Hygiene
a nurse is beginning a complete bed bath for a client. after removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?
a. face
b. feet
c. chest
d. arms
a. face
by the second post-op day, a client has not achieved satisfactory pain relief. based on this evaluation, which of the following actions should the nurse take, according the nursing process?
a. reassess the client to determine the reasons for inadequate pain relief
b. wait to see whether the pain lessens during the next 24 hours
c. change the plan of care to provide different pain relief interventions
d. teach the client about the plan of care for managing the pain
a. reassess the client to determine the reasons for inadequate pain relief.
a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. which of the following actions should the nurse take to decrease the risk of another fall? SAT
a. place the belt restraint on the client when they are sitting on the bedside commode
b. keep the bed in its lowest position with all side rails up
c. make sure the client's call light is within reach
d. provide the client with nonskid footwear
e. complete a fall-risk assessment
c. make sure the client's call light is within reach
d. provide the client with nonskid footwear
e. complete a fall-risk assessment
a nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. which of the following actions should the nurse include in the client's plan of care?
a. schedule rest periods during morning care
b. discontinue morning care for 2 days
c. perform all care as quickly as possible
d. ask a family member to come in to bathe the client
a. schedule rest periods during morning care
a charge nurse is observing a newly licensed nurse care for a client who reports pain. the nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. the prescription reads ever 4 hr PRN for pain. the nurse administered the medication and checked with the client 40 min later, when the client reported improvement. the newly licensed nurse left out which of the following steps of the nursing process?
a. assessment
b. planning
c. intervention
d. evaluation
a. assessment
a nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. which of the following statements by a nurse requires further instruction?
a. i will place the client on their side
b. i will go to the nurses' station for assistance
c. i will note the time that the seizure begins
d. i will prepare to insert an airway
b. i will go to the nurses' station for assistance
a nurse is performing mouth car 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 two finger in the client's mouth to open it
c. brush the client's teeth once per day
d. inject a mouth rinse into the center of the client's mouth
a. turn the client's head to the side
a charge nurse is reviewing the steps of the nursing process with a group of nurses. which of the following data should the charge nurse identifying objective data?
a. respiratory rate is 22/min with even, unlabored respirations
b. the client's partner states, "they said they hurt after walking about 10 minutes."
c. the client's pain rating is 3 on a scale of 0 to 10
d. the client's skin is pink, warm, and dry
e. the assistive personnel reports that the client walked with a limp
a. respiratory rate is 22/min with even, unlabored respirations
d. the client's skin is pink, warm, and dry
e. the assistive personnel reports that the client walked with a limp
a nurse observes smoke coming from under the door of the staff's lounge. which of the following actions is the nurse's priority?
a. extinguish the fire
b. activate the fire alarm
c. move clients who are nearby
d. close all open door on the unit
c. move clients who are nearby
a nurse is preparing to perform denture care for a client. which of the following actions should the nurse plan to take?
a. pull down and out at the back of the upper denture to remove
b. brush the dentures with a toothbrush and denture cleaner
c. rinse the dentures with hot water after cleaning them
d. place the dentures in a clean, dry storage container after cleaning them
b. brush the dentures with a toothbrush and denture cleaner
a charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. which of the following interventions should the nurse include? SATA
a. writing a Rx for morphine
b. inserting NG tube to relieve gastric distention
c. showing the patient how to use progressive muscle relaxation
d. performing a daily bath after the evening meal
e. reposition a client every 2 hr to reduce pressure injury risk
c. showing the patient how to use progressive muscle relaxation
d. performing a daily bath after the evening meal
e. reposition a client every 2 hr to reduce pressure injury risk
a nurse is caring for a client who has a history of falls. which of the following actions if the nurse's priority?
a. complete a fall-risk assessment
b. educate the client and family about fall risks
c. eliminate safety hazards from the client's environment
d. make sure the client uses assistive aids in their possession
a. complete a fall-risk assessment
a nurse is instructing a client who has diabetes mellitus about foot care. which of the following guidelines should the nurse include? SATA
a. inspect the feet daily
b. use moisturizing lotion
c. wash the feet with warm water and let them air dry
d. use OTC products to treat abrasions
e. wear cotton socks
a. inspect the feet daily
b. use moisturizing lotion
e. wear cotton socks
a nurse is discussing the nursing process with a newly licensed nurse. which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning of the nursing process?
a. i will determine the most important client problems that we should address
b. i will review the past medical Hx on the client's record to get more information
c. i will carry out the new Rx from the provider
d. i will ask the client if their nausea has resolved
a. i will determine the most important client problems that we should address
a nurse discovers a small paper fire in a trash can in a client's bathroom. the client has been taken to safety and the alarm has been activated. which of the following actions should the nurse take?
a. open the windows in the client's room to allow smoke to escape
b. obtain a class C fire extinguisher to extinguish the fire
c. remove all electrical equipment from the client's room
d. place wet towels along the base of the door to the client's room
d. place wet towels along the base of the door to the client's room