A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? A. Clean hands with an alcohol-based hand rub immediately after removing gloves. B. Remove the cover gown in the client's room after providing care. C. Place the client in a room with negative-pressure airflow D. Wear a mask when administering oral medications to the client. B. Remove the cover gown in the client's room after providing care. (The nurse should initiate contact precautions for clients who have a C. difficile infection. Contact precautions include the removal of the cover gown and other personal protective equipment inside the client's room to prevent the spread of infection). A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? A. "You will need to sign a consent form before we begin the procedure." B. "I will place a gel pad directly above your pubic area before I place the probe." C. "You will need to hold your urine for 1 hour prior to the procedure." D. "You will receive a contrast dye through an IV catheter prior to the scan." B. "I will place a gel pad directly above your pubic area before I place the probe." (The nurse should use a gel pad, which promotes ultrasound transmission and accurate measurement. The correct placement of the ultrasound device is just above the symphysis pubis.) A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? A. Count the client's radial and apical pulses simultaneously with another nurse. B. Calculate the client's pulse for 30 seconds and multiply by 2. C. Assist the client to a side-lying position. D. Auscultate the area of the client's chest over the Erb's point. A. Count the client's radial and apical pulses simultaneously with another nurse. (The nurse should have another nurse count the radial pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates.) A nurse is preparing to obtain a clients vital signs. Which of the following actions should the nurse take when washing their hands? A. Rinse their forearms with running water before applying soap. B. Hold their hands above elbow level while washing and rinsing. C. Generate a lather by rubbing their hands together vigorously for 5 seconds. D. Turn off the faucet with a clean paper towel after drying hands. D. Turn off the faucet with a clean paper towel after drying hands. (If the nurse's hands are wet or the paper towel is wet when they turn off the faucet, they increase the risk of transferring micro-organisms from the faucet back to their hands.) A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A. A piston syringe. B. Barrier ointment. C. Chilled irrigation solution. D. Sterile cotton balls. A. A piston syringe (The nurse should use an irrigation or piston syringe with an angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to flush exudate and debris from the wound. A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions. A. Orthopneic. B. Dorsal recumbent. C. Sims' D. Prone. A. Orthopneic. (The nurse should assist the client into the orthopedic position by having the client sit upright either in bed or in a chair and lean forward. This position allows maximal chest expansion and facilitates breathing). A nurse in reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? A. Use pictures of different food groups to help the client plan a daily menu. B. Ask the client what they already know about meal planning. C. Give the client a brochure with sample menus for all meals. D. Involve the family in the discussion of the client's meal plan.
B. Ask the client what they already know about meal planning. (The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. Then, the nurse can plan education to meet the client's needs). A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter. D. Attach a humidifier to the base of the flow meter. (The nurse should attach a humidifier at the base of the flow meter to moisten the air for the client. This action will prevent dying mucous membranes when the client is receiving oxygen at a rate greater than 4 L/min). A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?" C. "Do you consume pork products?" D. "Do you oppose receiving a blood transfusion if it is needed?" C. "Do you consume pork products?" (Some clients who practice Islam do not consume pork or alcohol). A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? A. Use warm water when bathing the client. B. Place a donut shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position. A. Use warm water when bathing the client. (The nurse should use warm water to bathe the client because hot water can dry and damage the skin). A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A. A client who plans to leave the facility against medical advice. B. A client who informs the nurse that they have made their funeral arrangements. C. A client who tells the nurse that the night shift nurse did not bring their medication. D. A client who has just experienced the death of their child. D. A client who has just experienced the death of their child. (Silence is a therapeutic communication technique to use when a client is grieving. It demonstrates caring and patience and allows the client to speak when they are ready to do so). A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients? (Select all that apply) -Place immunocompromised clients in the same room. -Wash hands after removing gloves. -Use antimicrobial hand gel after refilling a client's water pitcher -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. -Administer a prophylactic dose of antibiotics prior to discharge. -Wash hands after removing gloves. (The nurse should perform hand hygiene after removing gloves to prevent the transmission of micro-organisms from one setting or client to another). -Use antimicrobial hand gel after refilling a client's water pitcher (The nurse should perform hand hygiene after touching a client's supplies to prevent the transmission of micro-organisms). -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. (The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of micro-organisms from one client to another). A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? A. BUN 18 mg/dL. B. A thready pulse. C. Hemoglobin 15 g/dL. D. Prominent neck veins. B. A thready pulse. ( A client who has fluid volume deficit will have thready peripheral pulses). A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? A. Administration of an enema. B. Performance of a paracentesis. C. Insertion of an indwelling urinary catheter. D. Placement of an NG tube. B. Performance of a paracentesis. (The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis). A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? A. Ego integrity vs. despair B. Generativity vs. self-absorption C. Identity vs. role confusion D. Intimacy vs. isolation A. Ego integrity vs. despair (The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. Supporting the client's ego integrity will help the client cope with the challenges of aging). A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A. Art therapy. B. Tai chi. C. Guided imagery. D. Biofeedback. C. Guided imagery. (Guided imagery is a technique that can produce physical changes in the body, such as decreasing pain levels, by concentrating on a visualization of a pleasurable memory). A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? A. "I know that I can change my advance directives if I need to in the future." B. "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney." C. "My family can overrule the decisions made by my health care surrogate." D. "Advance directive from one state are valid in any other state." A. "I know that I can change my advance directives if I need to in the future." (The client can change their advance directives at their discretion). A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." C. "Please don't get me out of bed this morning. It hurts too much." D. "I don't want to take my medicine. It makes me sick to my stomach." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." ( This situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurse and the nurse's responsibility to protect the client from harm during hospitalization). A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? A. Sharing the client's prognosis with a member of the client's family. B. Discussing the client's status with a member of the spiritual support team. C. Collaborating with a nurse from another unit about the client's care. D. Providing client information to another nurse at change of shift. D. Providing client information to another nurse at change of shift. (The nurse can share information with other staff who are caring for the client because it is essential to maintaining continuity of care, and does not violate the client's confidentiality. The nurse should only share information about the client with those directly involved in the client's care).
A nurse and an assistive personnel (AP) are providing postmortem care for a decease client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse? A. Fathering the client's personal belongings. B. Removing the client's dentures. C. Placing absorbent pads under the client's buttocks. D. Closing the client's eyes. B. Removing the client's dentures. (The client's dentures should remain in place in order to give the face a natural appearance). A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching? A. "Your visitors should wear a protective gown." B. "You should receive a pneumonia vaccine every year." C. "You should stand 1 foot away from others when coughing." D. "You should cover your mouth with a tissue when you cough." D. "You should cover your mouth with a tissue when you cough." (Pneumonia is spread by droplets. Covering the mouth with a tissue when coughing is an effective method of containing secretions to avoid spreading the infection). A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? A. "Keep your feet close together." B. "Tighten your stomach muscles." C. "Straighten your knees." D. "Bend at your waist." B. "Tighten your stomach muscles." (The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back). A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider? A. A purple-colored stoma. B. Protrusion of the stoma. C. A small amount of bleeding from the stoma. D. Intestinal gas in the pouch. A. A purple-colored stoma. (The stoma should be reddish-pink and moist. A purple-colored stoma is an indication of poor circulation and the nurse should report this finding to the provider immediately). A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports incisional pain as 7 on a scale of 0-10. B. The client reports increased nausea and chills. C. The client has an oral temperature of 38.5° (101.3° F). D. The client has tenderness and warmth in their calf. D. The client has tenderness and warmth in their calf. (When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report is tenderness and warmth in the client's calf, which can indicate the presence of a thrombus. If it moves from the vein to the heart, brain or lungs, it can cause life-threatening complications). A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? (The audio clip contains a conversation of two nurses, "I heard that a dog attacked Mr. Jones'...") A. Inform the nurses that the neighbor's dog did NOT cause the wound. B. Tell the nurses to change the topic of conversation. C. Complete an incident report upon returning to the unit. D. Report the nurses' conversation to the client's provider. B. Tell the nurses to change the topic of conversation. (The nurse has the responsibility to protect the client's right to confidentiality and should intervene on the client's behalf. A breach of client confidentiality can result in liability for those involved). A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? A. "Stand with your feet together and your arms at your sides." B. "After I place the turning fork, tell me when you no longer hear the sound." C. "I'm going to stroke the lateral side of the bottom of your foot." D. "Touch each fingertip as quickly as possible with your thumb." A. "Stand with your feet together and your arms at your sides." (The Romberg test measures stability with and without the eyes closed. The nurse should instruct the client to stand with their feet together and their arms at their sides). A nurse is contributing to the plan of care for a client who is dying. Which of the following intervention should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) -Keep the family updated about the client's status. -Suggest that family members return home at night to allow the client to rest. -Encourage the family to comb the client's hair. -Tell the client's family what to expect as the client's death nears. - Ask the family to encourage the client to eat. -Keep the family updated about the client's status. (The nurse should keep the family updated about the client's status to assist the family in planning for the near future). -Encourage the family to comb the client's hair. (The nurse should find simple care activities for the family to perform, such as combing the client's hair). -Tell the client's family what to expect as the client's death nears. (Many family members do no know what to expect. The nurse should explain the manifestations of impending death to reduce the family member's anxiety and stress). A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? A. "Perform muscle relaxation before bedtime." B. "Exercise vigorously 1 hour prior to going to bed." C. "Drink a cup of hot chocolate at bedtime." D. "Change the time you go to sleep each day." A. "Perform muscle relaxation before bedtime." (The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep). A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? A. "I will place my baby on her side to sleep." B. "I should avoid giving my baby a pacifier." C. "I will remove all stuffed animals from my baby's crib." D. "I will cover my baby with a light blanket when she is sleeping." C. "I will remove all stuffed animals from my baby's crib." (The nurse should reinforce the need to remove all stuffed animals and toys when the infant is sleeping to reduce the risk for SIDS). A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance) -Place a towel under the client's head with an emesis basin under their chin. -Assess the client's gag reflex. -Cleanse the client's mouth using a toothbrush. -Separate the client's upper and lower teeth with an oral airway device. -Position the client on their side with their head turned to the side. 1- Assess the client's gag reflex. (The nurse should first assess the client's gag reflex to determine risk for aspiration) 2- Position the client on their side with their head turned to the side. (Turning the client on their side allows secretions to drain from the mouth). 3- -Place a towel under the client's head with an emesis basin under their chin.(Using a towel and emesis basin helps protect bed linens). 4- Separate the client's upper and lower teeth with an oral airway device. (An oral airway device allows safe access to the client's mouth). 5- Cleanse the client's mouth using a toothbrush (Finally, the client's mouth can be cleansed with a toothbrush or swabs). A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take? A. Measure the client's gastric residual before each feeding. B. Change the bag and tubing every 24 hours. C. Document intake and output. D. Flush the tubing with 30 mL of water after each feeding. A. Measure the client's gastric residual before each feeding. (When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take). A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? A. Sit beside the client. B. Speak slowly and loudly. C. Dim the lights in the client's room. D. Choose a private room for the interview. D. Choose a private room for the interview. (The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying). A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which the following entities? A. An insurance agency offering a life insurance policy. B. A family member who requests the client's diagnosis. C. A physical therapist who is involved in the client's care. D. An employer completing a pre-employment screening. D. An employer completing a pre-employment screening. (According to HIPPA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care). A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include? A. "This dressing keeps the wound bed dry." B. "This dressing allows the wound bed to breathe." C. "This dressing requires a secondary dressing." D. This dressing requires paper tape to secure." B. "This dressing allows the wound bed to breathe." (A transparent dressing is applied to allow oxygen to pass through the dressing. This is referred to as "breathing" and promotes healing of the wound.) A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure? A. Fluid Overload B. Diarrhea C. Headache D. Difficulty voiding C. Headache (The nurse should identify that a headache can be an adverse effect following a lumbar puncture. To minimize the client's discomfort, the nurse should administer analgesics, other fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider). A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client? A. Four-point B. Three-point C. Two-point D. Swing-through B. Three-point (The nurse should identify that the client needs to be able to bear weight on the unaffected leg; therefore, a three-point gait provides at least two points of support at all times. A nurse assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? A. Heart rate 89/min. B. Pink mucous membranes. C. Pallor with scaly skin. D. Body mass index 23. C. Pallor with scaly skin. (The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of sun-exposed skin in clients who are well-nourished). A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy. A. Eggs. B. Latex. C. Seafood. D. Bee stings. B. Latex. (Nurses use products containing latex, including gloves, tourniquets, and IV tubing to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives or a more serious reaction, such as dyspnea or laryngospasm). A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Clean the perineal area at least once a day. B. Empty the drainage bag when it is three-fourths full. C. Flush the catheter with sterile water daily. D. Disconnect the drainage bag when emptying and measuring urine. A. Clean the perineal area at least once a day. (The nurse should clean the perineal area at least once a day to reduce the risk for infection). A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? A. Complicated grief. B. Maturational loss. C. Disenfranchised grief. D. Actual loss. D. Actual loss. (The nurse should identify that the client's comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear or know an object, another person, or a part of themselves, such as the loss of a body part). A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 ib. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) Answer: 13.6 kg. A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? A. "It must be difficult facing this type of surgery." B. "Other clients who have had this surgery have done just fine." C. "This facility is known for providing excellent care for people who need this type of surgery." D. "I can request a sleeping pill, if you think that will help." A. "It must be difficult facing this type of surgery." A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? A. Client is itching from medication. B. Client states, "I started to itch after taking that medication." C. It appears that the client has a rash from the medication. D. Rash from medication noted. B. Client states, "I started to itch after taking that medication." (The nurse should document information using an objective description, putting the client's exact words in quotation marks). A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take? A.Other information about alternative therapies to the procedure. B. Contact a family member to convince the client to change their mind. C. Tell the client the benefits of the surgery. D. Notify the charge nurse of the client's concerns. D. Notify the charge nurse of the client's concerns. (The nurse should notify the charge nurse of the client's concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure). A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation? A. Completion of an incident report. B. Name of the nurse certifying the client's death. C. Release of personal belongings form. D. One client identifier at the client's time of death. C. Release of personal belongings form. (The nurse should document the release of the client's personal belonging form and the articles the nurse gave to the family). A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation? A. "Complained about having incisional pain." B. "Voided adequate amounts through the shift." C. "Became short of breath when ambulating." D. "Appeared to be sleeping while in bed." C. "Became short of breath when ambulating." (The nurse should include objective and significant information about the client when documenting client data in the electronic health record). A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should be taken first? A. Perform a bladder scan. B. Cleanse the meatus. C. Provide perineal care. D. Lubricate the catheter. A. Perform a bladder scan. (The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations). A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask? A. "What types of foods have you been eating?" B. "Are you using stool softeners or laxatives?" C. "Have you been passing gas?" D. "Have you had small liquid stools?" D. "Have you had small liquid stools?" (Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Therefore, the first question for the nurse to ask is if the client has had any small liquid stools, which can indicate that there is seepage of liquid feces around the impacted mass). A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? A. Lift the staple remover when squeezing the handle. B. Avoid completely closing the handle after squeezing. C. Expect the staples to bend at each outer side of the staple. D. Remove the staple from the skin after both sides are visible. D. Remove the staple from the skin after both sides are visible. (The nurse should remove the staple from the skin after both sides of the staple are visible, which indicates proper dislodgment of the staple and prevents pulling on the skin around the incision, which can cause needless discomfort). A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? A. A client who has pneumonia. B. A client who has measles. C. A client who has pertussis. D. A client who has methicillin-resistant Staphylococcus aureus (MRSA). B. A client who has measles. (The nurse should initiate airborne precautions for a client who has measles). A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Avoid using gestures when communicating with the client. B. Communicate with the client using a translation dictionary. C. Speak loudly when communicating with the client. D. Use printed materials written in the client's language. D. Use printed materials written in the client's language. (The nurse should use printed materials written in the client's language to reinforce teaching for the client and promote understanding). A nurse is assisting with the admission of older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make? A. "I will have the nursing staff check on you frequently during the night." B. "You are right to be afraid. This is a new place for you?" C. "I will give you your prescribed sleeping medication to help you fall asleep." D. "Describe your concerns about sleeping to me." D. "Describe your concerns about sleeping to me." (The statement is open-ended and allows for further communication. This addresses the client's concerns and builds trust). A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide? A. "Encourage meals at least three times daily." B. "Keeping the room warm will help them breathe easier." C. "Help them onto their left side if they are experiencing nausea." D. "Provide mouth care to them at least every 2 hours." D. "Provide mouth care to them at least every 2 hours." (Providing oral car was needed to a client who is near death will help reduce discomfort from dehydration, nausea, and dry mucous membranes). A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? A. Offer the client a straw to drink liquids. B. Place food toward the back of the client's mouth. C. Encourage the client to lie down and rest for 30 min after meals. D. Instruct the client to tilt their head forward while eating. D. Instruct the client to tilt their head forward while eating. (A client who has dysphagia following a stroke should sit upright with their head tilted forward to facilitate swallowing and to prevent aspiration). A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? A. Reduce the intake of calcium-rich foods. B. Use sunscreen with skin protection factor (SPF) of 8. C. Take vitamin D supplements. D. Use a tanning bed 2 hr weekly. C. Take vitamin D supplements. (The human body requires sunlight exposure to synthesize Vitamin D. Therefore, the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D). A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? A. 1+ pitting edema. B. 2+ pitting edema. C. 3+ pitting edema. D. 4+ pitting edema. C. 3+ pitting edema. (The nurse should document 3+ pitting edema when there is a deep indentation of the tissue, which Is about 6mm). A nurse is reinforcing teaching with a client about self-administration of opthalmic drops. Which of the following instructions should the nurse include? A. "You will need to look to the side when you put the drops in your eyes." B. "You should put the drops directly in the center of your eyeball." C. "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." D. "You should avoid pressing on your tear duct after putting the drops in your eye." C. "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." (The nurse should instruct the client to cleanse the eye from the inner to outer cants to prevent contamination of the lacrimal duct). A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan? A. Flex the client's feet using pillows. B. Support the client's feet with foot boots. C. Place a hand roll under the client's heels. D. Remove ankle-foot orthotic devices at bed time. B. Support the client's feet with foot boots. (The nurse should support the feet in dorsiflexion with foot boots to prevent foot drop.) A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? A. Client reports voiding three times during the night. B. Client reports burning and discomfort with urination. C. The client's WBC count is 11,000/mm^3 D. The client's output was 60 mL for the past 3 hr. D. The client's output was 60 mL for the past 3 hr. (When using the urgent vs non urgent approach to client care, the nurse should determine the the priority finding to report to the provider is a urinary output 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function). A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understand of the teaching? A. "I will wait 15 minutes after drinking coffee to measure my blood pressure." B. "I will measure in my blood pressure while my arm is elevated above my heart." C. "I should remove constrictive clothing prior to measuring my blood pressure." D. "I should measure my blood pressure immediately after eating breakfast." C. "I should remove constrictive clothing prior to measuring my blood pressure." (The nurse should instruct the client to remove constrictive clothing prior to measuring their blood pressure because constrictive clothing can cause falsely elevated blood pressure readings). |
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