Mobility
A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease who always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client?
A.Back of the skull
B. Elbows
C. Sacrum
D. Heels
C. Sacrum
Pg. 1069 Taylor
The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?
A.fracture pan
B. bedside commode
C. bed pan
D. regular bathroom
B. bedside commode
Chapter 38: Urinary Elimination - Page 1464
To prevent further urinary tract infections in a preschooler, what measures would you teach her mother?
A. Encourage her to be more ambulatory to increase urine output.
B. Teach her to take frequent tub baths to clean her perineal area.
C. Suggest she drink less fluid daily to concentrate urine.
D. Teach her to wipe her perineum front to back after voiding.
D. Teach her to wipe her perineum front to back after voiding.
Chapter 43: Nursing Care of the Child With an Alteration in Urinary Elimination/Genitourinary Disorder - Page 1566
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?
A. nonblanchable redness
B. a shallow open injury
C. visible subcutaneous fat
D.exposed bone with eschar
A. nonblanchable redness
Chapter 33: Skin Integrity and Wound Care - Page 1164
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client?
A.deep vein thrombosis
B. circulatory alterations
C. orthostatic hypotension
D. hypertension
C. Orthostatic Hypotension
Chapter 34: Activity - Page 1254
A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, “My armpits are so sore.” Which information does the nurse provide?
A. “Your armpits will grow accustomed to the weight in a few days.
B. “I hear that a lot from clients.”
C. “Try to bear your weight on your hands, not your armpits.”
D. “Fortunately you will only need to be on crutches for a week or two.”
C. “Try to bear your weight on your hands, not your armpits.”
Chapter 34: Activity - Page 1282
A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition?
A. Anuria
B. Oliguria
C. Polyuria
D. Dysuria
D. Dysuria
- Page 1283 Taylor
The nurse is caring for a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?
A. Using antibacterial soap when bathing clients with MRSA
B. Conducting culture surveys on a regularly scheduled basis
C. Performing hand hygiene before and after contact with every client
D. Using aseptic housekeeping practices for environmental cleaning
C. Performing hand hygiene before and after contact with every client
Chapter 66: Management of Patients with Infectious Diseases - Page 2154
The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?
A.Determine the extent of wound undermining.
B. Measure length, width, and depth of the wound.
C. Massage the healthy tissue surrounding the wound.
D. Document the color, odor, amount, and type of wound drainage.
D. Document the color, odor, amount, and type of wound drainage.
Chapter 33: Skin Integrity and Wound Care - Page 1171
The nurse observes slight bruising on the client's left thigh during a bed bath and palpates a lump on the anterior surface of the thigh. Which will the nurse document on the electronic health record (EHR)?
A. "During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh."
B. "Bed bath completed."
C. "Client has bruising on left thigh from previous fall."
D. "During bed bath, nurse palpated 5-cm lump on client’s left thigh."
A. "During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh."
Chapter 32: Hygiene - Page 1102
The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated?
A. Active range of motion
B. Passive range of motion
C. Active assistive range of motion
D. Limited range of motion
A. Active Range of Motion
Chapter 34: Activity - Page 1274
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?
A. “This will determine what foods you are allergic to that affect digestion and elimination.”
B. “This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer.”
C. “This test detects heme, an iron compound in blood within the stool.”
D. “This test will help determine whether you have an infectious process in the intestines.”
C. “This test detects heme, an iron compound in blood within the stool.”
Chapter 39: Bowel Elimination - Page 1529
The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus (MRSA) infection?
A. airborne
B. droplet
C. contact
D. reverse isolation
C. Contact
Chapter 25: Asepsis and Infection Control - Page 676
A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?
A. Implement a 2-hour repositioning schedule
B. Perform passive range-of-motion exercises
C. Massage skin surfaces daily, especially areas under pressure and bony prominences
D.Frequently orient client to place and situation
A. Implement a 2-hour repositioning schedule Chapter 33: Skin Integrity and Wound Care - Page 1178
A nurse has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the nurse do?
A. Provide total physical hygiene, including perineal care.
B. Provide total physical hygiene, excluding hair care.
C. Provide supplies and orient the client to the bathroom.
D. Provide supplies and assist with hard-to-reach areas.
D. Provide supplies and assist with hard-to-reach areas.
Chapter 32: Hygiene - Page 1098
An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?
A. “Place your head lower than your heart if you begin to feel dizzy.”
B. “Move slowly and sit on the edge of the bed before transferring to the chair.”
C. “Place feet firmly on the floor when rising to maintain balance.”
D. “Drink a glass of water before attempting to stand to promote circulation.”
B. “Move slowly and sit on the edge of the bed before transferring to the chair.”
Chapter 34: Activity - Page 1274
A nurse is preparing a discharge note for an older adult client with constipation. Which suggestion should the nurse write in the client's discharge note for a healthier bowel elimination habit?
A. Prepare meals that are high in fiber.
B. Hold stool for 5 to 10 minutes when you have an urge to defecate.
C. Use laxatives and enemas regularly.
D. Avoid foods high in water content.
A. Prepare meals that are high in fiber.
Chapter 39: Bowel Elimination - Page 1523
An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?
A. Healthcare-associated infection
B. Respiratory infection
C. Droplet infection
D. Sexually transmitted infection
A. Healthcare-associated infection
Chapter 25: Asepsis and Infection Control - Page 676
When measuring the size, depth, and wound tunneling of a patient's stage IV pressure ulcer, what action should the nurse perform first?
A. Perform hand hygiene.
B.Insert a swab into the wound at 90 degrees.
C. Measure the width of the wound with a disposable ruler.
D. Assess the condition of the visible wound bed.
A. Perform hand hygiene.
Page 984 Taylor
The nurse is caring for an older adult client on the medical unit admitted for diagnostic testing. The client is alert and oriented and lives independently. The client was wearing glasses upon admission. Which nursing intervention will be most effective in the prevention of falls for this client?
A. using a gait belt each time the client ambulates
B. ensuring the client's glasses are close by the bed
C. placing a bed alarm on the bed
D. moving the client to a room close to the nurse's station
B. ensuring the client's glasses are close by the bed
Chapter 24: Middle and Older Adulthood - Page 645
The nurse is assisting a client from a bed to a wheelchair. Which nursing action is appropriate?
A. Discourage the client from helping with the transfer.
B. Administer pain medication following the transfer.
C. Grab and hold the client by the arms.
D. Lock the wheelchair prior to moving the client.
D. Lock the wheelchair prior to moving the client
Chapter 34: Activity - Page 1274
Which outcome indicates effective client teaching to prevent constipation?
A. The client verbalizes consumption of low-fiber foods.
B. The client maintains a sedentary lifestyle.
C. The client limits water intake to three glasses per day.
D. The client reports engaging in a regular exercise regimen.
D. The client reports engaging in a regular exercise regimen.
Chapter 41: Management of Patients with Intestinal and Rectal Disorders - Page 1287
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?
A. Vancomycin-resistant enterococci and urinary tract infection
B. Clostridioides difficile and colitis
C. Coronary artery bypass grafting
D. MRSA in the wound
D. MRSA in the wound
Chapter 25: Asepsis and Infection Control - Page 67
Which client is most likely to experience impaired (slow) wound healing?
A. A client with a diagnosis of type 1 diabetes and a history of poor blood sugar control
B. A child whose severe cleft lip and palate have required a series of surgeries over several months
C. A client who takes nebulized bronchodilators several times daily to treat chronic obstructive pulmonary disease
D. A client with persistent hypertension who takes a beta-blocker and a potassium-wasting diuretic daily
A. A client with a diagnosis of type 1 diabetes and a history of poor blood sugar control
Chapter 9: Inflammation, Tissue Repair, and Wound Healing - Page 209
A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?
A. Glasgow scale
B. Braden scale
C. FLACC scale
D. Morse scale
B. Braden scale
Chapter 33: Skin Integrity and Wound Care - Page 1173