Remediation Quiz A
A nurse is teaching a client how to perform active range-of-motion exercises of the lower extremities to improve mobility. Which of the following instructions should the nurse include in the teaching? -Move each joint just beyond the point of resistance -Perform each exercise six time each session -Complete each session two times per day -Start with a different set of joints each session
Complete each session two times per day Rationale: the nurse should instruct the client to complete each session two times per day to reduce the risk of injury
A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings. Which of the following findings should the nurse report to the provider? -Gastric residual of 50 mL -Weight gain of 0.23 kg (0.5lb) in 24 hr -2 loose stools in 48 hours -Gastric aspirate pH of 7
Gastric aspirate pH of 7 Rationale: the nurses should identify that a gastric pH of 7 is an indication the nasogastric tube is not in the stomach. Gastric pH is usually between 1 and 4 but can be up to 6, if the client receives a medication that alters the gastric pH. The client is at risk for aspiration and the nurse should report this finding to the provider
A nurse is preparing the room for a client who is transferring from the emergency department and is on seizure precautions. Which of the following items should the nurse place in the client's room? -Oral-nasal suction -Tongue blade -Sterile gloves -Wire cutters
Oral-nasal suction Rationale: the nurse should place oral-nasal suction equipment in the client's room to clear the client's airway which reduces the risk of aspiration
A nurse is teaching a class about home safety. Which of the following instructions should the nurse include in the teaching? -Change smoking detector batteries every 2 years -Place toddlers in rear-facing car seats until they are 2 years old -Store toxic liquids in plastic soft drink bottles -Tape frayed electric cords before using them
Place toddlers in rear-facing car seats until they are 2 years old Rationale: the nurse should instruct clients to place infants and toddlers in rear-facing car seats in the back seat of the car until they are 2 years old to reduce the risk of injury
A nurse is evaluating the developmental motor skills of a 4-month-old infant. Which of the following findings should the nurse expect? -Uses a spoon to feed themself -Sits up with support -Uses a pincher grasp -Creeps on hands and knees
Sits up with support Rationale: the nurse should expect a 4-month-old infant to be able to sit up with support. By this age, the infant should have no head lag with sitting.
A nurse is assessing an older adult client who has hemiparesis following a stroke. Which of the following findings should the nurse report to a nutritionist? -The client has a decrease in lean body mass -The client reports living alone -The client reports difficulty with dressing -The client has dyspnea on exertion
The client has a decrease in lean body mass Rationale: a nutritionist educates clients about the therapeutic diets and ensure that clients have resources for obtaining and preparing food. The nurse should report this information to the nutritionist who can assist the client meet their nutritional needs
A nurse is performing a skin assessment for a client using the Braden scale. Which of the following findings should the nurse identify as increasing the risk for skin breakdown? -The client ambulates independently three times during the day -The client consumes 75% of each meal -The client is incontinent of urine and feces -The client reports pain in the right foot
The client is incontinent of urine and feces Rationale: according to the braden scale, a client is at risk for skin breakdown due to the frequency of exposure to the moisture from the incontinence of urine and feces
A nurse is providing teaching to a client who has severe weakness in their right lower extremity and is learning to walk using a cane. Which of the following actions by the client indicates an understanding of the teaching? -The client moves the cane forward before taking steps -The client holds the cane on their weaker side -The client moves their stronger leg before moving the weaker side -The client keeps their elbows straight when holding the cane
The client moves the cane forward before taking a step Rationale: the client should move the cane forward by about 15 to 30 cm (6 in to 1 ft) before taking a step with the weaker leg to maintain stability
A nurse is working at a provider's office that uses various forms of electronic communication. Which of the following actions should the nurse take to protect client confidentiality? -Delete email correspondences once a client's situation has been handled -Ensure that the computer system does not use encryption or firewall services -Verify that recipient contact information is correct before faxing information -Avoid including a cover sheet when sending a facsimile
Verify that the recipient contact information is correct before faxing information Rationale: before sending protected health information using fax machine, the nurse should verify the fax number of the individual receiving the information. This prevents individuals without a legal right to the client's records from having access to the information
A nurse is performing a preoperative assessment on four clients. The nurse should identify that which of the following clients is at risk for a latex allergy? -A client who has an allergy to walnuts -A client who has spina bifida -A client who has a family history of malignant hyperthermia -A client who has a history of smoking
A client who has spina bifida Rationale: a client who has spina bifida is at risk for a latex allergy because of their history of frequent contact with latex products, such as urinary catheters. The nurse should use latex-free products to reduce the risk of hypersensitivity reaction.
A nurse in a provider's office is reviewing the laboratory reports for a client who is at risk for heart disease. Which of the following results should the nurse report to the provider? -An elevated HDL level -An elevated LDL level -A decreased C-reactive protein level -A decreased alkaline phosphatase level
An elevated LDL level Rationale: an ldl level above the expected reference range places the client at increased risk for heart disease; therefore, the nurse should report their result to the provider
A nurse is completing an informed consent document for a 16-year-old adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take? -Locate the adolescent's partner to sign the form prior to appendectomy -Document the consent is implied due to the urgency of the procedure -Tell the client that a general consent to treatment covers the surgical procedures -Ask the client if they understand the provider's plan for the appendectomy
Ask the client if they understand the provider's plan for the appendectomy Rationale: to ensure informed consent, the nurse should ask the client if they understand the planned procedure. In most states, a married adolescent is considered emancipated and has the legal authority to provide their own consent
A nurse is planning care to prevent plantar flexion for a client who is in a coma. Which of the following intervention should the nurse include in the plan of care? -Internally rotate the client's ankle and feet -Place pillows under the client's ankles -Brace the client's feet with ankle-foot orthotics -Apply elastic wraps to prevent hyperextension of the client's ankles and feet
Brace the client's feet with ankle-foot orthotoics Rationale: the nurse should apply ankle-foot orthotics to prevent plantar flexion, which will allow the client to dorsiflex the foot when conscious
A nurse in a provider's clinic is teaching a female client about how to collect a clean-catch urine specimen at home. Which of the following information should the nurse include in the teaching? -Use sterile gloves when collecting your urine specimen -You may refrigerate your urine specimen fro up to 12 hours before bringing it to the laboratory -Collect your urine specimen as soon as you start your stream -Clean your vagina area from the front to the back
Clean your vagina area from the front to back Rationale: the nurse should instruct the client to clean the vaginal area using a front-to-back motion two to three times using a fresh towelette, cotton ball, or gauze pad each time
A nurse at a provider's office is caring for a young adult client. Which of the following information should the nurse provide regarding health promotion strategies? -Have breast cancer screenings after 40 years of age -Schedule a tuberculin skin test every 5 years -Have your cholesterol checked every 10 years -Schedule a baseline ECG at age 45
Have a breast cancer screenings after 40 years of age. Rationale: the nurse should instruct the client to have breast cancer screenings after 40 years of age if they desire. Clients who ar3e 45 to 54 years of age are encouraged to receive annual mammograms.
A nurse is teaching a client about health promotion and secondary prevention strategies. Which of the following recommendations should the nurse include? -Influenza immunization -Rehabilitation therapy -Genetic screening -Hypertension screening
Hypertension screening Rationale: a hypertensive screening is an example of secondary prevention and focuses on early detection of a disease and interventions to provide prompt treatment of disease.
A nurse is completing dietary teaching with a client who has heart failure and has a prescription for a 2 g sodium diet. Which of the following statements made by the client indicates an understanding of the teaching? -I can have nonfat yogurt as a dessert -I can eat processed foods as long as it has less than 500 mg of sodium per serving -I can have baking soda when I bake -I should season my foods with salt sparingly
I can have nonfat yogurt as a dessert Rationale: the nurse should identify that yogurt is a recommend dessert for a client on a 2 g sodium diet who has heart failure because it is low in sodium and fat
A charge nurse is teaching a newly hired nurse about the facility's computerized documentation system. Which of the following actions should the nurse take? -Direct the newly hired nurse to wait until the end of the shift to document client care -Instruct the newly hired nurse to use direct quotes when recording client statements -Perform documentation for the newly hired nurse until the orientation period is complete -Print records from previously discharged clients as examples for the newly hired nurse to review
Instruct the newly hired nurse to use direct quotes when recording client statements Rationale: the newly hired nurse should include both subjective data, what the client says, and objective data, what the nurse observes, when entering computer documentation. It is important to directly quote what the client says rather than summarizing to provide factual information
A nurse is planning comfort measures to decrease painful stimuli for a client who has back pain. Which of the following interventions should the nurse include in the plan of care? -Assist the client onto a regular bedpan by placing a hand under the client's shoulders -Move the client up in bed by pulling under the client's arms -Logroll the client every 4 hours -Place pillows between the client's legs when lying laterally
Place pillows between the client's legs when lying laterally Rationale: the nurse should place pillows between the client's legs to maintain good body alignment, which promotes comfort for a client who has back pain and prevents pressure on the boney prominences
A nurse is planning to perform postmortem care for a client. Which of the following actions should the nurse plan to take? -Request family members to leave the client's room -Remove dentures from the client's mouth -Verify whether the client requires an autopsy -Lower the head of the client's bed
Verify whether the client requires an autopsy Rationale: the nurse should verify whether the client requires an autopsy before completing the postmortem care or removing any indwelling lines, tubes, or catheters