skills final review

An older adult client with mild hypothermia has been admitted to the health care facility. Which intervention will the nurse use to promote comfort and sleep for the older adult client?

Ensure that the environment is warmer.

An older adult client tells the nurse, "I don't bother exercising because I get too tired very quickly." What is the appropriate nursing response?

"Alternate periods of activity with periods of rest."

An older adult client reports, "Walking for exercise is useless for me because I get too tired." What is the appropriate nursing response?

"Alternate periods of rest and activity so that you don't get overtired."

The nurse is administering medications to a client with neuropathic pain. The client asks why an antidepressant medication is prescribed when the client is not depressed. Which is the best response by the nurse?

"Antidepressants have been shown to be effective in treating and managing neuropathic pain."

The nurse is caring for a client who reports having cloudy, foul-smelling urine. Which assessment question should the nurse ask the client?

"Are you experiencing burning and frequency?"

A client with severe osteoarthritis is having a left hip replacement. Which aspect(s) of care is important for a client following hip replacement surgery? Select all that apply.

-Prevent adduction of the left hip and leg. -Prevent movement of the leg toward or past the midline of the body. -Prevent hip flexion of greater than 90 degrees. -Keep the operative leg in a neutral position with the toes pointing up.

The nurse is caring for a client who has undergone a left mastectomy. Which example of active exercise will the nurse teach? Select all that apply.

-Provide a comb for the client to comb her hair with her left hand. -Instruct the client to squeeze a stress ball with her left hand.

A nurse is preparing a client to undergo mechanical immobilization. For what reasons is mechanical immobilization commonly used? Select all that apply.

-Relieve pain and muscle spasm. -Support and align skeletal injuries. -Maintain a functional position until healing is complete.

The nurse is educating the older adult client and family about home safety. Which teaching will the nurse provide? Select all that apply.

-Remove scatter rugs from floors. -Replace worn rubber handgrips on walker. -Rearrange furniture if necessary to have clear pathways.

A nurse provides community education classes about activity and exercise for older adults. What benefit(s) of exercise and activity will the nurse include? Select all that apply.

-Strength training has been effectively used with older adults and can increase range of motion, strength, and balance. -Exercise regimens such as tai chi are proving beneficial in enhancing muscle strength and endurance for older adults. -After a stroke, exercise is useful for older adults to improve speed, tolerance, and independence in walking. -Exercise helps older adults with diabetes to obtain better control over blood glucose levels.

The nurse is delegating ambulation of a client with generalized weakness to the unlicensed assistive personnel (UAP). Which teaching will the nurse provide? Select all that apply.

-Utilize a gait belt around the client's waist. -When available, use parallel bars for support.

The nurse has delegated ambulation of a client with fatigue to the unlicensed assistive personnel (UAP). Which teaching will the nurse provide to the UAP? Select all that apply.

-Walk slightly behind the client to provide support. -Support the client's arm while ambulating. -Use parallel bars for support if available.

A nurse is providing range-of-motion exercises for an immobilized client. Which action accurately describes a recommended guideline when using this skill? Select all that apply.

-While performing the exercises, begin at the head and move down one side of the body at a time. -Encourage the client to do as many of these exercises by himself as possible. -Lower the side rail and uncover only the limb to be used during the exercise.

The nurse is caring for a group of clients on the acute care unit. Which client(s) will benefit from urinary catheterization? Select all that apply.

-a client in septic shock that is unresponsive -a confused client that requires a sterile urine specimen to be obtained -a client with an enlarged prostate that is unable to void

A 5-year-old is admitted to the ICU after a head trauma from a bike injury. The child is awake but confused, and continues to pull at IV tubing and a catheter. When the provider orders a restraint, what options would be least restrictive? Select all that apply.

-administration of sedation -four side rails up -having a parent stay with the child

A nurse is assisting with a rectal examination. The nurse would most likely place the client in which position? Select all that apply.

-dorsal recumbent -Sims' -knee-chest

A group of nursing students is reviewing normal patterns of urinary elimination and factors that affect it. The students demonstrate an understanding of the information when they identify which of the following as a factor? Select all that apply.

-fluid intake -cognition -body position

A nurse is to perform capillary blood glucose testing with a client. Which materials would the nurse gather to perform this procedure? Select all that apply.

-glucometer -control solution -lancet holder

The nurse is caring for a client who has undergone a mastectomy. Which example(s) of active exercise will the nurse emphasize? Select all that apply.

-having the client comb her hair with the arm on the surgical side -asking the client to squeeze a soft ball -instructing the client to swing a rope attached to a doorknob

The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply.

-situational low self-esteem -risk for infection

Which procedures are commonly done with the client in the Sims' position? Select all that apply.

-vaginal examination -rectal temperature assessment -suppository insertion -enema administration

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50 mmHg. What is the name for this condition?

orthostatic hypotension

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?

orthostatic hypotension

Assessment of the pulse amplitude is accomplished by:

palpating the flow of blood through an artery.

A nurse is cleansing the skin and tissue around the pin site of a client. Which sign confirms the need to obtain a wound culture?

purulent drainage

The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

rapid and deep

The nurse is performing client education with a 58-year-old client who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to help the client control their blood pressure?

reduce sodium intake

Based on recent personality changes, a client is suspected of having a brain tumor and will soon undergo magnetic resonance imaging (MRI). What action should the nurse prioritize when preparing this client for this diagnostic procedure?

removing all metal objects from the client and ensuring the client has no internal metal objects

A nurse walks into a client's room and finds the client complaining of chest pain and having difficulty breathing. The client has bradycardia and hypotension. What should the nurse do next?

report findings to the physician immediately

The community nurse working at a community health fair is assessing a client's vital signs at rest. Which finding requires nursing intervention?

respirations 28 per minute

The nurse suspects that a person has experienced cardiac arrest. The nurse shakes the person and asks in a loud voice, "Are you okay?" The nurse is assessing:

responsiveness.

A client in a health care facility has had a urinary catheter in situ for the past several days. The client's nurse has amended the client's plan of care to reflect the use of the device. What nursing diagnosis is a priority in this aspect of the client's care?

risk for infection

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent?

systolic pressure

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

tachycardia

A pulse deficit is the difference between:

the apical and the radial pulse rates.

Who is the authority on the presence and extent of pain experienced by a client?

the client

For which client should the nurse question an order to be placed in the supine position?

the client with a history of heart failure

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the client's ability to assist

The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure?

the first appearance of faint but distinctive tapping sounds

A nurse is repositioning a client who has physical limitations due to recent back surgery. The nurse should turn the client in bed every:

two hours.

A nurse is caring for a client with low body temperature. Which of these thermometers should be the nurse's first choice to measure the client's body temperature?

tympanic

A nurse is reviewing the results of a polysomnogram for a client who is experiencing difficulty sleeping. When looking at the encephalogram component, which wave characteristic would the nurse identify as indicating rapid eye movement sleep?

waves similar to wake state

A nurse is explaining to a client how a cane is used. What reason would the nurse cite as the most common reason for a cane?

weakness on one side of the body

A 70-year-old woman has experienced a decline in her quality of life because of mobility limitations caused by rheumatoid arthritis (RA). The nurse is aware that the symptoms of RA are primarily caused by joint inflammation. What drug class is particularly effective at treating pain caused by inflammation?

nonsteroidal anti-inflammatory drugs (NSAIDs)

A student is reading the medical record of an assigned client and notes that the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate?

normal body temperature

The nurse is turning a client in bed. Where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed?

opposite the client's center

A client presents to the Emergency Department with a temperature of 100.6F (38.1°C) and BP of 108/60 mmHg. What intervention does the nurse anticipate providing?

oral fluids

What is an average normal temperature in Celsius for a healthy adult?

oral: 37°C

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

orthopnea

The nurse is preparing to turn a client from the supine position into the lateral position. Which instruction will the nurse provide the client when performing this action?

"I am going to help you flex your knee over and cross your arms over your chest."

A client is to be discharged home with an indwelling catheter. The client asks, "How will I be able to move around and carry this bag?" Which statement by the nurse will teach the client about the appropriate use of a leg bag?

"I can show you how to use a leg bag when you are up and walking about."

Which misconception is common in clients in pain?

"I will get addicted to pain medications."

A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education?

"I will have my wife push the PCA button when I'm asleep."

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?

"Move slowly and sit on the edge of the bed before transferring to the chair."

A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?

"Put away the salt shaker and eat low-salt foods."

While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement does the nurse identify as consistent with caregiver role strain?

"Sometimes it seems like I can never get a moment to myself."

A client who had a recent amputation below the knee tells the nurse about feeling as though the toes are cramping in the missing leg. Which statement will the nurse use to educate the client?

"That is called phantom pain and it is not unusual."

A parent calls the nurse and says, "I do not know what is wrong with my infant. The infant cried all night and kept pulling at the ear." Which response by the nurse is appropriate for informing the parent about obtaining care for the infant?

"That may mean that the ear hurts. Bring your infant in to be checked."

After having a cast removed, a client anxiously says, "What happened to my arm? It is so much smaller now!" What is the appropriate nursing response?

"The unexercised muscle normally looks this way after cast removal."

A client has to perform quadriceps setting exercises. The client asks the nurse how the exercises will help. Which response from the nurse would be most accurate?

"These exercises will help your ability to stand and support your body weight."

A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide?

"Try to bear your weight on your hands, not your armpits."

The telehealth nurse is speaking with a parent whose child jumped from a swing set and now reports forearm pain. How will the nurse explain splinting? Select all that apply.

-"Apply the splinting device from the joint above the injured area to the joint below the injured area." -"Secure the splint with duct tape." -"Pad the elbow with soft material under the splint."

A nurse provides home care for an older woman with severe osteoporosis. Which strategy(ies) does the nurse include in the client's care plan to help prevent fractures? Select all that apply.

-Encourage client to take prescribed calcium and vitamin D -Instruct client to take magnesium and eat foods high in iron -Check area rugs have a slip-resistant foundation -Recommend installation of handrails in bathrooms -Instruct client to engage in weight-bearing exercise at least once per day

The nurse is assisting with client transfer. Which guidelines will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.

-Lower the bed to the lowest position allowing the client's soles to contact the floor. -Provide the client with nonskid slippers to put on prior to standing up. -Provide step by step instructions to the client before the transfer begins.

The nurse is discharging a client who has a casted leg. Which teaching will the nurse provide regarding home care? Select all that apply.

-Report worsening of symptoms immediately. -Place an ice bag on the cast over the injury every 20 minutes. -Monitor sensation and circulation every 30 minutes.

A client is recovering from a recent stroke and the care team suspects that the client has been aspirating food, despite the use of a high-texture diet. Aspiration of food and liquids into the lungs is associated with what nursing diagnoses? Select all that apply.

-Risk for Infection -Ineffective Airway Clearance -Impaired Gas Exchange -Ineffective Breathing Pattern

Which of the following are the purposes for collecting specimens? Select all that apply.

-Screen for health problems. -Diagnose health problems. -Direct the plan of care.

The nurse is providing education to a community about creation of a safe exercise program. Which teaching will the nurse include? Select all that apply.

-See a health care provider prior to starting an exercise program. -Build up to 30 minutes or more of moderate-intensity physical activity on most days. -Dress in layers according to temperature. -Wear supportive shoes.

A nurse is educating an older adult client on how to use a walker. Which instructions to the client ensure accurate use of this device? Select all that apply.

-Stand between the back legs of the walker. -Keep arms relaxed at the side. -Line up the top of the walker with the crease on the inside of your wrist.

A client being prepared for a stress test asks the nurse what changes will be seen in the function of the heart. Which explanation(s) will the nurse provide? Select all that apply.

-The heart is working hard because you will be walking progressively faster and at an incline on a treadmill. -Ideally, your heart will be working up to at least 85% of its maximum capacity. -The heart's rate will be reacting to increased activity levels. -The strength and timing of the heart's electrical signals will be reacting to increased workloads.

The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply.

-There is a large pillow under the client's head. -The knee gatch on the bed is engaged. -The client's foot is in the plantar flexion position.

A client is experiencing wheezing and difficulty breathing during an asthma attack and is administered an aerosolized breathing treatment with a short-acting beta-2 agonist (SABA). Which data obtained from the client indicates that the treatment has had the desired effect? Select all that apply.

-client reports the ability to breathe without difficulty -spontaneous coughing occurs -sputum is expectorated -pulse oximetry reading is 97% from a previous 88%

The nurse is obtaining data from an older adult client upon admission to the long-term care facility. Which age-related respiratory change(s) will the nurse identify as placing the client at risk for respiratory illness? Select all that apply.

-difficulty swallowing (dysphagia) due to structural changes -respiratory muscles diminish in strength -cough reflex diminishes -increased rigidity of the chest wall -respiratory cilia are less efficient

The nurse is observing an unlicensed assistive personnel (UAP) transferring a client with left-sided weakness from the bed to the chair. What observations made by the nurse require immediate intervention to prevent injury to the client? Select all that apply.

-instructing the client to hold on to the side rail when standing to move into the chair -standing next to the client when the client is sitting on the side of the bed -standing near the client's head and shoulders before sitting the client up in bed

An older adult is having a diagnostic test at 10:00 am and is to have nothing to eat or drink after midnight the night before. How can the nurse determine that the patient is tolerating the fasting state? Select all that apply.

-mental status -urinary output -blood pressure

The nurse is caring for a client who had an above-the-knee amputation of the right leg 6 months ago. Today, the client reports right foot pain. Which terms will the nurse use to accurately describe the pain when documenting the client's pain status? Select all that apply.

-neuropathic -chronic

The nurse is working with a client with impaired mobility. Which interventions for increasing muscular strength and the ability to bear weight might the nurse employ with this client? Select all that apply.

-performing isometric exercises with the lower limbs -performing isotonic exercises with the upper arms -dangling the legs at the bedside -providing education regading mobility aids.

The nurse is preparing a client to undergo an endoscopy. What is the appropriate nursing responsibility(ies)? Select all that apply.

-preparing the examination room -obtaining equipment and supplies for the procedure -ensuring the client has an identification bracelet present -reporting any incorrect test preparations promptly before the procedure

An older adult client is scheduled to receive passive range-of-motion (ROM) exercises. The family is present to learn how to do the exercises for the client at home. What interventions would the nurse include? Select all that apply.

-provide slow and gentle movements while supporting the extremity -perform the exercise to the point of resistance

The nurse is conducting an assessment of a client who has chronic joint pain and renal insufficiency. In the client record, which adjuvant drug(s) will the nurse expect to find in the client's treatment history? Select all that apply.

-selective serotonin reuptake inhibitor (SSRI) -anticonvulsant -glucosamine as nutritional supplement

A nurse is caring for a client with cancer who has an urostomy. What should the nurse use to maintain the integrity of the peristomal skin? Select all that apply.

-skin barrier products -antibiotic ointments -steroid ointment

What are examples of orthoses? Select all that apply.

-splints -immobilizers -braces

Which are considered vital signs? Select all that apply.

-temperature -pulse -respiratory rate -blood pressure

A client is on the rehabilitation unit after sustaining a spinal cord injury resulting in paraplegia. Which actions would be most appropriate for the nurse to do to ensure safe transfers? Select all that apply.

-using a transfer belt when moving the client to a wheelchair -teaching the client to use the trapeze for transfer and upper body exercise

The nurse is providing step-by-step instructions to a client who has left-sided weakness and is learning how to climb stairs while using axillary crutches. Arrange 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."

A nurse has specific responsibilities before a client undergoes a diagnostic test. Place the sequence of conducting these duties in the correct order, from first to last.

1. Determine whether the client understands the test's purpose and the activities involved. 2. Assist with obtaining the client's consent. 3. Prepare the client. 4. Obtain the equipment and supplies. 5. Ready the examination area.

A nurse is preparing to suction a client. Place the suction procedure in the correct order.

1. Gather equipment. 2. Adjust the suction to 120 to 150 mm Hg with tubing occluded. 3. Provide preoxygenation. 4. Set up a sterile field and apply gloves. 5. Insert the catheter without suction approximately 5 to 6 inches. 6. Withdraw the catheter, applying intermittent suction, and oxygenate the client.

When caring for a client at the health care facility, the nurse has to record the client's daily urinary output. Which would indicate a normal urine volume?

2,000 mL/day

The nurse is caring for four clients. Which client does the nurse anticipate is at highest risk for latex sensitivity?

27-year-old who cannot eat avocados

The nurse is providing education to a client who has been recently diagnosed with type 2 diabetes. The nurse confirms teaching is effective when the client indicates they will check their blood glucose how long before a scheduled meal?

30

A nurse has taken a throat culture from a client. The nurse will refrigerate the specimen if it will take longer than how many minutes to deliver it to the laboratory? Record your answer using a whole number.

60

A client is to undergo a test that requires fasting prior to it. How many hours should the nurse advise the client to withhold food for before the test? Record your answer using a whole number.

8

The normal adult temperature obtained through the oral route ranges from:

97.6°F to 99.6°F (36.4°C to 37.6°C).

A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique?

A nurse applies intermittent heat and cold to a client's leg.

The nurse is caring for a client following major surgery. Which intervention helps to prevent orthostatic hypotension in the postsurgical client?

Administer intravenous fluids per the health care provider's prescription.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

After the initial stream is initiated, collect the sample.

A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?

Apply lotions and take warm baths or soaks.

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen?

Aspirate urine from the collection port.

The nurse is helping a client with musculoskeletal alterations to perform range-of-motion exercises. In what order would the nurse perform the exercises for the client?

Begin with exercises of the head. Move down the body, completing exercises equally on either side of the body.

The nurse is teaching a client about proper use of a glucometer. Which teaching will the nurse provide?

Blood glucose levels are obtained 30 minutes before eating, and before bedtime.

The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?

Blood sugar

A nurse is inserting an indwelling urethral catheter. Which action does the nurse take to prepare the client to cooperate during the insertion of a catheter?

Close the door and curtain and explain the procedure to the client.

Which instructions should the nurse give a client who needs to provide a urine sample for a pregnancy test?

Collect the first morning urine or urine that has been in the bladder for at least 4 hours.

The nurse is caring for a client who was admitted with a suspected streptococcal throat infection. Which action should the nurse take first?

Collect the throat culture.

The nurse is assisting a client out of bed for the first time after several days of bed rest. On standing, the client becomes light-headed. The nurse assists the client back to bed. Later that morning, the nurse attempts to get the client out of bed again. What would the nurse have the client do?

Dangle at the side of the bed for a time.

A postsurgical client and family have differing opinions about the level of pain that the client is experiencing. Which is the best way to educate the client and family about pain and pain relief?

Discuss with the family that the client is the best person to describe its level.

A older adult client admitted for dehydration is being discharged. In which way should the nurse instruct the client to maintain proper hydration?

Drink six to eight 8-oz glasses of fluid (1,500 to 2,000 mL) per day.

A nurse is caring for a middle-age client who looks worried and flares his nostrils when breathing. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client's condition?

Dyspnea

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Encourage fluid intake.

The nurse sees the client stick something inside a cast to scratch whatever itched. What action would be appropriate for the nurse to take?

Encourage the client to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists.

A postsurgical client has been admitted to the unit with an indwelling urinary catheter that was inserted in the operating room and which is scheduled for removal the following morning. How can the nurse best avoid backflow of urine into the client's bladder and subsequent infection?

Ensure that the collection bag is always lower than the client's bladder.

A nurse notes that the volume of the client's urinary elimination is less than 300 ml/day. Which nursing intervention will be appropriate to use with this client?

Evaluating fluid intake

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's

The nurse likes to use humor to help clients deal with pain. What guidelines should the nurse follow when using humor to foster pain relief?

Humor should take into account the client's personality and circumstances.

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.

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP?

Inform the UAP that she should be wearing gloves.

Upon cast assessment of a client with an open tibia fracture, the nurse notices yellowish drainage coming from within the cast. Which nursing intervention is appropriate?

Monitor white blood cell count.

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

A client who had an open hysterectomy 2 days ago is ambulating around the unit four times daily. The health care provider has not yet written a prescription to discontinue the client's urinary catheter. What is the appropriate nursing action?

Request a prescription for catheter discontinuation from the health care provider.

A nurse is walking with a client, who suddenly seems about to faint. What action would the nurse take next?

Slide an arm under the client's axilla and place a foot to the side.

A pregnant client visits a health care facility for her scheduled checkup before her delivery date. The physician needs to check the client's reproductive organs for any kind of irritation or discomfort. The physician asks the nurse to help the client into the lithotomy position. Which statement describes the lithotomy position?

The client should be in a reclining position with the feet in stirrups.

A nurse is educating an older adult client's family on the basics of exercise for the client. What should the nurse include in the teaching?

The client should have plenty of water during exercise.

The nurse is caring for a client who is learning to walk with a cane. When assessing the client's gait, the nurse notes the cane is being used effectively when what is observed?

The handle of the cane is parallel to the client's hip.

When administering an injection to a client with hepatitis C in a health care facility, the nurse sustained a needlestick injury. Which ensuing action would be most important?

The nurse needs to file an incident report after the event occurs.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

The reading will be erroneously high.

A nurse places a client in the position shown in the accompanying photo. What position is the client assuming?

Trendelenburg

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

A client has had an upper endoscopy with conscious sedation and topical anesthesia spray. What should the nurse do to prevent aspiration after the procedure is finished?

Withhold food or fluids for at least 2 hours after the procedure or until return of the gag reflex.

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use?

Wong-Baker FACES® scale

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

Which client would be classified as having chronic pain?

a client with rheumatoid arthritis

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis

Clients demonstrating apnea have what?

a temporary cessation of breathing

The proper use of the principles of body mechanics:

acts to prevent injury to the client and/or nurse.

A middle-age client tells the nurse that the client's neck pain reduced considerably after the client underwent a treatment in which thin needles were inserted into the skin. What kind of pain relief treatment did the client undergo?

acupuncture

Which client would be the most appropriate candidate to move by using a powered stand-assist device?

an alert client after knee-replacement surgery who is being assisted to ambulate

A physician orders a placebo for a client. What is a placebo?

an inactive substance given in place of a drug

What is the term used to describe a pharmaceutical agent that relieves pain?

analgesic

A nurse is checking the functionality of an automated external defibrillator (AED) before attaching it to a client. Which function is done by an AED machine?

analyzes heart rhythms and delivers an electrical shock

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?

apical

When collecting a throat culture, where is the best place the nurse should obtain the specimen from?

around the palatine tonsils

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be:

balanced over the center of gravity.

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

Which factor is not known to cause false blood pressure readings?

being in a warm environment

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

The occupational nurse is assessing an employee's vital signs at rest. Which finding requires nursing intervention?

blood pressure 140/90 mmHg

The nurse is measuring a client for the amount of body tissue that is lean versus fat. How will the nurse document this assessment finding?

body composition

The nurse is measuring the amount of body tissue that is lean versus the amount that is fat. How will the nurse document this assessment finding?

body composition

A client who tore his quadriceps muscle during a soccer match has been prescribed exercise for the quadriceps muscles. How should the client perform quadriceps-setting exercises?

by alternatively tensing and relaxing the muscles

Nurses must understand and practice proper body mechanics and often need to teach clients the use of proper body mechanics for safe walking and movement. The nurse is teaching a client to lift an object by bending at the knees and hips and keeping the back straight. When the client follows this advice, which principle of body mechanics is being followed to maintain balance?

center of gravity

The nurse is developing the plan of care for a client who is recovering from a bronchoscopy. Which action by the nurse would be a priority to prevent aspiration during administration of medication?

checking for a gag reflex

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed?

client restrictions

A client is prescribed oxycodone for pain relief. After teaching the client about the medication and common side effects, the nurse determines that the education was successful when the client identifies which side effect as most common?

constipation

A nurse is caring for a client with chronic back pain. The client attributes the pain to the client's teaching job, which involves long hours of standing in the classroom. Which position can contribute to a good standing posture and relieve the pain?

distributing weight equally between the feet

A man with numerous comorbid health problems has presented to the clinic for a scheduled appointment. The man states that he has been awakening frequently during the night to void. The nurse should inquire about the time of day that the client is taking his prescribed:

diuretic

A client with an infection on the genitalia visits a health care facility. In order to inspect the infection, the nurse assists the client into a reclining position with knees bent. What type of position has the nurse placed the client in for inspection?

dorsal recumbent position

Which condition will lead to an increase in cardiac output?

exercise

An obstetrics nurse is preparing to help a client up from her bed and to the bathroom 3 hours after the woman gave birth. Which action should the nurse perform first?

explain to the client how the nurse will assist her

A nurse is preparing to move a client up in bed. How can the nurse best demonstrate the principles of correct body mechanics?

facing the direction of movement

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

Who is responsible for ensuring that clients have sufficient information to give informed consent?

physicians

A nurse is caring for a client who is having difficulty breathing. Which bed accessory should the nurse use to provide a comfortable position to the client?

pillows

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movement

The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should:

provide the client with an overhead trapeze.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

pull the shoulder blade forward and out from under the client

The occupational nurse is assessing a worker's vital signs at rest. Which finding requires nursing intervention?

pulse rate 120 beats per minute

The nurse is assisting the physician with a paracentesis. The nurse would place the client in which position?

sitting

What organ is the primary site of heat loss in the body?

skin

A client is wearing the device shown in the accompanying photo. What device is the client wearing?

sling

An older adult client has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing diagnosis?

social isolation

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake

Why is it important for the nurse to teach and role model proper body mechanics?

to promote health and prevent illness

The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of:

tolerance.

The nurse is providing client education on crutch-walking. Into which shape should the client place the feet and crutches to provide balance and support?

triangle

An older adult client is planning to move with the son and daughter-in-law into a bigger apartment. The son asks the nurse for some tips to keep the parent safe. Which safety principles should the nurse include in the client teaching?

Put a small nightlight in the hall and stairway.

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

greater than normal urinary volume

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair?

having the client sit on the side of the bed for several minutes before moving to the chair

The nurse moves a client's leg laterally away from the client's body and then crosses it over the other leg. What joint or muscle is the nurse exercising?

hip

The nurse observes slight bruising on the client's left thigh during a bed bath and palpates a lump on the anterior surface of the thigh. Which will the nurse document on the electronic health record (EHR)?

"During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh."

A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a:

hydraulic lift.

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The nurse is teaching a client about ambulatory electrocardiogram. Which client statement requires further nursing teaching? Select all that apply.

-"It is acceptable for me to go through the metal detector at the airport." -"This will help me understand how my heart performs when I swim."

The telehealth nurse has received a call from the caretaker of a client who fell from a ladder. The caretaker reports that the client's right leg and ankle appear deformed, and there is bleeding coming from an open wound. What teaching will the telehealth nurse provide? Select all that apply.

-"Leave high-top boots in place to minimize swelling." -"Cover the wound with a clean towel." -"Keep the client warm and safe until emergency workers arrive."

The nurse is caring for a client whose cast will be removed later in the day. What information will the nurse provide? Select all that apply.

-"The health care provider will remove the cast by cutting it with a cast cutter." -"The cast cutter looks like a circular saw." -"I will stay with you while the cast is removed."

A client is to do quadriceps drills as an isometric exercise after surgery. The nurse provides which information about this exercise? Select all that apply.

-"The muscle you are tightening is the one on the front of the thigh." -"Do not hold your breath while tightening the muscle."

The nurse is preparing the client for a Papanicolaou (Pap) test. The client asks the nurse, "What will this test tell me?" What responses by the nurse are correct? Select all that apply.

-"This test will screen for abnormal cervical cells." -"This test will help determine the status of reproductive hormone activity." -"This test will detect normal or infectious microorganisms in the vagina or uterus."

A client is undergoing a diagnostic test. While the procedure is going on, the nurse notices that the client is becoming emotional. What measures would the nurse employ? Select all that apply.

-Ask if the client is in pain or cold. -Implement comfort measures as needed. -Hold the client's hand. -Report the situation to the examiner.

The client reports taking bisacodyl daily for several weeks and remains constipated. What are appropriate actions of the nurse? Select all that apply.

-Ask the client about abdominal pain. -Auscultate the abdomen for bowel sounds. -Assess the client's diet and fluid intake. -Question the client about the color, consistency, pattern, and shape of stools.

The nurse is caring for an older adult client whose lower legs are casted. Which nursing interventions are appropriate? Select all that apply.

-Assess skin daily for signs of redness or pressure. -Encourage partnering with the physical therapist to promote range of motion. -Work with the occupational therapist to promote independent function with select ADLs.

A nurse is assessing a client's vital signs at a health care facility. The nurse observes that the client is sweating profusely. What area of the brain causes a client to sweat?

hypothalamus

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply.

-Diminished ability of kidneys to concentrate urine may result in nocturia. -Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. -Decreased bladder contractility may lead to urine retention and stasis. -Neuromuscular problems may interfere with voluntary control of urination. -Altered thought processes may cause urinary frequency.

A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern? Select all that apply.

-Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function -Assess cardiovascular function and blood pressure -Ask the client to provide details of the exercise regimen including frequency and type -Evaluate for diabetes mellitus

The nurse is providing discharge teaching to a family member of a client who has recently developed right sided weakness post-stroke. Which information will the nurse provide when educating the family member on how to assist the client to mobilize? Select all that apply.

-Have the client dangle legs on the side of the bed before standing. -Rock the client to standing position based on an agreed signal. -Have the client stand for 1 minute before trying to take steps. -Encourage the client to slowly take small steps.

A nurse is providing care for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position, leaning forward to improve oxygenation. Which assessment(s) provide data of possible impaired tissue integrity? Select all that apply.

-Monitor skin integrity of heels. -Monitor ischial tuberosities for pressure injury. -Evaluate client's awareness of pressure sensation. -Assess for edema.

A client is alert but nonverbal after a motor vehicle accident. Which action(s) will the nurse include in the assessment of pain for this client? Select all that apply.

-Observing for grimacing and other signs of pain -Using the Wong Baker FACES pain rating scale -Checking for loss of function of the extremities -Communicating with the client in writing -Performing vital signs

The middle-aged client asked the nurse about developing an exercise program to help lose weight and improve health. What instructions would the nurse include? Select all that apply.

-Obtain a medical evaluation by the primary care provider first. -Include warm-up and cool-down activities. -Participate in activities that you consider fun.

The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?

immediately assist the client back to bed

A nurse has to assist with obtaining a throat culture. Place the steps of this procedure in the correct sequence from first to last.

1. Loosen the cap on the tube in which the swab is located. Tell the client to open the mouth wide, stick out the tongue, and tilt the head back. 2. Depress the middle of the tongue with a tongue blade in your nondominant hand. 3. Rub and twist the tip of the swab around the tonsil areas and the back of the throat without touching the lips, teeth, or tongue. 4. Remove the swab and discard the tongue blade in a lined receptacle. 5. Spread the secretions on the swab across the glass slide. 6. Replace the swab securely within the tube, taking care not to touch the outside of the container. Crush the packet in the bottom of the tube.

The nurse is repositioning a client from supine to lateral position. The client has a chest tube and urinary catheter inserted. The nurse has checked the time of the last position change from the client record. Place in order the steps the nurse will take when carrying out repositioning this client. Use all options.

1. Request assistance from additional health care providers as needed. 2. Assess the positioning of the chest and urinary catheter tubing. 3. Provide a detailed explanation of the procedure to the client. 4. Provide a detailed explanation of the procedure to the client. 5. Raise the bed to elbow height for the nurse preparing to reposition. 6. Perform hand hygiene using handwashing or sanitizer. 7. With assistance, have the client slide to one side of the bed. 8. Raise the side rails on both sides of the bed. 9. Roll the client toward the side rail of preference.

A nurse is showing a group of clients the correct way to move their body parts during their daily exercise regimen at a health care facility. Which effect occurs when a person adheres to proper body mechanics?

increased muscle effectiveness

A nurse is assisting a client with the device shown in the accompanying image. What device is the client using?

inflatable splint

A nurse is preparing to complete an assessment on a client with a history of heart disease. Which technique will the nurse use to begin the assessment?

inspection

The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding?

jaundice

A nurse assists the client into the position shown in the accompanying image. Which position is the client assuming?

lateral oblique

A nurse is reviewing the trends of a client's vital signs since the client's admission and has noted significant variations in the client's blood pressure readings over the course of each day. Which statement best describes the typical circadian rhythm of blood pressure?

Blood pressure is lowest after midnight and begins to rise in the early morning.

A nurse is assessing the vital signs of a client who is moaning with pain. Which vital sign assessment warrants reporting to the health care provider?

Blood pressure of 165/93 mm Hg

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

Which is the primary source of heat in the body?

metabolism

Which of the following nonpharmacologic pain relief measures has been found to be effective for soothing agitated newborns and comatose clients?

music

A nurse is caring for a client diagnosed with congestive heart failure. Which urinary assessment finding is anticipated?

nocturia

A nurse suggests that an older adult client perform exercises in water. What is a benefit for older adults of performing exercises in water?

It reduces stress on the joints.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Nurses and unit assistants use telephones with handsets.

A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety?

Obtain a shower chair so the client can take a sit-down shower

An individual calls the telehealth nurse and reports that a family member was just found on the floor of an enclosed garage while a car was still running. The family member is unconscious and cherry red in color. What direction will the telehealth nurse provide?

Open garage doors and windows, and call 911.

A nurse is caring for a client who is undergoing thermal therapy for relieving pain. Which nursing intervention should the nurse implement during a thermal application?

Protect the skin with cloth or a towel before applying the hot or cold pack.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

While preparing the room for a bedside procedure, which action would be most appropriate for the nurse to take?

Remove any unnecessary furniture.

In a nursing unit, a physician is about to defibrillate a client. What is an appropriate action when the physician says "clear"?

Step away from the bed.

What is the leading cause of injury-related deaths in adults 65 and older?

falls

Before assessing a client's respiratory rate, the nurse should remind the client to breathe normally.

false

A 50-year-old client comes to the clinic for an annual physical examination. Which test would the nurse expect the client to undergo as a screening test for colorectal cancer?

fecal occult blood test

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

foot drop.

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

increased pulse rate

A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature?

proteins

A nurse has been appointed to oversee safety measures in an assisted living facility that caters to older adults. The nurse should prioritize measures aimed at reducing residents' risks of:

falls.

The nurse is caring for an older adult client in a long-term care facility that is incontinent of urine. The client is very upset about this loss of dignity and expressing anger to the nurse providing care. He states, "Get away from me. I can get to the restroom on my own. You don't know what I need." Which response would be the most therapeutic for the nurse to say?

"It sounds as if you are angry. Let's talk about it"

An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply.

-"Did you experience dizziness prior to the fall?" -"Can you tell what you were doing before you fell?" -"Did you have pain in your hip prior to the fall?" -"Is it possible you may have tripped over a rug or a cord?"

A client is being seen in the clinic due to insomnia that has been increasing in severity and frequency in recent months. What question(s) will the nurse include in an assessment of this client's health concern? Select all that apply.

-"Do you smoke?" -"What medications are you currently taking?" -"What is your routine for preparing for bed?" -"How would you state your mood is lately?"

The nurse is caring for several clients on a telemetry unit. Which client(s) requires the nurse to assess the pulse rate need for 1 full minute? Select all that apply.

-A client with a pulse rate of 38 beats/min. -A client diagnosed with a arrhythmia. -A client with a pulse rate of 130 beats/min.

A client has a nasogastric tube following abdominal surgery. Which intervention(s) does the nurse perform to prevent an alteration in the client's oral health? Select all that apply.

-Apply lubricant to the lips and nostrils -Offer water to rinse the mouth every hour -Encourage the client to swallow saliva naturally -Assist the client to brush teeth at least every 4 hours

The nurse has been notified that a client who has traveled outside the country is being admitted to the hospital. The client has a diagnosis of dengue fever, a viral hemorrhagic fever. What safety measures would the nurse implement prior to admission of the client to protect the other clients on the floor? Select all that apply.

-Assign the client to a private room that has negative-pressure capabilities. -Stock the anteroom with gowns, gloves, and N95 respirators. -Plan to instruct visitors how to place a surgical mask before entering into the client's room.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply.

-Avoid climbing on a chair or table to reach items that are too high. -Use a nightlight. -Remove clutter from walkways. -Keep electrical and telephone cords against the wall and out of walkways. -Consider the use of a raised toilet seat.

Which assessment finding(s) confirms or indicates that the client is experiencing rapid-eye movement (REM) sleep? Select all that apply.

-Blood pressure and pulse rate show wide variations and fluctuate rapidly. -The client is unable to move. -Deep tendon reflexes are depressed. -Muscles are relaxed, but muscle tone is maintained.

The nurse is preparing to measure a child's temperature with a temporal artery thermometer. For which reason(s) would the nurse choose this method of obtaining temperature in this client? Select all that apply.

-Children often cannot keep lips closed tight enough to capture a true reading. -Temporal temperature is close to oral temperature readings. -Research states temporal thermometers are more accurate. -There is a built-in verification of temperature by touching behind the ear.

Which action(s) does the nurse take to care for a client unable to care for dentures? Select all that apply.

-Clean the dentures with a mild commercial cleaning agent -Clean dentures with a soft toothbrush -Store dentures in water in a covered container -Keep dentures in a denture cup while carrying them to the sink -Remove upper dentures by rocking them forward

Which intervention(s) does the nurse use in perineal care for a postoperative uncircumcised client? Select all that apply.

-Clean the penile shaft from the tip downward toward the scrotum -Retract foreskin and wash the glans penis -Cleans the tip of the penis from the urethral meatus outward in a circular motion

During morning care, client who is postoperative day 1 blinks excessively and has dried secretions in the corners of the eyes. Which step(s) does the nurse include in eye care for the client? Select all that apply.

-Cleans from the inside of the eye toward the outside -Cleans the eyes with a washcloth or cotton ball soaked with saline or sterile water -If infection is not suspected, cleans each eye with a different part of the washcloth

Which intervention(s) does the nurse initiate to assist a client in preventing corns on the feet? Select all that apply.

-Client will wear clean, dry socks -Client will inspect feet daily. -Client will wear shoes that have extra padding -Client will wear shoes that are not tight around the toes

The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. Which action(s) will the nurse take to assess the client's use of the CPAP machine? Select all that apply.

-Discuss the client's habit of using the CPAP. -Examine the fit of the mask.

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply.

-Encourage the client to stand up from a sitting position slowly. -Ensure that the client is taking an adequate volume of fluids. -Assist the client in applying compression stockings to lower extremities. -Ask the client to wait 1 hour after meals to engage in physical activity.

An older adult client informs the nurse about having trouble falling asleep and staying asleep recently. Which recommendation(s) can the nurse provide to help alleviate insomnia? Select all that apply.

-Get regular exercise -Create a bedtime routine -Limit daytime napping -Talk about stressful issues -Drink a warm, caffeine-free, drink before bed

The nurse is caring for a client who scored 3 on the Hendrich II Fall Risk Model. Which intervention(s) is appropriate? Select all that apply.

-Implement normal fall prevention measures. -Document the finding in the electronic health record (EHR).

A client is hospitalized with uncontrolled diabetes. Which action(s) does the nurse take to promote circulation and prevent circulatory complications? Select all that apply.

-Inspect the client's feet daily. -Clean the feet daily with warm water and a mild soap. -Cut the toenails straight across and file the edges with an emery board.

The nurse is caring for a client diagnosed with emphysema and COPD. Which nursing intervention would the nurse include in the nursing care plan? Select all that apply.

-Monitor arterial blood gases (ABGs) -Encourage a healthy weight -Administer influenza and pneumococcal vaccines as needed -Check the client's capillary refill

The nurse is examining the client's skin to determine whether the delivery of oxygenated blood is sufficient. Which body area(s) will the nurse assess for color change? Select all that apply.

-Nail beds -Tongue -Lips

The nurse performs a comprehensive assessment of a client admitted today with a diagnosis of diabetes. Which essential information should the nurse obtain during the initial stage of the assessment? Select all that apply.

-Past medical health history -Most recent blood sugar readings -Living arrangements including work environment -Risk factors including family history -History of present illness including vital signs

A client has been diagnosed with peripheral vascular disease of the lower extremities. What will the nurse assess to accurately chart the circulation status in the client's legs? Select all that apply.

-Pitting edema -Pedal pulses -Skin temperature of feet -Capillary refill time

A client with a stroke has left-sided paralysis. Which action(s) does the nurse take to ensure proper positioning and support for this client? Select all that apply.

-Place a small pillow under client's waist -Straighten the left elbow and support it on a pillow -Place the left leg far enough in front of the body to prevent the client rolling onto the back -Bend the left knee and support the left leg on a pillow

The nurse is caring for a client who wears contacts. The client who states, "I sometimes sleep with my contact lenses and go 48 hours before removing them, even though I should take them out and disinfect them nightly." What education about contacts and eye care is most important to teach the client? Select all that apply.

-Secretions, dust, and pollen accumulate under the lenses as they are worn and increase the risk of an eye infection. -A reddened conjunctiva, excess tearing, and burning pain are symptoms of wearing contacts too long. -Contact lenses should be removed nightly and cleaned and disinfected after removal. -Hand hygiene should be performed before and after insertion and removal of contact lenses. -Contact lenses can cause corneal damage if left in place for too long.

The nurse is preparing to conduct a health interview with a client who is hearing impaired. Which considerations will the nurse make for the alteration in the client's hearing? Select all that apply.

-Sit directly in front of the client -Ensure any open windows are closed -Determine if hearing aids are required

A nurse on the night shift notices that a client is grinding the teeth while sleeping. Which information will the nurse teach the client? Select all that apply.

-Teeth grinding is called bruxism. -Teeth grinding can be caused by stress. -You should observe for damage to teeth. -With teeth grinding you should get regular dental care. -You should limit caffeine at night.

A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? Select all that apply.

-Temperature is 101.4° F (38.6 C.). -Heart rate is 130 beats per minute. -Oxygen saturation is 90%. -Pain is 8 on scale of 1 to 10.

A nurse assessing a client's blood pressure is obtaining falsely high readings. What would the nurse identify as contributing to this error? Select all that apply.

-The client was anxious when the reading was taken. -The cuff was deflated too slowly. -The cuff was wrapped unevenly.

The experienced nurse teaching a student to measure an apical pulse includes which critical information? Select all that apply.

-The diaphragm of the stethoscope is placed at the fifth intercostal space at the midclavicular line. -To determine the apical pulse, count the heartbeats for 1 full minute.

The nurse is assessing a client who recently experienced a concussion playing contact sports. When conducting a test of the visual acuity, the nurse is alerted to examine further when which finding(s) is observed? Select all that apply.

-The reactivity of both pupils varies. -Pupils remain the same size throughout the test.

The nurse provides care for a female client having difficulty urinating after a vaginal hysterectomy. Which strategy(ies) does the nurse use to assist the client with urinary elimination? Select all that apply.

-Turn on the water in the bathroom -Pour warm water over the perineum -Place client in sitting position -Provide a sitz bath

The nurse is making the initial assessment of a client following a surgical procedure with sedation. Place in order the nurse's assessment actions. Use all options.

-airway, breathing, and circulation -level of consciousness and orientation -intravenous access and IV fluids -wounds and tubes -items within the client's reach

The nursing is preparing to provide hygiene to a middle-aged male client who practices Christianity. The client told the nurse that he had his bath yesterday and does not need a bath today. What factors may be the reasons the client declined the bath? Select all that apply.

-culture -health status -personal preferences

During the physical assessment of a client, the nurse uses the head-to-toe approach. What are the advantages of this approach? Select all that apply.

-helps prevent overlooking some aspect of data collection -reduces the number of position changes required of the client -takes less time because the nurse doesn't have to constantly move around the client

The nurse obtained the above assessment data for a newly admitted client. The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply.

-history of a fall -fractured leg -administration of oxycodone

A nurse is performing chest compressions for an adult client with complete airway obstruction. At what rate should the nurse deliver the chest compression to adult clients to be effective?

100 times per minute

The nurse is teaching the parents of a teenager about safety. Which teaching will the nurse include?

Be alert for signs of peer pressure.

When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention?

Determine cause

An anxious adult child asks the nurse how to keep an older adult parent safe in the home. The client tells the nurse that the parent lives alone, has chronic illnesses, and also has sensory-perceptual alterations. What is the nurse's first action in forming an intervention plan?

Identify the hazards in the home.

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?

The client may alter the rate of respirations if the client is aware that his breaths are being counted.

A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?

The students will demonstrate proper use of safety equipment while playing sports.

A nurse is providing oral care for a client who has been in a coma for 2 weeks. For what oral hygiene alteration might this client be at risk?

White patches may be present that indicate a fungal infection called thrush.

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:

a dysrhythmia.

The nurse is providing care to a group of clients in an acute care facility. The client most likely to prefer a room that is warm as well as wearing thermal blankets is the client who is:

aged 74 years.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

During a regular dental checkup the client expresses concern to the nurse regarding discoloration of the teeth. Consumption of what food would be the most likely reason for the discoloration of the client's teeth?

coffee

The nurse is preparing to administer medication to a client. Which validation of client information is appropriate?

full name and date of birth

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

gas stove

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

identifies client's full name and date of birth

A nurse is preparing a community lecture about safety considerations for various age groups. For which age group would the nurse especially emphasize the prevention of falls?

older adults

A nurse is caring for a client with subnormal temperature. Which actions should the nurse perform to provide heat to the client's internal organs?

provide warm fluids

A nurse suspects that a client has abdominal ascites and prepares to assess the abdominal girth. How should this assessment be completed?

stretching a tape measure around the largest diameter and making guide marks on the skin

A nurse at a long-term care facility is planning to trim the toenails of many residents, most of whom are unable to do this hygiene task independently. The nurse should consult with a podiatrist before cutting the toenails of a resident:

who has a history of type 1 diabetes.

A nurse has been asked to record a client's body temperature every hour, using a digital thermometer. After recording the temperature, the nurse has to clean the thermometer. Which measure should the nurse follow to clean the thermometer?

wipe with isopropyl alcohol