An elderly client with a fractured left hip is on strict bed rest. Which nursing measure is essential to the client's nursing care?
Gently lift the client when moving in to a desired position
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?
Flush the tube with water.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
Give an around-the-clock schedule for administration of analgesics.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
Loosen the right wrist restraint.
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
What is the most important reason for starting intravenous infusion in the upper extremities rather than the lower extremities. of adults?
A decreased flow rate could result in the formation of a thrombosis.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the clients's usual range. What action is mis most important for the nurse to impl
Reassess the client's blood pressure using a larger cuff.
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
The body's receptors adapt over time as they are exposed to heat.
The nurse is instructing a client with high cholesterol about diet and life style modifications. What comment from the client indicates that the teaching has been effective?
I will limit my intake of beef to 4 ounces per week.
the UAPs working on a chronic neuro unit asks the nurse to help then determine the safest way to transfer an elderly client with left-side weakness from the bed to the chair. What method describes the correct transfer procedure for this client.
Move the chair parallel to the right side of the bed, and stand the client on the right foot.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
Reposition in a Sim's position with the client's weight on the anterior ilium.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
The nurse observes that a male client has removed the covering from a ice pack applied to his knee. What action should the nurse take first?
Observe the appearance of the skin under the ice pack.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH fluid withdrawn from the tube.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of dis=charge, timed-release capsules are not available, wh
8am, 4pm, and midnight.
An obese male client discusses with the nurse his plans to begin a long-term wight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take a stress management classes. After pra
Be sure to have a complete physical examination before beginning your planned exercise program.
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler delivered medication to demonstrate correct use of the inhaler?
During the inhalation.
Which action is most important for the nurse to implement when donning sterile gloves?
Keep gloved hands above the elbows.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus internal feedings through a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?
Fowler's.
A 730-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in the client's teaching plan?
Place a pillow between your knees while lying in bed to prevent hip dislocation.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?
Assist the ambulating client back to the bed.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?
Commend the client for selecting a high biologic value protein.
A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
What vitamin and mineral supplements do ou take?
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?
Encourage additional oral intake of juices and water.
What intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assess for bladder distention.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?
Ensure the accuracy of the blood type match.
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicated to the nurse that this client understands the dietary restrictions?
Skim milk, turkey salad, roll, and vanilla ice cream.
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?
Upper arm circumference.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action s
Notify the healthcare provider of the family's request.
After completing an assessment and determining that a client has a problem, which action should the nurse perform next?
Determine the etiology of the problem.
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at the greatest risk for a malpractice judgment?
The nurse who transferred the client to the chair when the fall occurred.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client...
demonstrates the would care procedure correctly.
When evaluating client's plan of care, that nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?
Note which actions were not implemented.
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
Examining a chest x-ray obtained after the tubing was inserted.
When assessing an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the
Upper torso.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
often follow relocation to new surroundings.
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feeding is
Fowler's.
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
Many complimentary healing practices can be used in conjunction with conventional practices.
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
Nutritional history.
Three days following surgery, a male client observes his colostomy form the first time. He becomes quite upset and tells the nurse that is is much bigger than he expected. What is the best response by the nurse?
Instruct the client that the stoma will become smaller when the initial swelling diminishes.
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this clients's
It is okay if you don't want to talk about your surgery. I will be available when you are ready.
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
The client voluntarily signed the form.
The nurse assigns a UAP to obtain vital sings from a very anxious client. What instructions should the nurse give the UAP?
Report the results of the vital signs to the nurse.
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?
It is important that you continue your medication while learning to meditate.
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?
Localized red rash composed of flat areas, pinpoint to 0.5 cm in size.
The nurse completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?
Front lobe.
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?
is disoriented to plance and time.
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct?
Inquire about the source and type of pain.
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices remain untouched. What explanation is most approp
Hot remedies restroe balance after surgery, which is considered a "cold" condition.
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel about the IV access site. Which action should the nurse take at this ti
Initiate an alternate site for the IV infusion of the medication.
The nurse performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?
Re-oxygenate the client before attempting to suction again.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first.
Reposition the client on her side.
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
Degree of flexion an extension of the client's knee joint.
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
Acknowledge the clients distress and tell her it is all right to cry.
A female client asks the nurse to find someone who can translate into her native language her concerns about treatment. Which action should the nurse take?
Request and document the name of the certified translator.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues coul
Malpractice.
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical recor
Healthcare provider notified of client's refusal to have blood specimens collected for testing.
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the clients findings?
Immediately after the assessments are completed.
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client?
Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met?
Accepts that punishment from God is not related to illness.
During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds?
Use the stethoscope bell over the valvular areas of the anterior chest.
A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration?
Mix each medication individually.
During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?
Closed-ended questions.
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?
Rashes in the axillary, groin, and skin fold regions.
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCI) 20mEq at 83 ml/hour. The client's eight-hour urine output is 400 m., blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilatera
Document in the medical record that these normal findings are expected outcomes.
What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications?
Insert a Huber-point needle into the port.
During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take?
Listen and show interest as the client expresses these feelings.
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment?
Client.
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?
Genetic and familial health disorders.