mobility
you are to get a patient with right sided weakness up in a chair. on what side of the bed will you place the chair?
on the patient's left side
on the patient's weak side
either side because you are assisting the patient
on whichever side the patient prefers
on the patient's left side (good side)
When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rational for the nurse's action?
outer skin layer becomes more resilient
skin becomes less subject to bruising
less frequent bathing may be required
sweat glands become more active
A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?
remove the restraint
place a blanket over the feet
immediately do a complete head to toe neurologic assessment
take the patient's BP, pulse, temp, and RR
remove the restraint
To reduce the risk of aspiration how long should the nurse keep the bed up 30 to 45 degrees after eating?
10 mins
20 mins
30 mins
60 mins
60 minutes
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse’s first priority?
call the rapid response team
start an IV line
administer pain relief meds
ask the patient to rate and describe the pain
ask the pt to rate and describe the pain
a nursing instrustor asks you what may cause orthostatic hypotension. you correctly reply:
low body weight
hyperkalemia
room temp
prolonged bed rest
prolonged bed rest
The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take?
leave the foreskin alone because there is little chance of infection
retract the foreskin for cleansing and allow it to return on its own
leave the foreskin retracted
retract the foreskin and return it to its natural position when done
retract the foreskin and return it to its natural position when done
The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?
pull the alarm, use the fire extinguisher, close doors and windows, remove the pt
1. remove the pt
2. pull the alarm
3. close doors and windows
4. use the fire extinguisher
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
ear, xyphoid process, nose
nose
ear
xyphoid process
The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse’s assessment?
the patient needed a substantial dose of naloxone
the patient needs increasingly higher doses of opioids to control pain
the patient no longer experiences sedation from the usual dose of opioid
the patient asks for pain med close to the time it is due around the clock
the pt needed increasingly higher doses of opioid to control pain
Which of the following instructions provided by the nurse to ancillary staff assigned the responsibility of bathing a patient who has been prescribed elastic stockings is most likely to ensure the continued skin integrity of the patient's legs?
"be sure to tell me if you see any redness, dryness, or cracking on her legs"
"please let me know when the stockings are off so i can look at her legs"
"turning the feet of the stockings inside out will make putting them on easier"
"remember to apply a little powder to her legs before applying the stockings"
"please let me know when the stockings are off so i can look at her legs"
The nurse is providing oral care to an unconscious patient. Which action should the nurse take?
moisten the mouth using lemon-glycerin sponges
hold the patient's mouth open with gloved fingers
suction the oral cavity
use foam swabs to help remove plaque
suction the oral cavity
what is the purpose of a gait belt
to provide support during transfers
An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the client has no teeth and is having difficulty eating. Which diet should the nurse encourage the physician to order for this client?
liquid supplements
mechanical soft
pureed
soft
mechanical soft
The nurse is caring for a patient to ease modifiable factors that contribute to pain. Which areas did the nurse focus on with this patient?
age and gender
anxiety and fear
culture and ethnicity
previous pain experiences and cognitive abilities
anxiety and fear
The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?
do nothing, no harm has occurred
notify the health care provider
complete an incident report
notify the charge nurse
notify the health care provider
A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care?
hygiene care is always routine and expected
during hygiene care, do not take the time to learn about pt needs
it is important to standardize a patient's hygienic practices
no two individuals perform hygiene in the same manner
no two individuals perform hygiene in the same manner
a patient's hendrich ll score is 6. what does this indicate?
no fall risk
low fall risk
moderate fall risk
high fall risk
high fall risk
The nurse evaluates which lab value to assess a patient's potential for wound healing?
potassium
lipids
protein
WBC
protein
The nurse is caring for a group of patients. Which task may the nurse delegate to the nursing assistive personnel (NAP)?
administer a back massage to a patient with pain
assessment of pain for a patient reporting abdominal pain
administer patient-controlled analgesia for postoperative patient
inappropriate medical tests are the most common mistakes
administer a back massage to a patient with pain
Which of the following patients would require repositioning?
"pt who has been sitting in a chair for 10 mins watching tv"
"pt in correct body alignment who has turned 2 hrs ago"
"pt with paraplegia who has been sitting in a chair for 10 mins but states that she is comfortable"
"pt who was repositioned for comfort 30 mins ago after being moved up in bed"
"pt in correct body alignment who has turned 2 hrs ago"
when giving perineal care to a female pt, the nurse should clean:
back to front
front to back
in circular motions
side to side
front to back
a nursing assistant attaches a restraint to a bed rail. what should the nurse do?
document it as proper technique
instruct to attach to bed frame instead
remove the restraint entirely
report to the nursing supervisor
instruct to attach to bed frame instead
A client is on a clear liquid diet. Which of the following should the nurse teach the client to avoid while on this diet?
strawberry gelatin
plain decaffeinated tea
black coffee
pureed soup
chicken broth
pureed soup
A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record?
somatic or visceral?
somatic pain