the provider will examine sensitive areas first

A

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for fall? A. An older adult client who is confused and has urinary frequency B. A client with diabetes mellitus who has a leg ulcer C. A client who is 1 day post op and needs help out of bed D. An adolescence client who has a leg fracture and has been using crutches for the past 2 days

A

While auscultating a clients heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. a systolic murmur B. a third heart sound (s3) C. an expected heart sound D. a fourth heart sound (s4)

A

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply) A. check for personal items when changing the bed linens B. Place a clean gown on the strongest arm first C. Keep the bath water temp between 43.3 (110 F) and 46.1 (155 F) D. Shave the clients hair in the direction of the har growth E. Wash the client's extremities from proximal to distal

A, C, D

A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching? A. You will need to take the entire prescription of antibiotics even if the condition improves B. Your provider may recommend a daily antihistamine to help control your symptoms C. You should cleanse your mouth with prescribed mouthwash each day D. Your provider will remove the lesions with solid carbon dioxide

B

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include? A. Remove the rubber tip when using the cane B. Hold the cane on the right side to provide support for the weaker leg C. Place the cane approx 61 cm in front of her feet before advancing D. Advance the right leg and the cane together to support the weaker leeg

B

A nurse is preparing to transfer a client who has left sided weakness from the bed to the chair. Which of the following actions should the nurse plan to take? A. Raise the client bed to the nurses waist B. Use a gait belt to stand and pivot the client C. Instruct the client to pace his hands around the Norse's neck during the transfer D. Place the chair on the client's weak side

B

A nurse is providing discharge teaching for a client who is postoperative following an inner maxillary fixation for facial fractures. Which of the following instructions should the nurse include in the teaching? A. Swallow using the supraglottic method B. Keep wire cutter with you C. Floss teeth daily D. Eat a mechanical soft diet

B

A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. which of the following statements by the client indicates an understanding of th e teaching? A. I should soak my feet before trimming my nails B. I should buy new shoes late in the day C. I should wear a clean pair of nylon socks every day D. I should use a heating pad at night when my feet feel cold

B

A nurse is assessing a client who has a new skin lesion that as a wavy border. The nurse should document the lesion using which of the following descriptions? A. Annular B. Sepignous C. Circinate D. Caolesced

B

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the clients abdomen? A. after palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen

B

A nurse is assessing an older adult who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the clients spine. The nurse should expect the provider to document which of the following disorders? A. Scoliosis B. Kyphosis C. Lordosis D. Ankylosis

B

A nurse is caring for an older adult client who was alert and orientated at admission, but now seems increasingly restless and intermittenly confused. Which of the following actions should the nurse take to address the clients safety needs? A. Call the family and ask them to stay with the client B. Move the client to a room closer to the nurses station C. Apply wrist and leg restraints to the client D. Administer medication to sedate the patient

B

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? A. Atrial gallop B. Ventricular gallop C. Closure of the mitral valve D. Closure of pulmonary valve

B

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? A. The client's ability to communicate B. The client's current weight-bearing status C. The client's height D. The type of equipment used in previous transfers

B

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply) A. Keep the clients room dark at night B. Teach the client to use the call light C. Keep the clients bed in the lowest position D. Place fall-risk identification band on the clients wrist E. Assess the client every 4 hrs

B, C, D

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit B. Activate the fire alarm C. Move any clients in the immediate vicinity D. Use a fire extinguisher to put out the fire

C

A nurse is measuring a client for knee-high antiembolic to help prevent venous stasis. Which of the following actions should the nurse take? A. Measure from the heel to the gluteal fold B. Measure the length of the feet C. Measure from the heel to the popliteal space D. Measure the ankle circumference

C

A nurse is teaching a client about crutch walking using the three-point gait. Which of the follpowing statements by the nurse shoud be included in the teaching? A.Look down at your feet before moving the crutches B. Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot C. Move both crutches forward while standing on the affected leg, then lift and swing your body past the crutches D. Support your body weight on the underarm crutch pads

C

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait? A. A client who is able to bear full weight on both lower extremities B. A client who has bilateral leg braces due to paralysis of the lower extrem C. A client who has a right femur fracture with no weight bearing on the affected leg D. A client who ha a right femur fracture with no weight bearing on the affected leg

C

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraints? A. The client has a capillary refill of less than 2 seconds B. The client has full range of motion in her wrist C. the client is attempting to remove the restraints D. the client's hand is cool and pale

D

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? A. restlessness B. retractions C. dependent edema D. clubbing of the fingers

D

A nurse is assessing a clients cranial nerves as part of a neurological examination. which of the following actions should the nurse take to assess cranial nerve III? A. Testing visual acuity B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary to light

D

A nurse is caring for four clients. The nurse should identify which of the following clients as having a contraindication to receive moist heat? A. A client who has osteoarthritis and has pain in the lower extremity joints B. A client has spinal cord injury and muscle spasms of the lower back C. A client who is 1 day postoperative and has deep vein thrombosis D. A client who broke his ankle 2 hr ago and has swelling of the lower extremities

D

A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene? A. Raises the bed to waist level B. Rolls the client to one side of the bed C. Lowers the side rail on the side closest to the AP D. Reaches over the bed to straighten the fitted sheet

D

a nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? A. Symmetrical convex sphere shape B. Concave umbilicus C. Bilateral bowel sounds in the lower quads D. Ecchymosis

D