HURST Fundamentals Complete Test.
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1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered
... [Show More] because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes.
3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client.
4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. - CORRECT ANSWER A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching?
1. Lowers side rails on both sides of bed.
2. Washes eyes with mild soap and water from the inner to outer canthus.
3. Makes certain bath water temperature is between 110-115°F (43-46°C).
4. Uses long, firm strokes to wash from wrist to shoulder of each arm.
5. Performs a back massage after completing the bath.
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1. Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand-mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results. - CORRECT ANSWER An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway?
1. Initiate seizure precautions
2. Monitor for signs of increased intracranial pressure
3. Orient to time, place, and person
4. Obtain vital signs q 15 minutes
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3. CORRECT: The true test of learning is for the client to be able to actually complete a self-care task independently. There is nothing wrong with the client referring to written instructions to complete the task. - CORRECT ANSWER A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement?
1. "My spouse can verbalize all the steps in order."
2. "I have attended all the sessions on ostomy care."
3. "I can do the irrigation if I refer to the instructions."
4. "I don't need to irrigate if the ostomy is making stool."
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