Hygiene
The nurse delegates hygiene care for an older adult stroke client. Which intervention would be appropriate for the nursing assistant to accomplish during the bath? A.) Check distal pulses, B.) Provide ROM to extremities, C.) Determine treatment for Stage I pressure ulcer, D.) Change dressing over IV site
What is: B.) Provide ROM to extremities
The nurse is caring for a client with dysphagia and is feeding her pureed chicken when she begins to choke. What is the priority nursing intervention? A.) Suction mouth and throat, B.) Turn client on her side, C.) put oxygen 2 L via nasal cannula, D.) Stop feeding and place client NPO
What is: D.) Stop feeding and place client NPO
When repositioning an immobile client, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A.) local skin infection requiring antibiotics, B.) sensitive skin that requires a special bed linen, C.) stage III pressure ulcer needing a dressing, D.) blanching, hyperemia, indicating the attempt by the body to overcome an ischemic episode
What is: D.) blanching, hyperemia, indicating the attempt by the body to overcome an ischemic episode
A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A.) Macaroni & cheese, B.) One medium apple with skin on, C.) One cup of plain yogurt, D.) Roast chicken & white rice
What is: B.) One medium apple with skin on
When assessing a client's first voided urine of the day, which finding should be reported to the healthcare provider? A.) Pale yellow urine, B.) Slightly cloudy urine, C.) Light pink urine, D.) Dark amber urine
What is: C.) Light pink urine
An 88 year-old client comes to the clinic regularly. During a recent visit the nurse noticed the client lost 10 lb in 6 weeks without being on a special diet. The client tells the nurse he has had trouble chewing his food. Which factors are normal aging changes of older adults? (Select-all-that-apply): A.) Dentures don't always fit properly, B.) Increase in saliva production, C.) Periodontal membrane becomes tighter and painful, D.) Many have lost teeth or have decayed teeth, E.) Teeth are more sensitive to hot/cold
What is: A.) Dentures don't always fit properly & D.) Many have lost teeth or have decayed teeth
A nurse in a senior center is counseling a group of older adults about their nutritional needs. Which of the following information should the nurse include? (Select-all-that-apply): A.) Older adults are more prone to dehydration than younger groups, B.) Older adults need the same amount of vitamins as younger groups do, C.) Many older adults need calcium supplementation, D.) Older adults need more calories than they did when younger, E.) Older adults should consume a diet low in carbs
What is: A.) Older adults are more prone to dehydration than younger groups, B.) Older adults need the same amount of vitamins as younger groups do, C.) Many older adults need calcium supplementation
Which skin-care measures are used to manage a client who is experiencing fecal and/or urinary incontinence? (Select-all-that-apply): A.) frequent position changes, B.) keep buttocks exposed to air at all times, C.) use large absorbent diaper, changing when saturated, D.) use incontinence cleaner, E.) frequent cleaning, applying an ointment, and covering area with thick absorbent towel, F.) Apply moisture barrier ointment
What is: A.) frequent position changes, D.) use incontinence cleaner & F.) Apply moisture barrier ointment
A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select-all-that-apply): A.) Bradycardia, B.) Hypotension, C.) Elevated temperature, D.) Poor skin turgor, E.) Peripheral edema
What is: B.) Hypotension, C.) Elevated temperature, D.) Poor skin turgor,
A nurse is preparing to initiate a bladder retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select-all-that-apply): A.) Restrict the client's fluid intake during the daytime, B.) Have the client record urination times, C.) Gradually increase the urination intervals, D.) Remind the client to hold urine until the next scheduled urination time, E.) Provide a sterile container for urine
What is: B.) Have the client record urination times, C.) Gradually increase the urination intervals & D.) Remind the client to hold urine until the next scheduled urination time
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 the side, B.) Place 2 fingers in the client's mouth to open it, C.) Brush the client's teeth once per day, D.) Inject a mouth rise into the center of the client's mouth
What is: A.) Turn the client's head to the side
A client is receiving both parenteral and enteral nutrition. When would the nurse collaborate with healthcare provider and request to discontinue the parenteral nutrition? A.) When 25% of nutritional needs met by the tube feedings, B.) When bowel sounds return, C.) When central line has been in for 10 days, D.) When 75% of nutritional needs met by tube feedings
What is: D.) When 75% of nutritional needs met by tube feedings
What does the Braden scale evaluate? A.) Skin integrity at bony prominences, including wounds, B.) Risk factors that place client at risk for skin breakdown, C.) Amount of repositioning that a client can tolerate, D.) Factors that place client at risk for poor wound healing
What is: B.) Risk factors that place client at risk for skin breakdown
Which nursing intervention is most important when caring for a client with an ileostomy? A.) Cleanse the stoma with hot water, B.) Insert a deodorant tablet into the stoma bag, C.) Select or cut a pouch with an appropriate size stoma opening, D.) Wear sterile gloves when caring for the stoma
What is: C.) Select or cut a pouch with an appropriate size stoma opening
Which nursing assessment question would best indicate that an incontinent male with a history of prostate enlargement might not be emptying his bladder adequately? A.) Do you leak urine when you cough or sneeze? B.) Do you need help getting to the toilet? C.) Do you dribble urine constantly? D.) Does it burn when you pass your urine?
What is: C.) Do you dribble urine constantly?
The nurse is assigned to care for the following clients. Which is most at risk for developing skin problems and requires thorough bathing & skin care? A.) 44 year-old female who has had removal of a breast lesion and is having her period, B.) 56 year-old male who is homeless and admitted to ED with malnutrition and dehydration, also has IV, C.) 60 year-old female who had a stroke with R-sided paralysis and has an orthopedic brace on left lower extremity, D.) 70 year-old male who has diabetes and dementia and has been incontinent of stool
What is: D.) 70 year-old male who has diabetes and dementia and has been incontinent of stool
Which clients are at high risk for nutritional deficiencies? (Select-all-that-apply): A.) divorced computer programmer who eats precooked food from local restaurant, B.) middle-aged female with celiac disease who doesn't follow gluten diet, C.) 45 year-old client with Type II Diabetes who monitors carb intake and exercises regularly, D.) 25 year-old client with Crohn's who follows strict diet but doesn't take vitamins or iron supplements or E.) 65 year-old client with gallbladder disease whose electrolyte, albumin and protein levels are normal
What is: B.) middle-aged female with celiac disease who doesn't follow gluten diet & D.) 25 year-old client with Crohn's who follows strict diet but doesn't take vitamins or iron supplements
What is the correct sequence of steps when performing wound irrigation to a large wound: 1.) Use slow, continuous pressure to irrigate wound, 2.) Attach 19 gauge angiocatheter to syringe, 3.) Fill syringe with irrigation fluid, 4.) Place waterproof bag near bed, 5.) Position angiocatheter over wound
What is: 4.) Place waterproof bag near bed, 3.) Fill syringe with irrigation fluid, 2.) Attach 19 gauge angiocatheter to syringe, 5.) Position angiocatheter over wound & 1.) Use slow, continuous pressure to irrigate wound
A nurse is taking a health history of a newly-admitted client with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the client or caregiver? A.) Have you eaten more high fiber foods lately? B.) Are your bowel movements soft and formed? C.) Have you experienced frequent, small, liquid stools lately? D.) Have you taken antibiotics recently?
What is: C.) Have you experienced frequent, small, liquid stools lately?
The nursing assistant reports to the nurse that a client's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? A.) Implement the "as-needed" order to irrigate the catheter, B.) Assess the catheter and drainage tubing for obvious occlusion, C.) Notify the healthcare provider immediately, D.) Assess the vital signs and intake & output
What is: B.) Assess the catheter and drainage tubing for obvious occlusion
The student nurse is teaching a family member the importance of foot care for their mother who has diabetes. Which safety precautions are important for the caregiver to know to prevent infection? (Select-all-that-apply): A.) Cut toe nails frequently, B.) Assess skin for redness, abrasions and open areas daily, C.) Soak feet for 10 minutes before nail care, D.) Apply lotion daily to feet, E.) Clean between toes after bathing
What is: B.) Assess skin for redness, abrasions and open areas daily, D.) Apply lotion daily to feet & E.) Clean between toes after bathing
The nurse is inserting a small bore NGT to start enteral feeds. Place the steps of the skill in order: 1.) Place client in high-fowler's position, 2.) Have client flex head toward chest, 3.) Assess client gag reflex, 4.) Measure length of NGT to insert, 5.) Obtain chest x-ray confirming NGT placement, 6.) Check pH of gastric aspirate to verify placement, 7.) Identify client with 2 identifiers
What is: 7.) Identify client with 2 identifiers, 1.) Place client in high-fowler's position, 3.) Assess client gag reflex, 4.) Measure length of NGT to insert, 2.) Have client flex head toward chest, 5.) Obtain chest x-ray confirming NGT placement, 6.) Check pH of gastric aspirate to verify placement
Which of the following are measures to reduce tissue damage from shear? (Select-all-that-apply): A.) Use a transfer device, B.) Have head of bed elevated when transferring, C.) Have head of bed flat when repositioning, D.) Raise head of bed 60 degrees when patient position supine, C.) Have head of bed flat when repositioning
What is: A.) Use a transfer device, C.) Have head of bed flat when repositioning & C.) Have head of bed flat when repositioning
Which instructions do you include when educating a client with chronic constipation? (Select-all-that-apply): A.) Increase fiber and fluids in diet, B.) Use a low volume enema daily, C.) Avoid gluten in the diet, D.) Take laxatives twice per day, E.) Exercise for 30 minutes per day, F.) Schedule time to use the toilet at the same time every day, G.) Take probiotics 5 times per week
What is: A.) Increase fiber and fluids in diet, E.) Exercise for 30 minutes per day, F.) Schedule time to use the toilet at the same time every day
Place the steps for inserting an indwelling urinary catheter in a female client in order: 1.) Insert and advance catheter, 2.) Lubricate catheter, 3.) Inflate catheter balloon, 4.) Cleanse urethral meatus with antiseptic solution, 5.) Drape client with sterile square and fenestrated drape, 6.) When urine appears, advance another 2.5-3 cm, 7.) Prepare sterile field and supplies, 8.) Gently pull catheter until resistance is felt, 9.) Attach drainage tubing
What is: 5.) Drape client with sterile square and fenestrated drape, 7.) Prepare sterile field and supplies, 2.) Lubricate catheter, 4.) Cleanse urethral meatus with antiseptic solution, 1.) Insert and advance catheter, 6.) When urine appears, advance another 2.5-3 cm, 3.) Inflate catheter balloon, 8.) Gently pull catheter until resistance is felt, 9.) Attach drainage tubing