The nurse is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the
... [Show More] nurse that there is an emergency phone call. Which appropriate action should the nurse take?
1. Finish the bath before answering the phone call.
2. Immediately walk out of the client’s room and answer the phone call.
3. Cover the client, place the call light within reach, and answer the phone call.
4. Leave the client’s door open so the client can be monitored and the nurse can answer the phone call.
The nurse manager is reviewing with the nursing staff the purposes for applying wrist and ankle restraints to a client. The nurse manager determines that further education is necessary when a nursing staff member states that which is an indication for the use of a restraint?
1. Limit movement of a limb.
2. Keep the client in bed at night.
3. Prevent the violent client from injuring self and others.
4. Prevent the client from pulling out intravenous lines and catheters.
The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?
1. A client requiring dressing changes
2. A client requiring frequent ambulation
3. A client on a bowel management program requiring rectal suppositories and a daily enema
4. A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures
The nurse should implement which measures to prevent an electrical shock when using electrical equipment? Select all that apply.
1. Use a two-prong outlet.
2. Check the electrical cord for fraying.
3. Keep the electrical cord away from the sink.
4. Place the excess electrical cord under a small carpet.
5. Grasp the electrical cord when unplugging the equipment.
6. Disconnect the electrical cord from the wall socket when cleaning the equipment.
HEALTH PROMOTION and MAINTENANCE
A female client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states that she will follow which instruction?
1. Cleanse the perineal area with soap and water once a day.
2. Keep the drainage bag lower than the level of the bladder.
3. Limit fluid intake so that the bag will not become full so quickly.
4. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.
The nurse has completed instructions regarding diet and fluid restriction for the client with chronic kidney disease. The nurse determines that the client understands the information presented if the client selected which dessert from the dietary menu?
1. Jell-O
2. Sherbet
3. Ice cream
4. Angel food cake
Psychosocial Integrity
The nurse is caring for a client with newly diagnosed type 1 diabetes mellitus. Which component of a teaching plan is most important initially?
1. Knowledge of the diabetic diet
2. Understanding of the diagnosis
3. Monitoring of blood glucose levels
4. Correct technique for administering insulin
A health care provider prescribes a follow-up home care visit for an older adult client with emphysema. When the home care nurse arrives, the client is smoking. Which statement by the nurse would be therapeutic?
1. “Well, I can see you never got to the stop smoking clinic!”
2. “I’m glad I caught you smoking! Now that your secret is out, let’s decide what you are going to do.”
3. “I notice that you are smoking. Did you explore the stop smoking program at the senior citizens center?”
4. “I wonder if you realize that you are slowly killing yourself. Why prolong the agony? You can just jump off the bridge!”
PHYSIOLOGICAL INTEGRITY
The nurse is developing a care plan for an older client being admitted to a long-term care facility. Which information should the nurse use to plan interventions for this client? Select all that apply.
1. Most older clients are incontinent.
2. Older clients are at risk for dehydration.
3. Depression is a normal part of the aging process.
4. Age-related skin changes require special monitoring.
5. Older clients are at risk for complications of immobility.
6. Confusion and cognitive changes are common
The nurse receives a telephone call from the emergency department and is told that a client in leg traction will be admitted to the nursing unit. The nurse prepares for the arrival of the client and asks the unlicensed assistive personnel to obtain which item that will be essential for helping the client move in bed while in leg traction?
1. A foot board
2. Extra pillows
3. A bed trapeze
4. An electric bed [Show Less]