Download Nursing Care: Prosthetic Eye, Catheter Insertion, Phantom Pain, Hygiene and more Exams Nursing in PDF only on Docsity!
1. The client began wearing hearing aids 5 weeks earlier. Which statement to
the nurse demonstrates that the client is successfully adapting to the hearing
aids?
A. “I need to wear the hearing aids only when I go out in public.” B. “I clean my ears with a cotton-tipped swab before I insert them.” C. “I place the hearing aids in the protective box to store them at night.” D. “I soak the plastic parts of the hearing aids in mild soap and water weekly.” ANSWER: C A. Hearing aids should be worn daily to adjust to their use. Noisy public situations are sometimes difficult for persons with hearing aids. B. Cotton-tipped swabs should not be inserted into the ear canal due to possible injury and infection. C. Hearing aids are expensive and delicate, and they should be stored in a protective container in a dry, safe place. D. Hearing aids should be kept dry except when cleaning the ear mold with mild soap and water.
2. The nurse is inserting a hearing aid in the adult client’s ear. Place an “X” to
indicate where the nurse’s fingers should be placed to facilitate insertion of
the hearing aid.
Placing the fingers on the helix to pull the car up and back straightens the ear canal.
3. The client has dentures, including both upper and lower plates. Which
technique should the nurse use to correctly perform oral hygiene for this
client?
A. Wear sterile gloves to remove the lower plate first and then the upper plate. B. Use a foam swab to pry the upper and lower plates loose before removing these. C. Grasp the upper plate at the front teeth with a piece of gauze and move it prior to removal. D. Leave the dentures in the client’s mouth and use a toothbrush to brush both denture plates. ANSWER: C A. Removing denture plates is a clean procedure, and sterile gloves are not necessary. B. Removing the denture plates with a foam swab to pry the plate could injure the client. C. Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client’s mouth. D. Dentures must be removed to properly clean the client’s mouth and the dentures.
4. The nurse is observing the UAP providing oral hygiene to the client Which
action by the UAP requires follow-up?
A. Replacing the upper denture before the lower denture. B. Placing the unconscious client in a supine position. C. Brushing the tongue with a soft-bristled toothbrush. D. Donning clean gloves prior to performing oral hygiene. ANSWER: B
7. The nurse is observing the UAP prepare a shower for the client who
requires assistance with ambulation and hygiene. Which action(s) by the UAP
indicate understanding of the procedure? Select all that apply.
A. Sets the water temperature at 100° to 105° F (37° to 40° C). B. Locks the door to provide the client with privacy. C. Uses a chair for the client to sit on in the shower. D. Ensures a nonskid surface is in the shower. E. Helps to wash areas the client cannot reach. ANSWER: C , D , E A. Water temperature should range from 110° to 115° F (43° to 46° C); the water temperature is too cool. B. The client who requires assistance should not be left unattended behind a locked door. The UAP will not be able to reach the client. C. This client requires assistance with ambulation and would be at risk for falling if attempting to shower without a shower chair. D. A nonskid surface promotes safety in a wet environment where slips and falls may occur. E. Assisting the client with hygiene in areas that the client cannot reach allows the client to be an active participant according to the client’s ability.
8. The client who has bilateral hand burns reports wearing soft contact lenses
that need to be removed. Which action(s) are important for the nurse to
include in this procedure? Select all that apply.
A. Perform hand hygiene and don gloves. B. Pinch the lens over the pupil and remove. C. Place the lens in a sterile container with normal saline. D. Irrigate the eye with normal saline to loosen the lens. E. Instruct the client to look up when removing the lens. ANSWER: A , C, E A. Hand hygiene reduces introduction of microorganisms into the eye. Donning gloves prevents exposure to blood or body fluids. B. The lens should slide down off the pupil before pinching and removing to prevent corneal abrasion. C. The lens needs to be kept moist. If contact lens solution is unavailable, sterile normal saline is the best option. D. Irrigating the eye could result in loss of the lens or injury to the cornea. E. Instructing the client to look up allows the nurse to slide the lens down off the pupil before removing it.
9. The nurse is inserting a urinary catheter in the client with urinary
retention. During balloon inflation, the client reports pain. What is the nurse’s
best action?
A. Withdraw the sterile water from the balloon and advance the catheter further. B. Continue inflating the balloon as this finding is expected during catheter insertion. C. Remove the catheter and reattempt insertion with a smaller urinary catheter. D. Reposition the catheter by rotating it slightly and continue to inflate the balloon. ANSWER: A A. The catheter tip may be in the urethra rather than the bladder, which causes pain. With- drawing the sterile water and advancing the catheter will allow the catheter to enter the bladder. B. Pain during balloon inflation is an abnormal finding. Continuing to inflate the balloon could damage the urethra. C. The catheter should be removed if an attempt to advance the catheter fails. The size of the catheter does influence pain experienced during balloon inflation when improperly located. D. Repositioning a catheter with a partially inflated balloon could damage the urethra and cause more pain for the client.
10. The client with an indwelling urinary catheter requires discharge
teaching. Which interventions should the nurse include in the teaching plan?
Select all that apply.
A. Plan to change the urinary catheter once a week. B. Cleanse the perineal area daily with soap and water. C. Secure the catheter tubing to the thigh with tape. D. Avoid showering while the catheter is in place. E. Perform hand hygiene before and after catheter care. ANSWER: B , C, E A. For clients with long-term indwelling urinary catheters, monthly catheter changes are recommended unless there is a greater risk for catheter blockage. B. Soap and water is an appropriate perineal cleansing agent; routine use of antimicrobial cleansers is not recommended. C. Securing the catheter to the thigh anchors the catheter and minimizes trauma to the urethra and bladder neck. D. An indwelling catheter does not alter the client’s method of meeting hygiene needs. The client may shower if the client’s condition permits. E. Performing hand hygiene prior to and after catheter reduces the risk of transmission of microorganisms that could cause UTI.
13. The client reports pain in the right leg even though it was amputated.
Which complementary therapy should the nurse use to control the phantom
pain associated with the client’s amputation?
A. A small dose of alprazolam at 8-hour intervals in addition to prescribed oxycodone and acetaminophen q6h pm B. A high-fiber diet and 2000 mL fluid intake in 24 hours while taking hydromorphone at 4- to 6- hour intervals pm C. Progressive relaxation exercises three times daily in addition to use of a transdermal patch of fentanyl D. A local anesthetic as a nerve block in addition to prescribed long-acting oxycodone ANSWER: C A. Combining an antianxiety medication such as alprazolam (Xanax) with an analgesic such as oxycodone and acetaminophen (Percocet) is a conventional medicinal intervention. B. Dietary interventions help control constipation associated with opioids such as hydrornorphone (Dilaudid) and are not a complementary therapy to control phantom limb pain. C. Progressive relaxation therapy, used along with prescribed analgesic medication such as fentanyl (Duragesic) to control phantom pain, is an example of complementary therapy. D. A nerve block with an analgesic such as oxycodone (OxyContin) is using conventional medicinal practice.
14. The client with a new colostomy asks how to deal with gas coming from the
stoma. To respond to the client’s concern, the nurse should ask the client to
take which action? Select all that apply.
A. Describe the dietary intake, including types of foods. B. Include cruciferous vegetables in the diet daily. C. Decrease fluid intake to 1200 mL per 24 hours. D. Prick the colostomy stoma pouch with a pin. E. Limit intake of gas-producing carbonated sodas. F. In the bathroom, open the pouch clamp to release gas. ANSWER: A , E, F A. The nurse can assess for foods and beverages known to produce gas if the usual dietary intake is described by the client. B. Cruciferous vegetables, which include vegetables of the cabbage family, are known to cause gas formation. C. The client needs at least 2000 mL of fluid daily to maintain proper function of the colostomy. D. Pricking the colostomy pouch with a pin leads to constant gas release and an unpleasant odor.
E. Limiting carbonated beverages reduces gas formation in the intestinal tract. F. Gas in the pouch should be released from the pouch in a restroom environment.
15. The postoperative male client has been unable to urinate into the urinal
while lying in bed. Which interventions are appropriate to promote voiding
for this client who is to be discharged home within a few hours? Select all that
apply.
A. Have the client apply an external condom catheter while lying flat in bed B. Assist the client to stand at the bedside to attempt to urinate in a urinal. C. Administer a prescribed analgesic if the client is experiencing pain. D. Turn on running water so it is heard while the client attempts to void. E. Ask the client to imagine being at home and voiding in his own bathroom. ANSWER: B , C, D, E A. Use of an external catheter will not assist the client to void; it may be used for incontinence. B. The nurse should try to assist the client to void by assisting him to the normal position of standing. C. Pain may be interfering with the ability to urinate and should be treated. D. Using the sound of running water stimulates the voiding reflex. E. Guided imagery is a relaxation technique that may help the client to void.
16. The client was treated for constipation 1 month earlier. On a return clinic
visit, which statement would best assist the nurse to evaluate that the client is
no longer constipated?
A. “I drink 2000 milliliters of fluids daily, including drinking 4 ounces of prune juice.” B. “I have had a soft-formed stool without straining every other day for the past 2 weeks.” C. “I needed to give myself only one disposable enema since my appointment last month.” D. “I have a lot of discomfort from hemorrhoids during my daily bowel movements.” ANSWER: B A. The fluid intake, which includes prune juice, shows the client is taking action to prevent constipation, but it does not indicate that the client is not constipated. B. Constipation is having fewer than three bowel movements per week. The client is no longer constipated when having a soft-formed stool without straining every other day. C. A disposable enema is used to stimulate bowel function. Using only one does not indicate that the client is no longer constipated. D. Although the client is having a daily stool, there is insufficient information in this statement to evaluate what the client used to stimulate daily bowel movements or the consistency of the stool.
19. The client uses a walker to ambulate with partial weight-bearing after foot
surgery. What should the nurse observe when this client is using the walker
correctly?
A. Has elbows bent at a 30-degree angle B. Is bent over the front bar of the walker C. While walking, lifts the walker 2 inches D. Has a walker that has four wheels in place ANSWER: A A. When a walker is at the proper height, the client’s elbows will be bent at a 30-degree angle. B. The client should stand erect and not bent over while using the walker. C. The client cannot be ambulating with partial weight-bearing if the client lifts the walker off the floor. D. The client cannot be ambulating with partial weight-bearing if using a walker with four wheels.
20. The nurse learns at shift report that the immobile client has bilateral foot
drop. Which finding during the nurse’s assessment supports the presence of
foot drop?
A. The client’s great toe is dorsiflexed, and the other toes are fanned out. B. The client’s feet are unable to be maintained perpendicular to the legs. C. The client is unable to move the feet into a position of plantar flexion. D. The client is only able to dorsiflex both feet when asked to bend the feet. ANSWER: B A. A positive Babinski’s sign occurs when the great To edorsiflexes and the toes fan out in response to stroking the lateral surface of the foot. B. The client with foot drop is unable to hold the feet up in dorsiflexion or in a perpendicular position to the leg. C. With foot drop, the feet stay in plantar flexion. D. The client with bilateral foot drop is unable to dorsiflex the feet.
21. The immobile client is in a hospital bed at home. Which information
should the home health nurse include when teaching family caregivers how to
safely move and reposition the client?
A. “Before moving the client, raise the bed to waist level. After completing the move, return the bed to the lowest level.” B. “The pillow should be removed from under the client’s head when positioning in a dorsal recumbent position.”
C. “Tighten your abdominal muscles and keep your feet together; use a lift sheet and pull the client up in bed.” D. “When the client is lying on the back, rest the client’s heels on the bed and keep the feet perpendicular to the legs.” ANSWER: A A. The nurse should instruct caregivers about safety measures. By raising the bed to waist level, caregivers put the client near their center of gravity. This improves their stability during the move and lessens the risk for injury. Returning the bed to the lowest position decreases the risk of injury if the client falls out of bed. B. The client in dorsal recumbent position should have a pillow under the head to prevent hyperextension of the neck. C. Family members should assume a broad stance to improve balance when moving the client. D. The heels of the client should be kept off the bed to eliminate pressure on the heels while feet are maintained perpendicular to the legs to avoid foot drop.
22. The hospitalized client is at risk for thromboembolism. Which direction
should the nurse include when teaching this client about wearing
antiembolism hose stockings?
A. “Wearing the hose is unnecessary if ambulating 10 times daily for 5 minutes at a time.” B. “When at home, apply the stockings in the morning before you stand to get out of bed.” C. “The hose can cause pain to underlying skin; request pain medication to help alleviate this.” D. “Cross your legs only while wearing these stockings; otherwise keep the legs uncrossed.” ANSWER: B A. Frequent ambulation prevents thromboembolism but should be in addition to wearing the antiembolism stockings. B. The most appropriate time to apply antiembolism stockings is before getting out of bed. Compression is maximized, thus lessening venous distention and development of edema. C. Pain could indicate impaired circulation. The nurse should assess the stockings for wrinkles and the skin underneath for impaired circulation. D. Crossing the legs impedes circulation and should be avoided with or without the antiembolism stockings.
23. The nurse applies a warm, moist compress to the site where an IV solution
has infiltrated. Which response is correct when the client asks the purpose of
the compress?
_________ lb (Record your answer as a whole number.)
ANSWER: 117
First calculate the client’s height in feet and inches. Since 1 foot equals 12 inches, the client’s height is 5 feet, 5 inches (65/12 = 5 remainder of 5). Apply the formula from the chart: 105 lb for 5 ft height 5 lb X 5 = 25 105 + 25 = 130 lb Since the client has a small body frame size, calculate 10% of 130 lb. 10% = 0. 0.1 x130 =13 lb Subtract the 10% due to small body frame size: 130 — 13 =117 lb.
26. The client residing in a nursing home has bilateral weak handgrips and
visual and hearing deficits. Which interventions should the nurse implement
when the client is eating a meal? Select all that apply.
A. Ask the client’s permission to open containers and cut up meats on the food tray. B. Obtain special easy-to-hold, built-up silverware for the client to use when eating. C. Observe the client, but avoid providing assistance even if the client is frustrated. D. Help feed the client if the client is eating too slowly so food does not get too cold. E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.
ANSWER: A , B, E
A. Asking permission allows the nurse to determine whether opening containers and cutting up meat are activities that the client is unable to perform. This promotes client autonomy and independence in decision making. B. With easy-to-hold, built-up silverware the client can maintain independence with eating. C. The nurse should observe the client and assist with specific obstacles to limit client frustration. D. Feeding the client who is slow at eating will tend to extinguish independent behaviors. E. The client will have greater independence with eating if eyeglasses and hearing aids are in place. The client should also have dentures in place if used.
27. The dietitian prescribes a 24-hour calorie count for the malnourished
hospitalized client. Which action should be taken by the nurse?
A. Ask the client to recall at the end of the day the food and beverages consumed. B. Inform the client how to count the calories in the food and beverages consumed. C. Inform the client that a record will be maintained of food and beverages consumed. D. Ask the client to identify the food groups and foods that are being consumed in each. ANSWER: C A. Having the client recall foods may or may not result in an accurate calorie count. B. When hospitalized, the dietitian (not the client) will determine the number of calories the client consumed in 24 hours. C. In a hospital, a calorie count involves the observation and documentation of the amount of foods eaten by the client from meal trays and snacks provided. D. Identifying the food groups and foods obtained does not accurately describe a calorie count.
28. The hospitalized client is able to stand to use an electronic digital scale for
obtaining the client’s prescribed daily weight. Which nursing interventions
best ensure that the client’s daily weight is accurate? Select all that apply.
A. Ask the client to wear supportive shoes before stepping on the scale B. Ensure that the scale is calibrated and “zeroed” before a weight is obtained C. Weigh the client by moving the sliding indicator until the scale balances D. Weigh the client at different times of the day and then average the weights E. Take the weight as soon as the client wakens in the morning and after voiding ANSWER: B , E A. The client should not wear shoes because this will add to the weight. B. Electronic digital scales should be calibrated and “zeroed” before weighing the client to ensure accuracy.
C. Clients with thromboeytopenia have lower than normal levels of platelets and are at increased risk of bleeding. Measuring the temperature rectally exposes the client to the risk of rectal bleeding. D. Monitoring rectal temperature is often used in clients with hypothermia; the temperature may be too low to be measured orally.
31. The NA tells the nurse that the unit’s small- adult BP cuff cannot be found
and that the client’s arm is too small to use a regular adult-sized cuff. Which
direction should the nurse give to the NA?
A. Document the other vital signs and note that the proper-fitting BP cuff is not available. B. Go to another nursing unit to obtain their small- adult BP cuff, and take the client’s BP. C. Use the regular-sized BP cuff and add 10 to the diastolic and systolic BP readings. D. If the cuff closes around the arm, take the client’s BP using the regular adult cuff. ANSWER: B A. The NA should not omit the BP but should obtain the correct-sized cuff. B. For an accurate reading, the BP must be taken with the correct-sized BP cuff. When one is not available on the unit, one option is to direct the NA to obtain one from another unit. C. Adding numbers to a BP when using an improperly sized cuff will not result in a correct BP measurement. D. A BP cuff that is too large will result in a lower BP reading.
32. Before ambulating the client for the first time, the nurse obtains the
client’s BP with an automatic BP machine. Which actions should the nurse
take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64
bpm?
A. Assess the client for dizziness and feel the temperature of extremities B. Obtain a manual BP cuff and machine and retake the client’s BP C. Elevate the head of the client’s bed and assist the client out of bed D. Review the medical record and determine the client’s normal BP range ANSWER: A A. The nurse should first assess the condition of the client and ascertain if there are physical signs consistent with hypotension. Dizziness is a sign of decreased perfusion to the brain; cool, clammy extremities are a sign of decreased peripheral circulation. B. After assessing the client’s condition, the nurse should recheck the BP to verify the accuracy of the reading. C. The nurse should not elevate the head of the client’s bed; this action would further lower the BP. The nurse should first assess the client before getting the client out of bed.
D. Determining the normal range of BP is indicated after condition assessment and verifying the reading.
33. The nurse is taking the client’s temperature. What should the nurse do to
correctly obtain the temperature with a tympanic thermometer?
A. Ensure that the probe tip seals the ear canal prior to taking a temperature. B. Irrigate the ear canal with sterile saline before obtaining the temperature. C. When inserting the thermometer in the adult ear, pull downward on the pinna. D. Check to be sure that the client does not have any tympanostomy tubes in place. ANSWER: A A. Failing to seal the ear canah will result in an inaccurate temperature reading. B. Irrigating the ear canal is not indicated; earwax does not affect the temperature and results. C. With an adult, the pinna of the ear should be pulled slightly upward to straighten the ear canal. D. The presence of tympanostomy tubes does not affect the accuracy of the temperature reading; for comfort, a tympanic temperature should not be taken for a week after placement of the tubes.
34. The nurse is evaluating the client’s ability to perform active ROM. Which
illustration demonstrates the client’s ability to correctly perform eversion?
B. Covering the baby’s eyes with eye shields will protect the baby’s eyes from the phototherapy light, which could be damaging to the retinas. C. Limiting the number of feedings is incorrect because bilirubin is excreted in the urine and stool, and excretion can be increased with increased feedings. D. A rash can be caused by capillary dilation and is not harmful to the baby. Diseontinuing therapy is not warranted.
36. The nurse is using a hypothermia blanket for the febrile client. Which
findings should prompt the nurse to consider that the client is hypotherrnic?
Select all that apply.
A. Increased urine output B. Increased drowsiness C. Decreased heart rate (HR) D. Decreased blood pressure (BP) E. Increased core body temperature ANSWER: B, C, D A. Urine output is decreased in the hypothennic client as a result of decreased renal perfusion. B. In hypothermia, a low cardiac output affects the CNS, producing drowsiness. C. ln hypothermia, the HR decreases due to the effects on the thermoregulation center in the brain. D. In hypothermia, the BP decreases due to the effects on the thermoregulation center in the brain. A lowering of the BP decreases cardiac workload and cardiac output. E. The core body temperature would be decreased, not increased, with hypothermia.
37. The client is in skeletal traction with 20 lb of traction applied to a right
lower leg fracture. Which intervention should the nurse perform at regular
intervals?
A. Perform pin site care B. Remove the weights C. Reposition the right leg D. Perform passive ROM to the legs ANSWER: A A. Pin site care should be routinely performed per agency policy to reduce the risk of infection. B. With skeletal traction the weights should never be removed except for emergencies. C. The leg in traction needs to stay in proper alignment, so it would not be repositioned. D. The leg in traction needs to stay in proper alignment, so ROM would not be performed on that leg.
38. The experienced nurse observes the student nurse caring for the client
with the wet plaster cast illustrated. Which conclusion by the experienced
nurse is correct?
A. The student should not be touching the plaster cast because it is wet. B. The student should be using a pillow to lift the client’s casted extremity. C. The student is correctly handling a wet plaster cast with the palms. D. The student should be using fingers and not the palms to handle the cast. ANSWER: C A. A plaster cast takes hours to dry and should be repositioned to allow drying of the underside of the cast and to prevent indentations. B. Handling a wet plaster cast only with a pillow will not allow inspection of the underside of the cast. C. The student nurse is observed safely handling the wet plaster cast with the palms of the hands to prevent indentations from the fingers. This technique prevents pressure areas from developing on the skin underneath the cast. D. Using the fingers will cause indentations in the cast that will cause pressure areas.
39. The nurse is caring for the client with a stage III pressure ulcer to the right
heel. Which actions should the nurse plan? Select all that apply.
A. Encourage foods high in vitamin C such as orange juice B. Premedicate with analgesics prior to dressing changes C. Monitor pedal pulses and capillary refill of affected extremity D. Use hydrogen peroxide for cleaning of the ulcer wound E. Turn and reposition the client every 1 to 2 hours F. Elevate the extremity on pillows, keeping the heel off the pillow ANSWER: A. B, C, E, F
