A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
1. The top of
... [Show More] the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane. - 3
The client should hold the cane on the stronger side of her body to increase support and maintain alignment.
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions should the nurse take first?
1. Reposition the client.
2. Document the client's IV intake in the medical record.
3. Request a new IV fluid prescription.
4. Check the IV tubing for obstruction. - 4
The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion of the NG tube into the esophagus. - 4
Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L - 4
This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
1."I can place an extension cord across my living room to plug in my television."
2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
3. "I will place my alarm clock on my bedroom dresser across the room."
4. "I will replace the old throw rug in my kitchen with a new one." - 2
Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? SATA
1. Assist the client with a partial bed bath.
2. Measure the client's BP after the nurse administers an antihypertensive medication.
3. Test the client's swallowing ability by providing thickened liquids.
4. Use a communication board to ask what the client wants for lunch.
5. Irrigate the client's indwelling urinary catheter. - 1, 2, 4
Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function.
Measuring a client's BP poses minimal risk to the client and is within the AP's range of function.
Using a communication board poses minimal risk to the client and is within the AP's range of function.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
1. Discuss the risk factors for colon cancer.
2. Focus teaching on what the client will need to do in the future to manage his illness.
3. Provide the client with written information about the phases of loss and grief.
4. Reassure the client that this is an expected response to grief. - 4
During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use?
1. Alginate
2. Gauze
3. Transparent
4. Hydrocolloid - 4
Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure the medication reaches the inner ear?
1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min. - 1
Pressing gently on the tragus of the ear will help the medication get into the inner ear.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
1. Place the client in a side-lying position.
2. Instill 15 mL of irrigation fluid into the catheter with each flush.
3. Subtract the amount of irrigant used from the client's urine output.
4. Perform the irrigation using a 20-mL syringe. - 3
The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.
A nurse is initiating a protective environment for a client who had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
1. Make sure the client's room has at least six air exchanges per hour.
2. Make sure the client wears a mask when outside her room if there is construction in the area.
3. Place the client in a private room with negative-pressure airflow.
4. Wear an N95 respirator when giving the client direct care. - 2
An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
1. Combine client care tasks when caring for multiple clients.
2. Wait until the end of the shift to document client care.
3. Use the planning step of the nursing process to prioritize client care delivery.
4. Allow for interruptions in tasks to discuss client care issues with colleagues. - 3
Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.
A nurse caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
1. Assist the client into a prone position.
2. Place a sleeve over the top of each leg with the opening at the knee.
3. Make sure two fingers can fit under the sleeves.
4. Set the ankle pressure at 65 mm Hg. - 3
The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
1. Insert the suction catheter while the client is swallowing.
2. Apply intermittent suction when withdrawing the catheter.
3. Place the catheter in a location that is clean and dry for later use.
4. Hold the suction catheter with her clean, nondominant hand. - 2
The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain?
1. "Is your pain constant or intermittent?"
2. "What would you rate your pain on a scale of 0 to 10?"
3. "Does the pain radiate?"
4. "Is your pain sharp or dull?" - 4
Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
1. Insert the needle at a 15° angle.
2. Aspirate for blood return prior to administration.
3. Administer the medication into the abdomen.
4. Massage the site following the injection. - 3
The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.
A nurse in a long-term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps
1. Place a name tag on the body
2. Obtain the pronouncement of death from the provider
3. Remove the tubes and indwelling lines
4. Wash the clients body
5. Ask the clients family member if they would like to view the body - 2,3,4,5,1
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
1. Remove the outer cannula cautiously for routine cleaning.
2. Use tracheostomy covers when outdoors.
3. Use sterile technique when performing tracheostomy care at home.
4. Cleanse irritated skin with full-strength hydrogen peroxide. - 2
Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions. Which of the actions should the nurse take?
1. Turn the client every 2 hr.
2. Administer an antiemetic every 6 hr.
3. Hold oral care.
4. Increase the room's temperature. - 1
The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
1. Examine personal values about the issue.
2. Tell the parents that this is a necessary procedure.
3. Inform the parents that the staff does not require their consent.
4. Contact a spiritual support person to explain the importance of the procedure. - 1
Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
1. Administer the medication with the needle at a 45° angle.
2. Administer the medication into the client's nondominant arm.
3. Pull the client's skin laterally or downward prior to administration.
4. Massage the injection site after administration. - 1
The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning?
1. During the admission process
2. As soon as the client's condition is stable
3. During the initial team conference
4. After consulting with the client's family - 1
Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. [Show Less]