Test #5: ch 39,40,43- fundamentals
A nurse is caring for a client who has a prescription for balancing skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?
re-position the client to keep him from staying in the same position in bed
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg in the last two months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis
provide a quiet low stimulus environment
A nurse is caring for a client who is one day post partum and is taking a sitz bath. To determine the clients tolerance of the procedure, which of the following assessments for the nurse perform
pulse rate
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in the diagram indicated that burns surface areas. Using the rule of nines, the nurse should estimate that the client has burned what percentage of body surface area
31.5%
A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements to the nurse identify as an indication that the client understands instructions
I will no longer have a glass of wine before bedtime
A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages to the nurse recommend
Lemon lime soda
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to assess the client
"do you have difficulty staying awake when you're driving"?
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the clients level of strength?
Ask the client to push her feet against the nurse's palms.
A nurse is teaching a client who has a new prescription for alprazolam to treat insomnia. Which of the following instructions should the nurse include
Avoid activities that require alertness such as driving
a nurse is caring for a client who is in her first trimester of pregnancy and ask the client if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate
daily jogging for up to 30 minutes is fine during pregnancy
A nurse is providing discharge teaching for a client who has postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity to the nurse include
do not apply heat to the area of irradiation
A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every two hours. which of the following actions should the nurse take as directed by the plan of care
instruct the client to tighten muscle groups for a short period and then relax
A nurse is teaching a client who has a new diagnosis of acute bursitis in her right shoulder. Which of the following self-care strategies for the nurse recommend
intermittent ice and heat
A nurse is assisting a client during ambulation with a client begins to fall. Which of the following action should the nurse take
lower the clean to the floor
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take
measure from the heel to the popliteal space
A nurse is teaching a group of clients who are in the first trimester about exercise during pregnancy. Which of the following statements to the nurse include in the teaching
moderate exercise improve circulation
A nurse is caring for a client who has clostridium difficile infection. Which of the following cleaning agents for the nurse to use for hand hygiene
nonantimicrobial soap
A nurse in a clinic is caring for an older adult client who reports dry flaky skin on her upper back. Which of the following is an intervention should the nurse complete
pinch up a fold of skin to check for turgor
A nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feelings of survival guilt, and difficulty concentrating. Which of the following diagnoses describe the client symptoms
post traumatic stress syndrome
A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching
press water form a sponge rather than wringing it
A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding
skeletal traction is more appropriate than skin traction for reducing a fracture
(SATA) A nurse is assessing a client who has narcolepsy. Which of the following should the nurse expect
sudden attacks of sleep hallucinations at the onset of sleep
A nurse is caring for a client reports low back pain as a nurse for specific exercise recommendations. Which of the following activities to the nurse suggest
swimming
A nurse is observing a new mother bathing her newborn son for the first time. Which of the following actions to the first intervene
The mother plans to use a cotton tipped swab to clean the nears
A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following actions should the nurse recommend
walking
He nurses instructing a young adult client about healthful sleep habits. Which of the following statements to the nurse identify as an indication that the client needs further
I watch television until I fall asleep at night
A nurse is providing care to a patient who is on strict bed rest following surgery. The nurse assisted patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed
Negligence
A nurse is providing teaching to client who has a skin infection a new prescription for a gentamicin topical cream. Which is the following instructions to the nurse provide
Watch the affected area with soap and water before applying cream
A nurse is caring for a client who has late stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift the client is fun climbing into the bed of another client who becomes upset and frightened. What do the following actions should the nurse
assess the client to the correct room
A nurse is implementing direct nursing care for a group of client in acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity
assigning tasks to an assistive personnel
A nurse is caring for a client who is experiencing a lacerated spleen and has been on bedrest for several days. The nurse ausculates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions
atelectasis
A nurse is an outpatient clinic is assessing a middle adult client as a part of a routine physical examination. The clients BP is 142/88mmhg, his body mass index is 31, and is a current smoker. The nurse should identify that the client has multiple risk factors for which of the following disorders
cardiovascular disease
(SATA) a nurse is providing hygiene care for a client who is immobile. which of the following action should the nurse take
check for personal items when changing the bed linens keep the bathwater temperature between 43.3 Celsius in 46.1 Celsius shave clients hair in the direction of the hair growth
The nurse is teaching a client who has type one diabetes mellitus about exercise. What are the following instructions should the nurse include
do not exercise if ketones are present in your urine
A nurse is caring for a client who has major depressive disorder and was prescribed citalopram two weeks ago with a planned dosage increase one week ago. The nurse reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. What's the following action should the nurse take
explain that antidepressants often take several weeks to be fully effective
A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel while the client is sleeping should prompt the nurse to intervene?
flushes the clients toilet after emptying the urinary catheter drainage bag
A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, inability to concentrate, and inability to complete every day tasks, and a preference to sleep all day. Which of the following intervention should be included in the plan of care?
give the client extra time to communicate needs
A nurse is planning care for an older adult who is at risk for developing pressure ulcers. Which of the following interventions should the nurse used to help maintain the Integrity of the clients skin?
use a transfer device to lift the client up in bed
A charge nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching
use chlorhexidine to wash hands if the client is immunosuppressed
A nurse is preparing to transfer client who has left side weakness from the bed to a chair which of the following action should the nurse plan to take
use of gait belt to stand and pivot the client
A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following introductions to the nurse include?
walk outside in the early mornings
A nurse is talking with a client who is beginning a program of moderate exercise. The client asked the nurse why warm up exercises are necessary. Which of the following responses to the nurse make
warm up exercises reduce the risk of injury
A nurse is creating a plan of care to maintain skin integrity of a client who is experiencing frequent diarrhea due to ulcerative colitis. Which of the following intervention should the nurse include in the plan
wipe perianal area with warm water and apply barrier cream
