review for fundementals of nursing chapters, hygine, saftey, activity.

The nurse is providing hygiene education for a family who will soon take an older adult client home from the hospital. Which statement by a family member requires further nursing instruction?

"I should provide soap for daily bathing to remove debris and keep my loved one's skin moist."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

"Make sure that you have smoke detectors in your house and that they're in working order."

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply.

1. independent maintenance of correct alignment 2. scissors gait 3. head, shoulders, and hips aligned in bed full range of motion

The nurse is caring for a client with dementia who lives alone at home and has begun wandering. What is the appropriate nursing response when the caregiver states, "What can I do? I am afraid my spouse is going to get lost."

Consider the Alzheimer's Association 'Safe Return' program."

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

Decreasing the incidence of hospital-acquired pneumonia Correct response:

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

File, rather than cut the nails.

The nurse is conducting a community education program on bike helmet safety. The nurse determines additional information is needed when a participant states:

I should be able to fit two fingers between my chin and the chin strap."

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his or her catheter.

The telehealth nurse receives a call stating that upon entering a family member's home, two people have been found semi-conscious with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg.

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

Short bones contribute to movement. Correct response:

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

Use the call bell for any needs and wear nonslip footwear." Correct response:

In which situation would it be appropriate to shave the beard of an unconscious client without his permission?

When inserting an endotracheal tube

The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?

You Selected: Use an electric razor for shaving purposes.

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

alongside the bed at the same height Correct response:

A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program?

obtain a pre-exercise medical examination for clearance

The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse?

pulling the razor against the direction of hair growth

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?

trapeze bar