A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take?
A. Turn the client's head to
... [Show More] the side.
B. Place two fingers in the client's mouth to open.
C. Brush the client's teeth once per day.
D. Inject a mouth rinse into the center of the client's mouth.
A. Turn the client's head to the side.
A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.)
A. Inspect the feet daily.
B. Use moisturizing lotion on the feet.
C. Washing the feet with warm water and let them air dry.
D. Use over-the-counter products to treat abrasions.
E. Wear cotton socks.
A. Inspect the feet daily.
B. Use moisturizing lotion on the feet.
E. Wear cotton socks.
A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care?
A. Schedule rest periods during morning care.
B. Discontinue morning care for 2 days.
C. Perform all care as quickly as possible.
D. Ask a family member to come in to bathe the client.
A. Schedule rest periods during morning care.
A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first?
A. Face
B. Feet
C. Chest
D. Arms
A. Face
A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take?
A. Pull down and out at the back of the upper denture to remove.
B. Brush the dentures with a toothbrush and denture cleaner.
C. Rinse the dentures with hot water after cleaning them.
D. Place the dentures in a clean, dry, storage container after cleaning them.
B. Brush the dentures with a toothbrush and denture cleaner.
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)
A. Planning and evaluating control and prevention strategies.
B. Determining public health priorities.
C. Ensuring proper medical treatment.
D. Identifying endemic disease.
E. Monitoring for common-source outbreaks.
A. Planning and evaluating control and prevention strategies.
B. Determining public health priorities.
C. Ensuring proper medical treatment.
E. Monitoring for common-source outbreaks.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions?
A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Herpes zoster
D. Herpes zoster
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
A. Prodromal
B. Incubation
C. Convalescence
D. Illness
D. Illness
A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.)
A. Fever
B. Malasia
C. Edema
D. Pain or tenderness
E. Increase in pulse and respiratory rate
A. Fever
B. Malasia
E. Increase in pulse and respiratory rate
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
A. Place the client in a room that has negative air pressure of that at least six exchanges per hour.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
D. Use sterile gloves when handling soiled linens.
E. Wear a gown when performing care that might result in contamination from secretions.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
E. Wear a gown when performing care that might result in contamination from secretions.
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)
A. Place a belt restraint on the client when he is sitting on the bedside commode.
B. Keep the bed in its lowest position with all side rails up.
C. Make sure that the client's call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.
C. Make sure that the client's call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.
A nurse manager is reviewing with nurses on the unit the care of a client who has had seizure. Which of the following statements by a nurse requires further instruction?
A. "I will place the client on his side."
B. "I will go to the nurses' station for assistance."
C. "I will administer his medications."
D. "I will prepare to insert an airway."
B. "I will go to the nurses' station for assistance."
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurses's priority.
A. Extinguish the fire.
B. Activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors on the unit.
C. Move clients who are nearby.
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority?
A. Complete a fall-risk assessment.
B. Educate the clients and family about fall risks.
C. Eliminate safety hazards from the client's environment.
D. Make sure the client uses assistive aids in his possession.
A. Complete a fall-risk assessment.
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station?
A. A middle adult who is postoperative following a laparoscopic cholecystectomy.
B. A middle adult who requires telemetry for a possible myocardial infarction.
C. A young adult who is postoperative following an open reduction internal fixation of the ankle.
D. An older adult who is postoperative following a below-the-knee amputation.
D. An older adult who is postoperative following a below-the-knee amputation.
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool.
E. A fire extinguisher should be readily available in the home.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the front door.
E. A fire extinguisher should be readily available in the home.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following.
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
A. Hypotension
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions?
A. "I will set my water heater at 130° F."
B. "Once my baby can sit up, he should be sage in the bathtub."
C. "I will place my baby on his stomach to sleep."
D. "Once my infant starts to push up, I will remove the mobile from over the crib."
D. "Once my infant starts to push up, I will remove the mobile from over the crib."
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling?
A. Carbon monoxide has a distinct odor.
B. Water heaters should be inspected every 5 years.
C. The lungs are damaged form carbon monoxide inhalation.
D. Carbon monoxide binds with hemoglobin in the body.
D. Carbon monoxide binds with hemoglobin in the body.
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.)
A. Most food poisoning is caused by a virus.
B. Immunocompromised individuals are at risk for complications form food poisoning.
C. Clients who are at high risk should eat or drink only.
D. Healthy individuals usually recover from the illness in a few weeks.
E. Handling raw and fresh food separately can prevent food poisoning.
B. Immunocompromised individuals are at risk for complications form food poisoning.
C. Clients who are at high risk should eat or drink only.
E. Handling raw and fresh food separately can prevent food poisoning.
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to a client?
A. Decreased subcutaneous fat
B. Muscle atrophy
C. Pressure ulcer
D. Fecal impaction
C. Pressure ulcer
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.)
A. Instruct the client not to perform the Valsalva maneuver.
B. Apply elastic stockings.
C. Review laboratory values for total protein level.
D. Place pillows under the client's knees and lower extremities.
E. Assist the client to change position often.
B. Apply elastic stockings.
E. Assist the client to change position often.
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?
A. Encourage the client to perform antiembolic exercises every 2 hr.
B. Instruct the client to cough and deep breathe every 4 hr.
C. Restrict the client's fluid intake.
D. Reposition the client every 4 hr.
A. Encourage the client to perform antiembolic exercises every 2 hr.
A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following clients statements should indicate to the nurse the client understands the teaching?
A. "This device will keep me form getting sores on my skin."
B. "This thing will keep the blood pumping through my leg."
C. "With this thing on, my leg muscles won't get weak."
D. "This device is going to keep my joints in good shape."
B. "This thing will keep the blood pumping through my leg."
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
C. Place the cane 38 cm (15 in) in front of the feet before advancing.
D. After advancing the cane, move the weaker leg forward.
E. Advance the stronger leg so that it aligns evenly with the cane.
A. Hold the cane on the right side.
B. Keep two points of support on the floor.
D. After advancing the cane, move the weaker leg forward.
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.)
A. Obtain culture specimens before initiating antimicrobials.
B. Restrict the client's oral fluid intake.
C. Encourage the client to rest and limit activity.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.
A. Obtain culture specimens before initiating antimicrobials.
C. Encourage the client to rest and limit activity.
E. Assist the client with oral hygiene frequently. [Show Less]