The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that
... [Show More] apply.
Wearing gloves when emptying the client's bedpan
Keeping all linens in the room until the implant is removed
Wearing a film (dosimeter) badge when in the client's room
Wearing a lead apron when providing direct care to the client
The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply.
Explain the procedure to the client.
Irrigate the NG tube with saline.
Elevate the head of the bed to 45 degrees.
The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply.
Time the start and stop of the seizure.
Apply oxygen at 2L with nasal cannula.
Turn the client to the side and do not restrain.
Note the distinguishing characteristics of the seizure.
Turn on the suction machine with oral catheter.
The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.
Use a friction-reducing slide sheet.
Use a mechanical lift to move the client.
Keep elbows close and work close to the body.
Obtain assistance of a second caregiver to assist with mechanical aids.
A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?
A bottle of alcohol
A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?
"Let me go over your prescribed medications with you again."
The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.
Homeopathy
Herbal supplements
The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply.
Place the client flat in bed.
Notify the registered nurse of the drainage.
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.
Monitoring the skin around the stoma site for skin irritation
Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube
The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client?
Wrap a light roll of gauze to cover the IV site.
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?
Activate the fire alarm
The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.
Pedal pulses
Capillary refill
Color of the extremity
Temperature of the skin
Presence of numbness
The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?
Alternating air pad
The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?
Reset the degrees of flexion or extension according to comfort.
The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.
Eat a nutritious diet with adequate protein.
Use a pressure relief pad while in a wheelchair.
Check the bottom sheet for wetness and wrinkles.
The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.
Securing the oxygen tubing to the client's bottom sheet
Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible
The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply.
Ask the client about needing to void or move bowels.
Turn on the nightlight in the hospital room and bathroom.
Turn on bed alarm
The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
A platelet count of 40,000 mm3 (40 × 109/L)
Which client is the safest one for a licensed practical nurse (LPN) to care for?
A client recovering from a scheduled cesarean delivery
The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?
Placing the needle and syringe in a puncture-resistant container
A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?
Closes the roller clamp on the IV tubing
The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.
Socialize with the restrained client.
Remove the restraint and perform range of motion activity.
Reapply the restraint after assisting the client to the bathroom.
The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?
There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.
A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.
Avoid activities that involve pulling or pushing.
Do not lift objects weighing more than 5 pounds.
Do not climb stairs until after the follow-up appointment with the surgeon.
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?
A pair of scissors
The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?
"We will be sure not to leave hot liquids unattended."
The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?
It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.
The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.
Testing stools and urine for blood
Using a soft toothbrush for mouth care
The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?
Blotting up the spill with a face cloth or cloth towel
A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?
"You should seek community after-school programs or activities for your children."
The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.
Question the client about feelings of dizziness.
Put the client's shoes on to help the client avoid slipping on the floor during the transfer.
Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?
Place two fingers under the restraint to determine snugness.
A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.
Removing any toy with bright blinking lights
Keeping the sides rails of the child's bed padded
Turning the infant on the side during any seizure
Having oxygen and suction available at the bedside
The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply.
Place a gait belt on the client.
If stretch bands are used, reinforce the correct use.
Observe for any signs/symptoms of dizziness the first time the client gets out of bed.
After the client sits on the side of the bed, remind the client to stand on the unaffected leg.
The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Refer to video. Click on the Question Video button to view a video showing preparation procedures.
Places the client in an upright position
A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?
The client adjusts the setting downward slightly. [Show Less]