RN NCLEX TEST BANK Practice Questions: Basic Care and Comfort 2024, Exams of Nursing

Download RN NCLEX TEST BANK Practice Questions: Basic Care and Comfort 2024 and more Exams Nursing in PDF only on Docsity! Basic Care and Comfort 2024 RN NCLEX TEST BANK Practice Questions: Basic Care and Comfort 2024 Of the following positions, which one facilitates maximum air exchange? a. Orthopneic b. Trendelenburg c. High Fowler's d. Lithotomy a. Orthopneic This is sitting in a leaning position, which allows for the most lung expansion. After your patient dies, the patient's family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient's nurse, what is your most appropriate course of action? a. Educate the family about custody of care and stay in the room b. Allow the ceremony and step out of the room c. Inform the family that religious rites are not allowed d. Allow the ceremony but remain as a witness b. Allow the ceremony and step out of the room Most hospitals do not have a policy that prohibits religious rites at the time of death. Remaining in the room shows disrespect and lack of trust a time of grieving. Basic Care and Comfort 2024 A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living (ADL)? a. TENS unit b. High-seat commode c. Recliner d. Abduction pillow b. High-seat commode This keeps the hip higher than the knee. After a high school athlete sustains a fractured femur during a competition, a full leg plaster cast is applied. When the nurse provides discharge instructions to the athlete and their parents six hours later, which statement by the athlete indicates a need for further education? a. I should walk around on my cast as soon as I get home. b. I will prop my cast on two pillows when I lie down. c. I'll put an ice pack over the cast to relieve itching. d. I should call my doctor if my toes turn blue or become numb. a. I should walk around on my cast as soon as I get home. Plaster casts are made up of a bandage and a hard covering, usually plaster of Paris. Client instructions include: 1) Keep the limb raised on a soft surface for as long as possible in the first few days, this will help decrease swelling. 2) Keep the cast dry; if the plaster gets wet, it weakens and is unable to support the bone. 3) Do not put anything into the cast to relieve itching. A hair dryer on cool or an ice pack over the itchy area can help. 4) Immediately report any pain, tingling, or numbness. Basic Care and Comfort 2024 d. It's going to hurt a little, but I know you're a brave girl. c. Tell me if this feels more like a pinch or a bug bite. Children should be prepared for procedures. Educate them, but don't suggest that there will be pain. Allow them to decide if there is discomfort. When cleaning the perineal area around the site of an indwelling catheter, the nurse should a. scrub the tubing toward the urinary meatus b. wipe the catheter away from the urinary meatus c. apply powder after giving perineal care d. vigorously wash the periurethral area b. wipe the catheter away from the urinary meatus The catheter should be wiped away from the meatus, to decrease the risk of introducing pathogens into the urinary tract. The perineum should be washed gently with soap and water. A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the healthcare provider that the stoma has retracted? a. narrowed and flattened b. dry and reddish purple c. concave and bowl shaped d. pinkish red and moist c. concave and bowl shaped A healthy stoma will protrude about 2.5 cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, Basic Care and Comfort 2024 or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for. A patient receiving chemotherapy is experiencing stomatitis. Which of the following should the healthcare provider offer the patient? a. warm saline rinses four times each day b. vigorous oral care with a commercial mouthwash c. plenty of ice chips between meals d. hot soup for lunch and dinner a. warm saline rinses four times each day Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and quality of life. Warm saline rinses are non-irritating and help eliminate bacteria that can cause infection. After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system? a. compress the bulb and close the valve b. fill the bulb with sterile saline solution c. place the bulb lower than the client's body d. open the valve and fill the bulb with air a. compress the bulb and close the valve A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain. Basic Care and Comfort 2024 During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse's PRIORITY? a. advise the family to increase the client's fluid and fiber intake b. teach family members to perform the disimpaction process c. give an analgesic or sedative to make the client comfortable d. recall that cardiac dysrhythmias are a possibility d. recall that cardiac dysrhythmias are a possibility Cardiac dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation. The nurse is providing postmortem care for a client who was being treated for Staphylococcus aureus. Which transmission-based precautions are indicated? a. droplet precautions b. contact precautions c. airborne precautions d. standard precautions b. contact precautions MRSA is transmitted by contact, and MRSA bacteria remain alive for up to 3 days after the host dies. The purpose of a splint is to a. immobilize and allow for tissue swelling b. wrap around an injury for full protection c. manage complex or unstable fractures Basic Care and Comfort 2024 not critically ill. A 24-gauge is used for pediatrics and adults who cannot tolerate a larger gauge. A 16- gauge IV is mostly used in ICUs and surgery units because most fluids and blood products can be quickly administered. A 26-gauge needle is used for injections. A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the healthcare provider should expect to hear which breath sounds? a. rhonchi b. crackles c. stridor d. wheezes b. crackles Crackles would most likely be heard because they indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airway. Stridor is an emergency lung sound that is seen in airway constriction and can lead to complete closure. Rhonchi are heard in mixed- issue airway constriction and secretions. Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate? a. hold the feeding bolus for two hours b. flush the tubing with warm water c. request a different enteral formula d. administer the bolus as prescribed d. administer the bolus as prescribed Standard practice includes measuring gastric residual volume prior to administering an enteral feeding. Enteral feedings can be administered with a residual up to 500 mL. Basic Care and Comfort 2024 Which meal best promotes healing for a patient recovering from a burn injury? a. pasta marinara, garlic bread, ginger ale b. peanut butter and jelly sandwich, banana, tea c. chicken breast, strawberries, milk d. pork chop, fried potatoes, coffee c. chicken breast, strawberries, milk The meal with the best nutrition for wound-healing includes protein and vitamin C. A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer? a. Stage III b. Stage II c. Stage I d. Stage IV b. Stage II Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed. Stage III pressure ulcers have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons. Contraindications for administering an enema include all of the following EXCEPT Basic Care and Comfort 2024 a. suspected appendicitis b. hypercalcemia treatment c. recent colon surgery d. acute MI b. hypercalcemia treatment An enema may be used to administer sodium polystyrene sulfonate (Kayexalate) for the treatment of hyperkalemia. Kayexalate can be administered either orally or as an enema. Sodium polystyrene sulfonate is not absorbed from the gastrointestinal tract. As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging them for sodium ions. The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site? a. RUQ b. LUQ c. RLQ d. LLQ c. RLQ A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe chronic constipation. The nurse teaching a 14-year-old client about her cervico-thoracolumbosacral orthosis (CTLSO) brace. Which statement by the client would indicate a lack of understanding about the brace? a. I can take it off in hot weather. Basic Care and Comfort 2024 d. semi-formed to formed The stool of a descending or sigmoid colostomy is semi-formed to formed, because much of the water has already been absorbed. The stool is firmer than that of a transverse colostomy and does not contain caustic enzymes. A client with diabetes insipidus has urine output described as polyuria Polyuria is a primary symptom of diabetes insipidus, with urine output more than 3 L/day. These clients have decreased or absent vasopressin secretion, which causes water loss in the urine and increased serum sodium. Anuria is the absence of urine output. Oliguria is urine output of less than 500 mL/day. Dysuria is difficult or painful urination. The nurse does an admit for a client with a diagnosis of pleural effusion. When doing a respiratory assessment of this client, the nurse will determine if the client has a. increased bronchial breath sounds on the affected side b. a decreased respiratory rate and use of accessory muscles c. increased percussion sounds at the area of effusion d. decreased chest expansion on the affected side d. decreased chest expansion on the affected side A pleural effusion is a collection of fluid between the pleural layers of the lung. The fluid prevents chest expansion on the affected side. Respiratory rate increases and use of accessory muscles can be observed. Breath sounds are decreased because ventilation on the affected side is also decreased. Resonance is dull and flat to percussion. Basic Care and Comfort 2024 A client with a diagnosis of congestive heart failure (CHF) is placed on strict intake and output (I&O). The unlicensed assistive personnel (UAP) records the client's intake at lunch as 8 oz. of black coffee, 6 oz. of orange juice, 4 oz. of lime jello, and 4 oz. of vanilla pudding. What is the client's intake? a. 240 mL b. 420 mL c. 660 mL d. 540 mL d. 540 mL Intake is considered any food that is liquid at room temperature. The client's intake is 8+6+4=18 fluid ounces. 1 fluid ounce = 30 mL, so 18 ounces = 540 mL. Pudding is not included, because it is not a liquid at room temperature. Liquids include coffee, tea, milk, soft drinks, water, gelatin (jello), broth, ice cream, popsicles, sorbet, and nutritional supplement drinks, such as Ensure. Note: Ice chips melt to half their volume. For example, if the client receives 8 oz. of ice chips, record the intake as 4 oz. The nurse is educating a client with primary adrenal insufficiency (Addison's disease) on diet and nutrition changes needed to manage the client's disease. Which statement by the client would indicate that the nurse's instructions have been effective? a. I should increase fluids, but limit sodium and potassium b. I will increase potassium and fluids, but limit sodium c. I will increase sodium and potassium, but limit fluids d. I should increase sodium and fluids, but limit potassium d. I should increase sodium and fluids, but limit potassium Addison's disease develops when the adrenal glands are damaged. They don't make enough of the hormones cortisol and aldosterone. Besides corticosteroid medications, dietary changes include increased sodium, decreased potassium, and adequate fluid intake. Basic Care and Comfort 2024 A pregnant client comes to the prenatal clinic for her first visit. The nurse notes that this is the client's third pregnancy. Four years ago, she delivered a healthy boy at 38 weeks, and two years ago, she delivered a healthy girl at 35 weeks. Using the gravida/para system to record the client's obstetrical history, the nurse will document a. Gravida 3 - Para 2 b. Gravida 2 - Para 2 c. Gravida 2 - Para 1 d. Gravida 3 - Para 1 a. Gravida 3 - Para 2 Using the gravida/para system, the nurse should record Gravida 3 - Para 2. The client is pregnant for the third time (Gravida 3) and has had two pregnancies of more than 20 weeks' gestation each (Para 2). The other options are incorrect. The post-anesthesia care unit (PACU) provides a report to the pediatric nurse on a 15-month-old who has had repair of a congenital hip deformity. What type of traction does the nurse anticipate will be used for the child? a. Buck's b. Russell's c. Bryant's d. Dunlop's c. Bryant's Bryant's traction is used following surgery to correct a congenital hip deformity. The child's legs are wrapped with moleskin tape and adhesive elastic bandages, which are connected to the traction's ropes and weights. The tension stabilizes the end of the femur in the hip socket as the site heals. Russell's traction is used to align a fractured femur. Buck's traction is skin traction used for femoral, acetabular, and hip fractures as well as low back pain. Dunlop's traction is used on children with certain fractures of the upper arm, when the arm must be kept in a flexed position Basic Care and Comfort 2024 a. Use an antibacterial soap every day b. Avoid shaving with a straight-edge razor c. Cover the treated area with sterile gauze d. Apply lotion right before each treatment b. Avoid shaving with a straight-edge razor During radiation therapy, the client should use an electric razor to avoid irritation or cuts. Antibacterial soaps are too harsh; a mild soap should be used instead. The radiation area is left open to the air. Lotion may be used several times a day, but not 4-5 hours before a treatment. Lotions or creams should not be applied over the radiation marks. A client with a severe ankle sprain will be using crutches. Which of the following indicates that the crutches have been fitted correctly? a. The client's elbow is locked with the hand on the handgrip b. The client's axilla rests on the crutch pad when the client ambulates c. The client's axilla is at the same level as the top of the crutch d. The client's elbow is at a 30-degree angle with the hand on the handgrip d. The client's elbow is at a 30-degree angle with the hand on the handgrip Proper crutch measurements result in the client's weight being on the hands, not the axilla. This avoids damage to the brachial plexus. The elbow should be at a 30-degree flex, not straight. The top of the crutch should be 2 to 3 finger widths lower than the axilla. A 32-year-old female with no significant history comes to the clinic for a routine check-up. Where is the most appropriate spot to measure this client's pulse? a. Apical Basic Care and Comfort 2024 b. Femoral c. Radial d. Carotid c. Radial For a client with an uncomplicated medical history, taking a radial pulse is appropriate. An apical pulse is appropriate for clients taking cardiovascular medications, such as Digoxin. A carotid pulse is appropriate for emergency situations, such as cardiac arrest. Taking a femoral pulse is not necessary and can be considered an invasion of privacy. A 10-year-old boy is admitted to the pediatric unit with a diagnosis of viral meningitis. He is experiencing a severe headache, vomiting, photophobia, drowsiness, and a stiff neck. The nurse can make him more comfortable by a. Providing a large, soft pillow b. Closing the shades and dimming the lights c. Encouraging him to drink fluids d. Teaching him deep breathing b. Closing the shades and dimming the lights The home health nurse notices that a client with a diagnosis of multiple sclerosis is having a recent difficulty chewing and swallowing. The appropriate diet for this client is a. Mechanical soft b. Pureed c. Full liquid d. Clear liquid A mechanical soft diet has a consistency that the client may be able to handle; this diet should be tried first. Basic Care and Comfort 2024 A full liquid diet can be challenging for a client with poor swallowing. Pureed foods can cause the client to regress or feel embarrassed. A clear liquid diet is not indicated and does not supply sufficient calories. A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living? a. High-seat commode b. TENS unit c. Abduction pillow d. Recliner a. High-seat commode A high-seat commode keeps the hip higher than the knee. A recliner is helpful because it prevents 90° flexion, but it is not necessary for activities of daily living (ADL). A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management An abduction pillow is used to prevent hip adduction and possibly dislocation of the prosthesis, but neither are part of ADL. Which lab value indicates hypokalemia? Basic Care and Comfort 2024 c. put down phone d. sit up straight a. uncross their legs A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the nurse would expect to hear which breath sound? a. wheezes b. rhonchi c. crackles d. stridor c. crackles Crackles would most likely be heard because they indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airways. Stridor is an emergency lung sound that is seen in airway constriction that can lead to complete closure. Rhonchi are heard in mixed-issue airway constriction and secretions. A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of a. fecal impaction b. diarrhea c. bowel incontinence Basic Care and Comfort 2024 d. constipation a. fecal impaction Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; or not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity. The nurse prepares a 5-year-old girl for a pre-operative IV insertion. Which statement is most appropriate to reduce the child's anxiety? a. "Hold onto your doll. This is going to hurt." b. "It's going to hurt a little, but I know you're a brave girl." c. "Tell me if this feels more like a pinch or a bug bite." d. "Just look at the television while I do this." c. "Tell me if this feels more like a pinch or a bug bite." The nurse is providing education for a client who has just been prescribed a transcutaneous electrical nerve stimulation (TENS) unit for relief of chronic back pain. Which of the following instructions for the client is correct? a. "Muscle twitching means the TENS is working." b. "Each TENS unit session lasts about 3 hours." c. "It will take several days to build up a tolerance." Basic Care and Comfort 2024 d. "Do not go to sleep with the TENS unit on." d. "Do not go to sleep with the TENS unit on." The parent of a child with a short leg fiberglass cast phones the clinic because their child complains of a constant itching inside the cast. Which intervention is appropriate for the nurse to suggest? a. Use a blunt-ended object to scratch. b. Apply powder or a mild lotion. c. Trickle ice water into the cast. d. Tap on the cast at the itchy spot. d. Tap on the cast at the itchy spot. When instructing a patient with Addison's disease about nutrition, which of the following diet modifications is NOT recommended? a. a diet with adequate caloric intake b. a diet high in grains c. a high protein diet d. a restricted sodium diet d. a restricted sodium diet A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to maintain electrolyte balance and prevent excess fluid loss. The patient should be instructed to maintain adequate caloric intake with a diet high in protein and complex carbohydrates, including grains. Basic Care and Comfort 2024 Types of drainage are: 1. Serous: clear and thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be indicative of infection and should be cultured. The amount of drainage is generally documented as absent, scant, minimal, moderate, large, or copious. The presence and degree of odor can be documented as absent, mild, or foul. Foul odors can be indicative of an infection. After your patient dies, the family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient's nurse, your most appropriate action is to a. educate the family about custody-of-care, and stay in the room. b. allow the ceremony, and step out of the room. c. inform the family that religious rites are not allowed. d. allow the ceremony, but remain as a witness. b. allow the ceremony, and step out of the room. During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse's PRIORITY? A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time. Treatment of fecal impaction includes administrating an enema to soften the stool to produce a bowel movement or manually removing the impaction. Basic Care and Comfort 2024 With a lubricated glove, insert the index finger into the rectum to break up the hardened stool with a circular motion. Cardiac dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation. The nurse is educating the parents of a young child with a recent diagnosis of cystic fibrosis. The nurse tells the parents that the child will be at risk for which vitamin deficiencies? People with cystic fibrosis have trouble absorbing fats, which means they also have trouble absorbing vitamins that need fat to be absorbed — A, D, E, and K. These fat-soluble vitamins are critical to normal growth and good nutrition. B-complex, C, folic acid, biotin, and pantothenic acid are water soluble and easily absorbed. People with cystic fibrosis have trouble absorbing fats, which means they also have trouble absorbing vitamins that need fat to be absorbed — A, D, E, and K. These fat-soluble vitamins are critical to normal growth and good nutrition. B-complex, C, folic acid, biotin, and pantothenic acid are water soluble and easily absorbed. Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and the quality of life. Warm saline rinses are non-irritating and help eliminate bacteria that can cause infection. Other nursing interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the physician. Basic Care and Comfort 2024 A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client? HINT: "IF IT'S DRY-LET IT LIE" NO DRESSING IS NEEDED Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema) eschar on the heels should not be removed. Eschar works as a natural barrier or biological dressing by protecting the wound bed from bacteria. Unless it is wet, draining, or loose, it should remain in place. Unless the nurse is a certified wound specialist, removal or debridement of eschar is performed by a health care provider (HCP). The other dressings are not indicated. A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the healthcare provider that the stoma has retracted? a. Pinkish-red and moist b. Dry and reddish-purple c. Narrowed and flattened d. Concave and bowl-shaped Basic Care and Comfort 2024 An AV fistula is a connection of an artery to a vein, created by a vascular surgeon. An AV fistula frequently requires 2 to 3 months to develop or mature before the patient can use it for long-term hemodialysis. The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site? RIGHT LOWER QUADRANT A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It may also be done for severe chronic constipation. The nurse is providing postmortem care for a client who was being treated for Staphylococcus aureus. Which transmission-based precautions are indicated? CONTACT PRECAUTIONS MRSA is transmitted by contact, and MRSA bacteria remain alive for up to 3 days after the host dies. Basic Care and Comfort 2024 Therefore, contact precautions must still be used after the client dies, including the use of a gown and gloves. The body and bag should also be labeled as MRSA contaminated so other hospital, transportation, and funeral home employees can protect themselves as well. The palliative care nurse is caring for a client with advanced multiple myeloma. Which intervention is MOST appropriate? Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. In 70% of multiple myeloma cases, the bones develop multiple holes, called osteolytic lesions. Multiple myeloma may also affect other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia, and bone damage. Multiple myeloma can cause erosion of bone mass and fractures. Extra care should be taken when moving or positioning a client because of the risk of pathological fractures. Pain is intense from the bones and nerves and should be treated. Fluid hydration of 3 L daily is recommended throughout the disease course and improves overall survival. What is the smallest gauge intravenous catheter that can be used to administer blood? An 18-gauge needle or catheter is generally used to administer blood or push fluids, or for testing protocols that require large IV bores. However, a 20-gauge is acceptable if the facility's policy allows it. This size is better for clients with small veins. Basic Care and Comfort 2024 A 22-gauge is used for IVs of short duration or for clients who are not critically ill. Usually, blood cannot be administered because of hemolysis of the RBCs. A 24-gauge is used for pediatrics and adults who cannot tolerate a larger gauge. A 16-gauge is mostly used in intensive care and surgery units because most fluids and blood products can be quickly administered. 26-gauge needles are used for injections. After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system? NEG PRESSURE DRAWS OUT FLUIDS a. Compress the bulb and close the valve. b. Open the valve and fill the bulb with air. c. Fill the bulb with sterile saline solution. d. Place the bulb lower than the client's body. A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain. Contraindications for administering an enema include all of the following EXCEPT Basic Care and Comfort 2024 Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate? HINT 100ML IS WNL Standard practice includes measuring gastric residual volume prior to administering an enteral feeding. According to current American Society for Parenteral and Enteral Nutrition, enteral feedings can be administered with a residual up to 500 mL; However, individual HCP orders should be followed. signs of feeding intolerance include abdominal distention and/or pain, constipation, nausea, vomiting, and sense of fullness. A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer? Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed. Stage III pressure ulcers have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons. Basic Care and Comfort 2024 Of the following positions, which one facilitates maximum air exchange? One of the nurse's patients has a nasogastric (NG) tube for tube feedings and medications. Which nursing action is appropriate when caring for this patient? The nurse should change the tape at the patient's nose every day and assess the skin for breakdown. Tubing and feeding items are replaced every 24 hours. The NG tube is flushed with warm water to avoid burning the patient or causing discomfort. The bed is placed in the high Fowler's position for tube feedings. The nurse is educating a client with a new diagnosis of bursitis of the elbow (olecranon bursitis). Which statement by the client would indicate an understanding of proper treatment? Bursitis is a painful condition that affects the small fluid-filled sacs (bursae) that cushion bones, tendons, and muscles near the joints. The most common locations for bursitis are the shoulder, elbow, and hip. The olecranon bursa is a thin fluid-filled sac located at the bony tip of the elbow (the olecranon). Moist heat dilates the blood vessels and decreases inflammation. The client should be instructed to apply the heat for 20 minutes tid. Treatment also involves taking NSAIDs and resting the joint by eliminating movements or exercise that can irritate the bursa. Basic Care and Comfort 2024 Resting elbows on a hard surface can cause bursitis. While ice can be used for the first 48 hours, dry ice is never used on a body surface. A client in the Emergency Department is experiencing the "fight-or-flight" response, a sympathetic nervous system reaction. Which of the following will the nurse expect to observe? The fight-or-flight response evolved as a survival mechanism, enabling humans and other mammals to react quickly to life-threatening situations. The carefully orchestrated yet near-instantaneous sequence of hormonal changes and physiological responses helps a creature fight off the threat or flee to safety. The catecholamine release results in increased pulse, blood pressure, bronchodilation, perspiration, pupil dilation, and mental acuity. Urine output is decreased. The nurse does an admit for a client with a diagnosis of pleural effusion. When doing a respiratory assessment of this client, the nurse will determine if the client has A pleural effusion is a collection of fluid between the pleural layers of the lung. The fluid prevents chest expansion on the affected side. Respiratory rate increases and use of accessory muscles can be observed. Breath sounds are decreased because ventilation on the affected side is also decreased. Resonance is dull and flat to percussion. Basic Care and Comfort 2024 5.Ingest a solution high in sodium. 6.Apply a pouch with a smaller opening. 1) CORRECT– The client should be instructed to drink warm fluids because this stimulates peristalsis, providing a mild cathartic effect. 2) CORRECT– The client should be instructed to massage the peristomal area because massage may stimulate peristalsis and encourage fecal elimination. 3) INCORRECT– Foods high in potassium would be recommended if the client was experiencing symptoms of dehydration. 4) CORRECT– The client should be instructed to take a warm shower or tub bath because this can help relax the abdominal muscles. 5) INCORRECT– Ingesting a solution high in sodium would be recommended if the client was experiencing symptoms of dehydration. 6) INCORRECT– The client should be instructed to apply a pouch with a larger opening. If the stoma is swollen, the pouch may create a mechanical obstruction to output. A client in Buck traction for a fractured right femur experiences increased anxiety and pain. Which non- pharmacological method of pain management is appropriate for the nurse to initiate? (Select all that apply.) 1.Play music. 2.Demonstrate yoga movements. Basic Care and Comfort 2024 3.Apply a fentanyl transdermal patch. 4.Turn the television on. 5.Administer a placebo. 1) CORRECT– The evidence demonstrates that listening to music decreases anxiety and increases client satisfaction, leading to decreased dosing of sedating medications. 2) INCORRECT– As the client is immobile, performing yoga is not appropriate at this time. 3) INCORRECT– Although a transdermal patch is considered noninvasive, fentanyl is an opioid medication used to treat pain and is not a non-pharmacological method to treat pain. 4) CORRECT– Distraction, through watching television, is a non-pharmacologic intervention. 5) INCORRECT– Placebos should not be used as a non-pharmacological method for this is considered deceptive and unethical. The nurse provides care to a client prescribed furosemide. Which meal will the nurse recommend as being appropriate for this client? (Select all that apply.) 1.Vegetable stir-fry with cauliflower, carrots, and green beans. 2.Fruit salad with blackberries, blueberries, and watermelon. 3.Cereal with a banana and orange juice. Basic Care and Comfort 2024 4.Baked potato topped with bean chili. 5.Winter squash lasagna. 3. Cereal with a banana and orange juice. 4. Bake potato topped with bean chill. 5. Winter squash lasagna. The selected answers are all high in potassium which is recommended for the client taking furosemide and at risk for hypokalemia. **Choices 1 and 2 are not high in potassium and should not be recommended by the nurse. The health care provider has pronounced the death of a client. Which action does the nurse perform when completing postmortem care? 1.Turn off intravenous infusions. 2.Remove the percutaneous endoscopic gastrostomy (PEG) tube. 3.Place the client in low-Fowler position. 4.Remove dentures. 1) CORRECT– The nurse should turn off infusions of any kind. Since there is no circulation, the IV site will become infiltrated. 2) INCORRECT– The nurse should leave the PEG tube in place, due to possible leakage of gastric contents, if removed, immediately after death. Basic Care and Comfort 2024 3.The client requests grilled chicken, greek yogurt, and milk for lunch. 4.The client's serum albumin is 4.0 g/dL (40 g/L). serum albumin is 4.0 -most objective Normal range 3.5-5.5 The nurse wants to assess the gait and lower limb mobility of an older adult client who had a knee replacement 6 months ago. Which action does the nurse ask the client to perform? (Select all that apply.) 1.Walk across the room and back. 2.Walk heel to toe across the room. 3.Close eyes then stand with feet together with arms resting at side. 4.Stand with feet together and touch toes. 5.Close eyes and stand on one foot. 6.Run the heel down the shin of the opposite leg toward the foot. 1) CORRECT– This allows observation of the gait for steadiness and stride. 2) CORRECT– This allows observation of the motor function required to step safely. Basic Care and Comfort 2024 3) CORRECT– This allows observation of ataxia, which is the lack of coordination of voluntary movements needed when walking. Also, it allows for observation of steadiness needed when walking. 4) INCORRECT– This tests back strength and flexibility but does not assess gait. 5) CORRECT– This assesses for ataxia (the lack of coordination of voluntary movements needed when walking) and sufficient leg strength for walking. 6) CORRECT– This assesses the motor control required for walking. The nurse uses the Braden Scale to assess a client’s level of risk for developing a pressure injury. The client’s scoring is as follows: sensory perception 3 moisture, 4 activity, 3 mobility, 3 nutrition, 3 friction and shear, 3. These results indicate to the nurse that the client is at which level of risk for pressure injury? Basic Care and Comfort 2024 HINT THE HIGHER THE NUMBER THE LOWER THE RISK 1.High risk. 2.Moderate risk. 3.Mild risk. 4.No risk. 4) CORRECT– The Braden Scale scoring for the 6 categories listed is 1 = completely limited, 2 = very limited, 3 = slightly limited, 4 = no impairment. The client’s score of 19 falls in the range of 19 to 23, indicating there is no risk for a pressure injury. The nurse in a pediatric clinic teaches a class on the care of infants and how to prevent diaper dermatitis. Which statement by a parent indicates teaching is successful? (Select all that apply.) 1.“I should change my baby’s diaper as soon as it gets wet or soiled.” 2.“Diaper rash is more likely to occur in breastfed babies than in bottle-fed babies.” 3.“Some disposable wipes may cause diaper rash.” 4.“When changing the diaper, it is important to remove all the barrier cream so the skin can be thoroughly cleaned.” Basic Care and Comfort 2024 2.Water aerobics. 3.Cushioning footwear. 4.Massage. 5.Adequate sleep. 6.Application of heat 2–3 times/day. 1) CORRECT– Yoga usually includes deep breathing exercises that promote relaxation. It also includes gentle stretching, which increases joint flexibility and reduces pain. 2) CORRECT– Water aerobics is a low-impact exercise that decreases pressure on the joints. It improves fitness and relieves stiffness and pain. 3) CORRECT– Cushioning footwear or orthotics can help reduce the impact on the lower extremities, which in turn can mediate pain in the lower back and lower legs. 4) CORRECT– Massage promotes relaxation of the muscles around the joints, which improves range of motion and relieves pain. 5) CORRECT– Lack of adequate sleep makes a person more vulnerable to pain and depression. 6) CORRECT– Heat improves circulation. It is especially helpful for pain and stiffness related to inactivity. The nurse provides care for immobile intubated clients in the intensive care unit (ICU). The nurse monitors lab levels with the knowledge that immobility may impair renal function due to elevated excretion of which electrolyte? Basic Care and Comfort 2024 1.Calcium. 2.Phosphorus. 3.Magnesium. 4.Sodium. 1) CORRECT– The development of renal calculi as a complication of immobility is associated with hypercalcemia, which raises the urinary concentrations of calcium phosphate and calcium oxalate. 2) INCORRECT– Urinary excretion of phosphorus may be slightly increased, but it is not associated with the development of renal calculi. 3) INCORRECT– Urinary excretion of magnesium may be slightly increased, but it is not associated with the development of renal calculi. 4) INCORRECT– Urinary excretion of sodium is typically only slightly increased and is not associated with the development of renal calculi. The nurse is caring for a client who has had a left-sided ischemic stroke and is having difficulty with expressive aphasia. Which interventions would be most appropriate to assist the client with communication? Select all that apply. Use long sentences with multiple questions. Increase the volume and tone of voice when speaking to the client. Offer the client a white board for communication. Decrease the amount of environmental noise. Give the client time to respond. Basic Care and Comfort 2024 -Offer the client a white board for communication. -Decrease the amount of environmental noise. -Give the client time to respond. The nurse is caring for a client who has been diagnosed with metastatic brain cancer and is moving to hospice care. For each potential prescription, click to specify if the prescription is anticipated, nonessential, or contraindicated for the care of the client. Apply fentanyl patch 50 mcg every 72 hours. Treat with curative radiation to head and neck once a week. Hold hydromorphone for RR <10. Treat with hydromorphone 7.5 mg oral (po) around the clock. Educate the client and family about narcotic addiction. Anticipated Contraindicated Contraindicated Anticipated Nonessential The nurse is providing postmortem care to a client whose death was anticipated. Priority nursing actions include ______ and ______. replacing dentures placing arms at the sides Sleep disturbances can have detrimental health effects on clients with medical conditions. Match the consequence of sleep disturbance to each client scenario. Each consequence may relate to more than one scenario. Decreased tissue renewal --> Pressure Ulcer Basic Care and Comfort 2024 May resist sleeping to show independence. --> 10 y.o. Has shorter episodes of deep sleep.--> 70 y.o. Bedtime fears and bed-wetting may occur. --> 4 y.o. Likely to have an electronic device on at bedtime. --> 16 y.o. Insomnia may be common.--> 50 y.o. The nurse is caring for a client who was admitted to the hospital after falling at home. The client is unable to ambulate, and their left leg is shortened and externally rotated. The nurse notes ecchymosis on the left lateral hip. The client is placed in skin traction. Place the traction weights on the bed. Inspect the skin every two hours. Assess neurovascular status every day. Assess vital signs every hour. Monitor blood glucose every two hours. Incentive spirometry every two hours. Indicated: -Inspect the skin every two hours. -Incentive spirometry every 2 hours. Nonessential: -Assess VS every hour -Monitor blood glucose every 2 hours. Contraindicated: -Place traction weights on the bed -Assess neurovascular status every day Basic Care and Comfort 2024 While ambulating with crutches, the client moves injured side's crutch forward with the injured leg and then moves the non-injured crutch at the same time as the injured leg. The nurse will document that the client is using a _______ gait while ambulating. While ambulating with crutches, the client moves both crutches forward and then moves both legs forward to the same point as the crutches. The nurse will document that the client is using a _______ gait while ambulating. When educating on the use of a cane going up the stairs, the nurse will instruct the client to move the ______ leg up first. 2-point gait swing-to strong Select to highlight the areas that are concerning to the nurse. Click to apply. 7/10 sharp pain Facial grimacing Diaphoretic Identify the additional assessments the nurse should complete for this client during the admissions assessment. Select the five (5) that apply. Size of indwelling urinary catheter Urine output and color Pedal pulses Bowel sounds Pain assessment after repositioning History of smoking Femoral pulses Sensation in left foot Preference for rehabilitation center Basic Care and Comfort 2024 1. Size of indwelling urinary catheter 2. Urine output and color 3. Pedal pulses 4. Bowel sounds 5. Pain assessment after repositioning Identify the staging of the pressure injury, 2 supporting findings, and 2 management strategies. Select the correct answers in the boxes provided. Findings: -Sacral pain -Open, shallow wound Staging: Stage 2 Management strategies: -Reposition -Hydrocolloid dressing Identify the appropriate actions the nurse should take. Click to select and drag the correct response(s) in the boxes provided to the right. -Prop client's affected leg on stool in extended position while in chair. -Ambulate client with cane. -Remove indwelling urinary catheter. -Place pillow between knees while client in bed. -Assist client by washing back, legs, and perineum. -Instruct client not to cross legs. Basic Care and Comfort 2024 Inappropriate--> -Allow the client to stay in bed and use the technique for changing an occupied bed. -Use a mouth wash rinse instead of a toothbrush during morning care. -Avoid soap when washing the feet due to the ingrown toenails. Complete the sentences by selecting the best options. The client may be experiencing _______ because of ______. The nurse should plan to _______ near bedtime. a sleep disorder chronic pain adminiter pain medications What additional measures should the nurse implement at this time to address this client's pain? Select all that apply. Speak calmly with the client. Initiate gentle passive range of motion. Reposition the client in bed. Apply an ice pack onto the right hip. Guide the client through guided imagery. -Speak calmly with the client. -Initiate gentle passive range of motion. -Reposition the client in bed. Click to select which non-pharmacological approaches to pain control are appropriate and which are inappropriate for this client. Elevate the legs on a pillow. Basic Care and Comfort 2024 Balance out rest and activity. Apply ice packs to areas of discomfort. Use compression stockings during the day and night. Sit with the legs dangling over the edge of the bed. Appropriate --> -Balance out rest and activity -Sit with the legs dangling over the edge of the bed Inappropriate --> -Elevate the legs on a pillow. -Apply ice packs to areas of discomfort -Use compression stockings during the day and night.