Skills ch. 4,7,9,12

The nurse needs to perform a portable bladder ultrasound on a client. Where should the nurse place the scanner head?

midline on the client's abdomen about 1 to 1.5 in (2.5 to 3.725 cm) above the symphysis pubis

A client in skeletal traction has a diagnosis of type 2 diabetes mellitus. The client asks why there is a prescription for a 1200 calorie diet. What is the correct response by the nurse?

"A 1200 calorie diet can help prevent high blood sugars, which can impair the healing process."

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse?

"Allow me to show you how to use your walker again."

The nurse is repositioning a client with a newly casted limb in bed. The client asks the nurse why the casted limb was placed on a pillow. What is the best response by the nurse?

"to prevent denting of the cast and development of pressure areas"

The nurse is providing nail care to a client. Which assessment findings require notification of the client's health care provider? Select all that apply.

- Red and swollen skin around the great toe - Blackened great toe nail - Bleeding under the nail bed and from the sides of the toes - Nails curled around the tip of the toes

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

- Toothbrush - Emesis basin - Disposable gloves - Toothpaste - Towel

What is the most important advantage of using a condom catheter versus an indwelling catheter?

Less potential for infection.

The nurse is removing the faceplate from a urinary stoma appliance. What is the recommended method for removing the plate?

Push the skin from the plate from the top to the bottom.

A toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint. The procedure is expected to take about 10 minutes. Which approach might the nurse suggest as an alternative to using a mummy restraint?

Therapeutic holding Rationale:An alternative approach for temporary restraint is therapeutic holding, which makes use of a secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 minutes or less. A vest or mitt restraint would not be an alternative to a mummy restraint. Straddling the child would be inappropriate.

A nurse is explaining to a client's caregiver the purpose of antiembolism stockings, which the client has received a prescription to wear. Which best explains their purpose?

They promote venous blood return to the heart.

The nurse is performing a portable bladder ultrasound on a client to assess for postvoid residual urine retention. Which postvoid residual volume amount indicates adequate bladder emptying?

less than 50 mL

The nurse should document the time, date, and location of the figure-eight bandage when applied or changed in the nursing record. What other information should the nurse record in the procedure documentation?

size of bandage

The nurse is caring for a client in the postanesthesia care unit (PACU) who has just undergone a third foot surgery. Which gate is best for the nurse to teach this client?

swing-to gait

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

the alternative measures attempted before applying the restraints

The nurse is applying a condom catheter to a client who is urinating frequently and unable to control his urination following surgery. Which accurately describes the correct procedure for this application?

Apply the condom sheath securely enough to prevent leakage, but not so tight as to restrict blood flow.

A family member assisted the client with an arm cast to bathe. The client reports that the cast "got a little wet." What action should the nurse take?

Assess cast integrity and report any abnormalities.

The unresponsive client's spouse at bedside asks the nurse about oral care. The spouse states, "If my spouse is not eating, why do you still brush the teeth?" How does the nurse best respond?

Mouth care during this time helps prevent complications." Rationale: The best response by the nurse is to explain that mouth care for the unconscious client prevents dental problems such as decay and prevents pneumonia due to bacterial growth in the oropharynx. This most completely addresses the spouse's question. Bacteria would normally be partially washed away by saliva, dental care does remain important, and moist oral mucosa does feel good to the client. However, these responses do no completely address the spouse's concern.

The nurse is observing the client's caregiver apply a figure-eight bandage to the client's ankle. The caregiver begins wrapping the elastic bandage around the ankle and unrolls the entire bandage before wrapping the ankle in figure-eight fashion. What should the nurse instruct the caregiver?

Re-roll the bandage, wrap twice AROUND the ankle, and then alternate with the bandage rolled ascending and descending with every turn.

A client with diabetes asks the nurse what should be done for a large callus on the right great toe. What is the best response by the nurse?

"I encourage you to see your podiatrist to get a recommendation for your callus."

When applying a condom catheter to a client, how much space would the nurse leave between the tip of the penis and the end of the condom?

1 to 2 in (2.5 to 5 cm)

When changing the urinary ostomy appliance for a client, the nurse measures the stoma and traces the same size on the back center of the appliance. How much larger would the nurse cut the hole to ensure accurate fit?

1/8 inch

The nurse is performing an irrigation of the client's catheter using a closed system. What should the nurse use to disinfect the aspiration port?

An antimicrobial swab.

Which aspect of denture care is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Brushing the dentures.

The nurse, changing a urinary stoma appliance, removes the faceplate from the skin and assesses the stoma. What does a change in the size or color of a urinary stoma indicate?

Circulatory problems.

The nurse is irrigating a client's urinary catheter using a closed system. What action would the nurse perform after cleansing the access port on the catheter?

Clamp or fold the catheter tubing below the access port.

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

The nurse is assessing a client with a figure-eight bandage on the right ankle. The client has returned from the bathroom and the bandage is loose and has migrated over the tips of the toes. What action does the nurse perform next?

Discard the bandage and replace with a new bandage following the figure-eight pattern

The nurse is changing the appliance for a client with a urinary stoma. What is the best time to change the appliance?

Early morning, when the urine production is low.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Ensure proper positioning of the scanner head and rescan.

The nurse is preparing to change the appliance of a client with a urinary stoma. How often would the appliance be changed?

Every five days.

A client who is in skeletal traction following a fracture of the femur reports unbearable pain and asks whether weights can be removed periodically for pain relief. Which action should the nurse take?

Explain that proper traction reduces the risk of injury and that weights may not be removed.

The nurse is caring for a client who sustained a fracture of the ulna and has had a long-arm cast applied for 24 hours. The client's pain has been effectively managed with intermittent ice application and administration of oral analgesics. The client now states, "My cast feels too tight and the pain is the worst it has ever been." Which action is most appropriate?

Immediately assess the neurovascular status of the affected extremity and contact the primary care provider.

A client with an indwelling urinary catheter has a PRN prescription for intermittent catheter irrigation. The nurse notices there is no urine coming out of the catheter and that the client is complaining of bladder pain and pressure. What might the nurse do to rectify this situation?

Irrigate the catheter with normal saline to restore patency.

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform?

Perform a circulation check and offer toileting and hydration.

A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?

Raise the bed to elbow height

The nurse has a prescription to apply a sling to a client with a new fracture of the humerus. The client is anxious about the procedure and expresses a pain rating of 8 on a 0 to 10 scale. What should the nurse do next?

Review the medication administration record (MAR) and administer PRN pain medication as prescribed.

Prior to placing a continuous passive motion device, what step must the nurse complete?

Review the prescription in the medical record order and check for prescribed degrees of flexion and extension.

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

Sitting at the edge of the bed

The nurse needs to perform a portable bladder ultrasound on a client. What position should the nurse place the client for this procedure?

Supine

The nurse has delegated contact lens removal to the unlicensed assistive personnel (UAP) for a client in the preoperative area. Which action by the UAP requires intervention by the nurse?

The UAP has placed the client in a side-lying position.

A nurse must provide oral care for an older adult client who cannot effectively manipulate a toothbrush. How often should the nurse brush and floss the client's teeth?

Twice a day

How should the nurse position the weights for a client in skin traction?

Weights should hang freely, off the floor and bed.

When applying a sling to the upper extremity, how should the nurse position the forearm of the injured side?

at a 90-degree angle with the hand slightly higher than the elbow

The nurse is caring for a client who had knee replacement surgery. The client's family member asks why a footplate is used with a continuous passive motion device. What is the correct response by the nurse?

"to maintain the client's foot in a neutral position"

The nurse is caring for a client with a suprapubic urinary catheter. The client has several areas of skin breakdown in the perineum. Why would a suprapubic urinary catheter be preferred over an indwelling urinary catheter for long-term catheterization for this client?

Decreased risk of wound contamination.

The client experiences leakage around the condom catheter. Which action does the nurse perform?

Obtain the correct supplies and replace it.

The nurse irrigates an indwelling urinary catheter through a closed system. Why is this preferable to opening the catheter?

Opening the catheter can lead to contamination and infection.

The nurse is providing pin care for a client with skeletal traction. Proper pin insertion site cleaning technique is important to prevent which potential complication?

osteomyelitis

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms?

wiping down the handles of the walker once the client has returned to bed

A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse notes that the hourly drainage is less than the amount of the irrigation being given. Which actions by the nurse would be most appropriate? Select all that apply.

- Palpate the client's bladder for distention - Check the tubing for any kinking

A nurse is administering intermittent closed-catheter irrigation to a client. Place the following steps in the correct order. Use all options.

1)Cleanse the access port on the catheter with an antimicrobial swab. 2)Clamp or fold the catheter tubing below the access port. 3)Attach the syringe to the access port on the catheter using a twisting motion. 4)Gently instill solution into the catheter. 5)Remove the syringe from the access port. 6)Unclamp or unfold the tubing and allow the irrigant and urine to flow into the drainage bag.

A nurse is preparing to initiate a continuous closed bladder irrigation for a client. The nurse has completed the preparation steps. The sterile irrigation bag is prepared, labeled, and flushed. The tubing is clamped, and the end cover has been replaced. The nurse has put on gloves and then completes the next steps listed below. Place them in the order that the nurse would perform them. Use all options.

1)Cleanse the irrigation port with an alcohol swab. 2)Aseptically attach irrigation tubing to irrigation port of the three-way catheter. 3)Check to make sure the clamp on the drainage tubing is open. 4)Release the clamp o the irrigation tubing. 5)Regulate the flow at the determined drip rate.

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first?

1)Place a protective pad under the client's head and shoulders after removing the pillow. 2)Fill the pitcher with water at an appropriate temperature. 3)Place the shampoo board under the client's head. 4)Position a drain container underneath the drain of the shampoo board. 5)Put on gloves and give the client a folded washcloth to hold over the forehead.6)Saturate the client's hair with water from the pitcher.

The nurse has instructed the client with a knee injury on how to perform crutch walking with a four-point gait. Which statement clarifies client understanding?

"The four-point gait uses one crutch, then one leg, followed by the other crutch, and then the other leg."

How should the nurse teach the client who is ambulating with a cane?

Instruct the client to advance the cane 4 to 12 in (10 to 30 cm) and then, while supporting weight on the stronger leg and the cane, advance the weaker foot forward, parallel with the cane.

The nurse is applying a condom catheter to an older adult client who has become incontinent of urine following hip surgery. In what position would the nurse place the client when applying this device?

Lying flat

The nurse is assigned a client for whom an elbow restraint is prescribed. Which general principles of correct placement of the elbow restraint will the nurse follow? Select all that apply.

a. Pad bony prominences b. Confirm the restraint does not extend below the wrist or place pressure on the axilla c. Ensure the restraint is the correct size for the client

The nurse is caring for a client who will be receiving a suprapubic catheter. Which statement about suprapubic catheters should the nurse mention to the client?

They are often preferred over an indwelling urethral catheter for long-term urinary drainage.

After measuring the size of the client's urinary stoma when changing an ostomy appliance, what would be the nurse's next step?

Trace the same size opening on the back center of the new appliance.

The client has decreased strength in the left leg. How should the nurse instruct the client to hold a cane for assistance?

on the right side

A client's health care provider has prescribed the use of knee-high graduated compression stockings. To ensure that the correct size is obtained for the client, the nurse would measure which area? Select all that apply.

- Around the widest part of the calf - From the bottom of the heel to the back of the knee

The nurse is teaching a client with peripheral vascular disease about foot care. What will be included in the teaching plan? Select all that apply.

- Wear appropriate footwear. - Schedule foot exams with podiatrist at least once per year. - See a podiatrist for treatment for bunions.

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply.

- Wear nonskid shoes or slippers. - Choose a walker with wheels on the front legs if you have a faster gait. - Check the walker for signs of damage, frame deformity, or loose or missing parts before use.

The nurse must apply a mummy restraint to a small child. Place the steps in the correct order. Use all options.

1)Secure a prescription from the health care provider. 2)Explain the reason for use to the client and family. 3)Open the blanket or sheet and place the child on the blanket. 4)Position the child's right arm alongside the body and pull the right side of the blanket tightly over the child's right shoulder and chest. 5)Secure the blanket under the right side of the child's body. 6)Fold the lower part of the blanket up and pull over the child's body.

The nurse is changing a client's bedding while the client is out of the room getting an X-ray. What would the nurse do with the reusable linens?

Fold the linens in fourths on the bed and then hang them over a clean chair. Rationale: The nurse would fold reusable bedding, such as a sheet, blanket, or spread, in fourths on the bed and then hang it over a clean chair. Folding the reusable linens saves time and energy when they are replaced on the bed. Folding bedding while it is on the bed reduces strain on the nurse's arms. Having another nurse assist may not be an effective use of time. The overbed table should be reserved for client items. The nurse would want to place the reusable lines on the bed after the client has returned to the bed.

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted?

Insert the fist between the restraint and the client. Rationale: The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

A nurse is caring for a client who recently had total knee arthroplasty and has been prescribed use a continuous passive motion machine to increase joint mobility. Which actions should the nurse take while assisting the client with using the machine? Select all that apply.

Using the tape measure, determine the distance between the gluteal crease and the popliteal space.Make sure the affected extremity is in a slightly abducted position.Make sure the knee is at the hinged joint of the device.

A nurse is preparing to wash the hair of a client who is confined to bed. The nurse plans on using a shampoo cap. Which action would the nurse do first?

Warm the cap in the microwave.

When monitoring a client with a condom catheter, the nurse finds that the catheter will not stay on the client. What would be the initial recommended step for this situation?

Ensure that the condom catheter is the right size.

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching?

"I will pull the skin taut to reduce the risk for ingrown hairs."

The nurse is caring for a client with a new suprapubic urinary catheter. The client asks why the drainage sponge needs to be changed so often. What is the best response by the nurse?

"The sponge needs to be changed to prevent skin irritation and breakdown."

A nurse delegates the application of graduated compressions stockings to a licensed practical nurse. A while later, the client's spouse pulls the nurse aside and says, "I think the other nurse put the stockings on backwards. The opening is facing up." Which response by the nurse would be most appropriate?

"The opening is face up to prevent any interference with the circulation."

The nurse is teaching a client about denture care. Which statement from the client indicates a need for further teaching?

"When I eat, I will remove my dentures and place them in a napkin."

A nurse is caring for a client receiving a continuous closed bladder irrigation. The client's urine output prior to initiating the irrigation was 350 mL. After approximately 6 hours, the nurse empties the drainage bag and records an amount of 1,200 mL. The irrigation is running at 100 mL/hour as prescribed. The nurse documents a urine output of which amount?

600mL

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure. Which intervention should take priority?

Assess the circulation to the client's fingers and hands

The nurse is caring for a client who is using a continuous passive motion device. What distance from the knee to beyond the bottom of the foot should the nurse measure for the client?

14 in (35.5 cm)

What should the nurse do immediately after cast application?

Assess the extremity for pulses, color, temperature, sensation, and motion.

After assisting a bed-bound client with oral care, what action does the nurse take?

Assist the client to a comfortable position in the bed.

A client who is wearing soft contact lenses is unable to remove the lenses before bedtime. What action should the nurse take?

Assist the client to remove the lenses using a small pair of rubber grippers.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.

The client with a newly applied sling for an arm injury reports finger numbness and tingling on the affected side. What should the nurse do next?

"Replace padding under the strap to cushion the neck."

The nurse is supervising an unlicensed assistive personnel (UAP) team member. The UAP asks the nurse why the blood pressure cannot be taken in the left arm of a client with a left arm arteriovenous (AV) fistula. What would be the nurse's best response to the UAP?

"The client's AV fistula could be damaged by obtaining blood pressure measurement in the left arm."

A client who has had an open fracture of the ulna with soft tissue damage is scheduled to receive an external fixation device. The client is upset and wants to know why she cannot just have a cast. What should the nurse tell this client?

"The device will support your fractured bone while allowing treatment of the soft tissues."

The client has a newly surgically inserted peritoneal dialysis catheter, for which the nurse performs frequent dressing changes at the surgical site. The client express concern about being able to afford the sterile supplies needed to complete these changes when released from the hospital. Which is the nurse's best response?

"When the site is healed and you return home, you will not need sterile supplies."

A client who has a plaster arm cast reports itching under the cast and asks the nurse what to do about it. What is the appropriate response by the nurse?

"You can tap lightly on the outside of the cast or use a hair dryer on cool setting to blow cool air into the cast."

A nurse is administering continuous closed-bladder irrigation to a client. After performing this intervention, the nurse observes that the irrigation solution is not flowing at the prescribed rate. Which actions should the nurse take? Select all that apply.

- Check the tubing for kinks or pressure points - Open the clamp all the way. - Raise the bag 3 to 6 in (7.5 to 15 cm).

A nurse is providing nail care for an older adult client. Which actions should the nurse take? Select all that apply.

- Cut the nail straight across - Round the tips of the nails in a gentle curve using a file - File the nail straight across - Gently clean under the nails using an orangewood stick

A client has been out of bed, sitting in the chair for the past hour. The nurse is preparing to apply knee-high length graduated compression stockings as prescribed by the client's health care provider. Which action would be appropriate for the nurse to do? Select all that apply.

- Elevate the client's feet and legs for about 15 minutes. - Assist the client back to bed.

A nurse is observing a client who recently received a peritoneal dialysis catheter site. Which signs would indicate peritonitis in this client? Select all that apply.

- Foul odor - Fever - Cloudy drainage - Abdominal pain on palpation - Purulent drainage

The nurse is caring for a postoperative client just returning from surgical insertion of a peritoneal dialysis catheter. Which are the priority assessments by the nurse of the peritoneal dialysis catheter insertion site? Select all that apply.

- bleeding - drainage - odor - pain

The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply.

- having blood pressure measurements in the affected arm - getting venipuncture in the affected arm - carrying heavy items including purses or luggage with the affected arm - sleeping with the affected arm under the head or body

The nurse is caring for a client who has had a cast placed. What are the most common reasons that clients may need cast application? Select all that apply.

- to treat injuries - to correct a deformity - to stabilize weakened joints - to promote healing after surgery

The nurse is preparing to assess a client's postvoid residual using a bladder scanner. Place the following steps in the correct order. Use all options.

1)Press the appropriate gender button. 2)Position the scanner head with the directional arrow pointing to the head. 3)Press the scanner head onto the skin 1 to 1.5 inches above the symphysis pubis. 4)Aim the scanner head toward the coccyx and activate the scan. 5)Verify that screen crossbars fall within the bladder image. 6)Observe and record the volume measurement on the screen.

A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse inspects the solution bag labeled as bladder irrigant and notes that the solution was started this morning at 6:30 am. The nurse would plan to discard this solution and hang new bag of irrigant solution if the current solution was not completely infused by which time?

6:30 am tomorrow

A nurse is shaving a male client's face. Which should the nurse do?

Pull the skin taut and shave in the direction of hair growth using short strokesRationale: The skin on the face is more sensitive and needs to be shaved with the direction of hair growth in short strokes to prevent discomfort. The skin should be pulled taut so that the razor can cut the hair more effectively.

When removing the faceplate from a urinary stoma, the nurse meets resistance when pushing the skin from the plate. What is the recommended guideline for this situation?

Apply adhesive remover to the skin under the plate.

A nurse is assisting a client with denture care. What is the best way to remove the client's dentures?

Apply gentle pressure with a 4 × 4 gauze to grasp the denture plate.

The nurse is providing denture care for a client who is too sedated to assist. Which is a recommended guideline for this procedure?

Apply gentle pressure with a piece of gauze to remove the upper dentures.

Which methods can be used to remove a client's soft contact lenses? Select all that apply.

Ask the client to remove them, if able., Use the pads of the index finger and thumb to gently pinch and remove the lens. Rationale: When assisting with basic hygiene, it is important to respect individual client preferences and give only the care that clients cannot, or should not, provide for themselves. Thus, the nurse should have the client remove the lenses, if able. To remove a client's soft contact lenses, the nurse should do the following: using the pads of the thumb and index finger, grasp the lens with a gentle pinching motion and remove. A tool with a small suction cup is appropriate for the removal of hard lenses but not for soft lenses. Applying pressure to the lower eyelid is used to remove hard lenses, not soft ones. A small pair of rubber grippers is used to remove soft lenses that are difficult to remove, not two cotton-tipped applicators.

A nurse is caring for a client who is unconscious and notes in the client's history that the client wears contact lenses. What is the most appropriate action by the nurse at this time?

Assess both eyes for contact lenses.

The nurse is caring for a client who requires a cast. Prior to assistance with cast application, what should the nurse do? Select all that apply.

Assess the client for pain and administer PRN medication if appropriate., Cleanse and dry the affected extremity., Explain the procedure to the client and verify area to be casted.

The nurse is caring for a newly admitted client who sustained a hip fracture and is scheduled to have surgery within the next 24 hours. The nurse should anticipate applying which type of traction until surgery is performed?

Buck's extension

When changing the appliance on a urinary stoma, the nurse places a waterproof pad under the client and puts on gloves. What is the next step in this procedure?

Empty the contents of the urinary appliance into a graduated container.

When providing oral care to an unconscious client, the nurse takes which action?

Ensure there is a towel and basin positioned for drainage.

The nurse is changing the appliance on a urinary stoma. What would the nurse place over the stoma after removing the old appliance?

Gauze squares.

When performing pin care, the nurse notes scabs on the skin at the pin insertion sites. What is the appropriate action by the nurse?

Gently remove scabs if they can be removed easily; leave in place if there is difficulty during removal.

The nurse is caring for a client with skin traction. The nurse applies the boot portion of the skin traction to prevent what potential complication?

Heel skin breakdown.

When performing pin care, the nurse notes that the client's external fixation device seems loose. What is the appropriate action by the nurse?

Instruct the client to limit movement of the extremity and notify the health care provider.

The nurse in the emergency department is caring for a client who has been hit in the eye with a baseball. The client reports that wearing contact lenses. What is the priority action by the nurse?

Notify the emergency department health care provider the client is wearing contact lenses. Rationale: If client who is wearing contact lenses receives an injury to the eye, the priority is to notify the health care provider about the presence of the contact lens to minimize injury. Removing the lens places the client at risk for further injury and should not be performed by the nurse. Asking the client to remove the lens from the unaffected eye may not cause further injury, but it is not the priority.

The client with a full arm plaster cast reports pain unrelieved by the analgesic and a feeling of tightness in the arm. In addition, the fingers are cool, with sluggish capillary refill. What intervention(s) should the nurse implement? Select all that apply.

Notify the health care provider of the situation immediately., Prepare for bivalving of the cast., Adjust the position of the arm so that it is higher than heart level.

The nurse is caring for a client with a suprapubic urinary catheter. When cleaning the site, the catheter becomes dislodged and comes out. What is the next step by the nurse?

Notify the health care provider.

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings.

The nurse in the orthopedic clinic cares for a variety of client populations. The nurse is aware that which population has increased risk for impaired skin integrity?

Older adults

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint?

Pad bony prominences. Rationale: Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. Th

The nurse is changing the linens on a client's bed. What is the nurse's primary objective for this nursing action?

Provide client comfort Rationale: The main purpose for changing the linens on a client's bed is to provide client comfort. Tidying up the room, preparing for visitors, and removing soiled linens are also benefits of this action, but the main objective is to make the client comfortable and free of skin alterations due to wrinkled linens.

The nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint. The elbow restraint should not impede circulation. Which pulse will the nurse assess to decide if circulation is compromised?

Radial

What should the nurse teach the client with an external fixation device?

Range-of-motion exercises should be performed every 2 hours while awake.

The nurse has placed the rolled, soiled linens in the laundry hamper. What should be the nurse's next action?

Remove gloves, unless indicated for transmission precautions. Rationale: After placing the soiled linens in the laundry hamper, the nurse would remove gloves, unless indicated for transmission precautions, and then place the bottom sheet with its center fold in the middle of the bed. This can be done without gloves, because the linens are clean. If the mattress is soiled, it should be cleaned according to facility policy. Scrubbing the mattress with antimicrobial cleanser is not necessary.

The nurse is caring for a middle-aged adult who has been prescribed elbow restraints. The nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. What is the best action by the nurse?

Remove restraints more frequently and perform range of motion (ROM)

The nurse completes the task of changing the dressing of a recent surgically inserted peritoneal dialysis catheter. The nurse has applied antibiotic ointment as prescribed, covered the site with 4 × 4 gauze, and labeled the dressing with the date, time of change, and initials of the nurse performing the task. Prior to leaving the client's bedside, the nurse should complete which task next?

Secure the tubing of the peritoneal dialysis catheter to the client's abdomen.

The nurse is caring for a client with skeletal traction. What is the proper way for the nurse to clean pin sites using a sterile cotton applicator for a client in skeletal traction?

Start at the pin insertion area and work outward, away from the pin site.

The nurse is providing oral care to an unconscious client. Which piece of equipment would be important use to individualize care for this client?

Suction toothbrush Rationale: A suction toothbrush provides a means to remove oral hygiene products and saliva from the unconscious client's mouth, thereby preventing aspiration. A regular toothbrush and an oral suction catheter may also be used. An emesis basin, towel, and toothpaste would be expected for use for any client during oral care.

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types?

The client continually tries to move from head of the bed toward the foot of the bed. Rationale: Research suggests that waist restraints pose the same risks for asphyxial death as vest restraints. When the client is very mobile in the bed or chair, the risk for asphyxiation increases. The nurse should pad skin and bony prominences that will be covered by the restraint to reduce friction and pressure to skin and underlying tissue. Restraints ground a client's center of gravity, thus helping to prevent injuries and falls such as rolling off a stretcher or falling out of bed. Because the nurse should be following the removal schedule (every 2 hours), the client is at less risk for incontinence and dehydration because these

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine.

The nurse is caring for a client with an external fixation device. What is the benefit of an external fixation device for this client?

The device can be adjusted externally to ensure the bones remain in an optimal position during the healing process.

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse?

Use a safety monitoring device.

Which modification to bathing should be implemented for a client who is incontinent?

Use special perineal skin cleansers and moisture barriers.

The nurse is caring for a client with a suprapubic urinary catheter. How should the nurse properly cleanse the catheter insertion site?

Using a circular motion, move from the inside toward the outside of the insertion site.

The nurse is cleaning the stoma of a client with a urinary diversion. What would the nurse use to clean the stoma?

Warm water and soap.

When repositioning a client, how should the nurse handle an arm cast that is not fully dry?

by using the palms of the hands and lifting gently

The client is 1 day postsurgery with a figure-eight bandage in place after an open reduction internal fixation (ORIF) of a left wrist fracture. How often should the nurse check the neurovascular status of the left wrist and hand?

every 4 hours

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

extremity restraint

What would be most important to document after shaving a client?

hat the chin was nicked with the razorRationale: Shaving a client does not usually require documentation. If the skin is broken while shaving, it is important to document the occurrence and any assessment findings. Otherwise, the time, the type of shaving cream and aftershave are not important to document.

The nurse is caring for a client with a cast and notes both decreased sensation and capillary refill in the casted extremity. What complication should the nurse report?

impaired circulation

The nurse is talking to a client who has been using crutches for ambulation. The client reports intermittent numbness of the upper arms. What should the nurse instruct the client to avoid?

leaning for prolonged periods by the axilla on the crutches

After applying a restraint to a client, the nurse is required to stay with the client while it in use. Which type of restraint has the nurse applied?

mummy restraint Rationale:A mummy restraint restricts all movement, and thus the nurse should stay with the client while it is in place. The other types of restraint do not restrict the client's movements as completely and thus require checks at specified intervals, but not the constant presence of the nurse.

The nurse is caring for a hysterical child who requires assessment of a dog bite near the eye. The parent is in emotional state that is not appropriate for helping to immobilize the child. The nurse should implement which restraints to best enable the health care provider to examine the client's injury?

mummy restraint Rationale:The mummy restraint is appropriate during an examination or while providing care for the head or neck, because it provides short-term restraint designed to control all movement. The vest restraint, extremity restraint, and elbow restraint are not appropriate in this situation.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

notifying the health care provider of the assessment findings.

For a client in skin traction, how should the nurse position the line of pull?

parallel to the bed

The nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint. The infant's parent asks the nurse what will be used to implement the mummy restraint on the infant. What is the best response by the nurse?

sheet or blanket Rationale:A small blanket or sheet is applied and folded to construct the mummy restraint. A vest restraint is made for adult clients. Towels are too small to be able to fold in the prescribed manner around the child. There are no manufactured mummy restraints.

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider?

thrill and bruit

The nurse is demonstrating proper ambulation technique with crutches to a child with a fractured ankle. What is priority assessment should the nurse perform?

weight bearing status

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

"Let me assess the patches. They may indicate the development of a fungal infection."

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need?

"Place all four feet of the walker on the ground before stepping forward."

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse?

"The health care provider will see the client and assess whether the restraint prescription should be renewed." Rationale: After restraints have been worn for 24 hours, the health care provider who is responsible for the care of the client must see and assess the client before writing a new prescription for the use of restraint or seclusion for the management of violent or self-destructive behavior. The health care provider will indicate that the client should remain in restraints if violent or self-destructive behavior continues. The client must be taken out of restraints before discharge, but the nurse would not know whether the health care provider would continue to renew the prescription for restraints for each 24-hour period until the client's discharge. If tests were needed to determine why the client is violent, the health care provider would have prescribed them before this time.

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

"Use of special bathing products and avoidance of scrubbing help keep your skin intact."

The nurse is caring for a 2-year-old child for whom elbow restraints have been prescribed. The nurse should remove the restraints and assess the child every how many hour(s)?

1

The nurse is providing step-by-step instructions to a client who is learning how to climb stairs while using crutches. Place the following instructions in the correct order. Use all options.

1)"Place both crutches under your left arm." 2)"Grasp the stair railing with your right arm." 3)"Place your unaffected leg on the first stair tread." 4)"Transfer your weight to the unaffected leg." 5)"Move up onto the stair tread." 6)"Move your crutches and the affected leg up onto the stair tread."

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100°F (38°C)

A nurse is preparing to shampoo a client's hair while the client is in bed and gathers the water in a pitcher. The nurse checks the temperature of the water and decides to continue based on which water temperature reading?

105oF (40.6oC)

The nurse is caring for a client who had knee replacement surgery. The client is using a continuous passive motion device. The nurse is aware that clients using a continuous passive motion device are at risk for which potential complications? Select all that apply.

impaired skin integrity, impaired bed mobility, impaired peripheral neurovascular function

A client who is recovering from surgery is beginning to ambulate. This client is strong enough to walk without assistance but has poor balance. Which type of mobility aid would be most appropriate for this client?

A cane with four prongs on the end (quad cane) Rationale: The quad cane provides a wide base of support and thus is recommended for clients with poor balance. A single-ended cane with a half-circle handle is recommended for clients requiring minimal support and for those who will be using stairs frequently. A single-ended cane with a straight handle is recommended for clients with hand weakness because the handgrip is easier to hold but it is not recommended for clients with poor balance. A walker with four fixed legs must be completely lifted off the floor between steps and is not recommended for clients with poor balance.

A nurse is providing care to several clients who are extremely weak and need to have their hair shampooed while remaining in bed. When gathering the necessary supplies, the nurse would anticipate needing to adapt the shampoo board for the client with which condition?

Acute spinal cord injury

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

Alternate between a full bed bath on one day and use of skin lotion or bath oil on the next.

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse?

Apply pressure with a gauze pad for 2 to 3 minutes. Rationale: If a client is cut during shaving and is bleeding, the nurse should apply pressure with a gauze pad or a towel for 2 to 3 minutes, and then check for continued bleeding. After the bleeding has stopped, it is safe to resume shaving. The priority is to stop the bleeding. Applying pressure does this, but it typically does not need 7 to 8 minutes. Rinsing with water will not aid in stopping bleeding, nor will a transparent dressing.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate?

Assess the client's need for fluids and toileting every 2 hours.

How should the nurse open the bottom sheet when making an unoccupied bed?

Fanfold to the center Rationale: The nurse would place the bottom sheet with its center fold in the center of the bed, open the sheet and fanfold to the center of the bed. Opening items on the bed reduces strain on the nurse's arms and diminishes the spread of microorganisms. Centering the sheet provides sufficient coverage for both sides of the mattress.

Where should the nurse roll soiled linens when removing them from an unoccupied bed?

Inside the bottom sheet Rationale: The nurse should snugly roll all the soiled linen inside the bottom sheet and place it directly into the hamper to help prevent the spread of microorganisms. The floor is heavily contaminated, and soiled linens would further contaminate the furniture. Rolling the used lines inside the top sheet is not efficient.

The nurse is preparing to perform oral care for a client who has full dentures. Which actions should the nurse take? Select all that apply.

Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.

The nurse is changing the figure-eight bandage on the client's hand after hand surgery. In addition to the gauze bandage, a small gauze pad is placed in between each finger to prevent what complication?

To pad between fingers so there is no skin to skin contact under the bandage.

The nurse is providing oral care for a client who has suffered head trauma. The client is unresponsive. How will the nurse best position the client?

Side-lying

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take?

Tell the client he can remove them for 20 or 30 minutes during this shift.

The nurse is teaching proper cane use to a client who has had ankle surgery. The client has been cleared to begin bearing weight on the affected leg. What outcome would be unexpected?

The client reports increased strength in the weaker leg Rationale: Increased strength in the weaker leg is not considered a projected outcome for proper cane usage. Rather, the cane is used for balance and support to increase safety and independence

What should the nurse teach the client about climbing stairs with a cane?

The client should advance the stronger leg up the stair first, followed by the cane and weaker leg.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

The client should be allowed to complete as much of the bath as he can.

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

The client should use an electric razor. Rationale: Client who is prescribed anticoagulant therapy is at risk for bleeding; therefore, it would be important to use an electric razor rather than a blade. Before shaving a client, it is important to assess shaving preferences and this information should be shared with the UAP, but these are not as important as preventing bleeding.

A nurse is applying a sling to support a splint on the forearm of a client who has a fractured radius. How should the nurse position the sling and forearm to ensure proper alignment, provide support, and prevent edema?

The forearm should be slightly elevated from the horizontal and the elbow should form a right angle.

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate?

Tying the restraint behind the chair Rationale: The nurse should run the restraint under the arm rests and tie it behind the chair. Tying the restraint out of the client's reach promotes security. Tying the restraint to the side rail or in the front of the chair would allow the client to untie the restraint. Tying the restraint under the chair would not provide the nurse with swift access to the quick-release knot.

A client with a history of diabetes is demonstrating nail care to the nurse. Which action by the client requires teaching by the nurse?

Using a nail clipper to cut the nail straight across

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment?

cognitive function level