NUR 215 Exam 2 Questions

A client who had a stroke has hemiplegia on the right side of her body. What will the nurse observe during their assessment?

a. Paralysis on the left side

b. Weakness on the right side

c. Paralysis on the right side

d. Weakness on the left side

c. Paralysis on the right side

A client with limited mobility is able to clean his face and upper body but not his lower body, back, nor his perineal area. The nurse has assisted the client. What type of bath will the nurse document? a. Complete bath

b. Bag bath

c. Partial bath

d. Shower

c. Partial bath

A nurse is preparing to give a complete bed bath to a client. Which area of the body will the nurse bathe first?

a. Perineum

b. Eyes

c. Hands

d. Face

b. Eyes

Many clients need assistance with hygiene care while hospitalized. Which clients may need hygiene help from the nurse? (Select all that apply).

a. A client with newly diagnosed diabetes

b. A client on bedrest

c. A postoperative client

d. A client that is blind

e. A paraplegic client

f. A client with advanced arthritis

b. A client on bedrest

e. A paraplegic client

f. A client with advanced arthritis

d. A client that is blind

The nurse is providing perineal care to a female client. Which technique should the nurse use? a. Wash from the public area to the anus b. Wash from the back to the front c. Wash upward from the anus to the pubic area d. Wash in a circular motion

a. Wash from the pubis area to the anus

A client is asking the nurse about nutrients. Which response by the nurse defines protein?

a. "Proteins help build and repair muscle."

b. “Proteins are the primary source of energy in the diet.” c. “Proteins help the body absorb vitamins.”

d. “Proteins support optimal functioning of the body.”

a. "Proteins help build and repair muscle."

The registered nurse and assistive personnel are giving a complete bed bath. What benefit does the nurse gain in giving this bath? a. Demonstrate hygiene care to the assistive personnel

b. Evaluate the client's self-care abilities

c. Ability to do a skin assessment only

d. Decrease the client’s body odor

b. Evaluate the client's self-care abilities

Which of the following influence clients’ hygiene practices? (Select all that apply).

a. Dementia diagnosis

b. Hygiene products used

c. Gender

d. Work commute

e. Body image

f. Religion

g. Resources

a. Dementia diagnosis

b. Hygiene products used

e. Body image

f. Religion

g. Resources

The nurse is initiating parenteral nutrition for a client. How is the nurse going to provide nutrition to this client?

a. Through a nasogastric tube

b. Through the mouth

c. Through a gastrostomy tube

d. Through the vein

d. Through the vein

A nurse is feeding a client when the client suddenly begins to cough. What condition is the client displaying?

a. Dysphagia

b. Chondromalacia

c. Aphasia

d. Fatigue

a. Dysphagia

A nurse is preparing to insert a nasogastric feeding tube. What three landmarks are used to ensure correct length of the tube?

a. Tip of the nose

b. Earlobe

c. Umbilicus (belly button)

d. Ear pinna

e. Xiphoid process

f. Bridge of the nose

a. Tip of the nose

b. Earlobe

e. Xiphoid process

A nurse is providing hygiene care for a 91-year-old client and selects which of the following as a consideration in the plan of care? a. Hormonal changes require the use of gentle face cleansers

b. Medications may reduce the client’s desire to bathe

c. Bathing less often may be required because of dryer, less elastic skin

d. Dentures may fit poorly due to increased gum vascularity

c. Bathing less often may be required because of dryer, less elastic skin

The nurse is implementing infection control practices while providing hygiene for a client. Which actions reinforce this practice? (Select all that apply).

a. The nurse holds dirty linens away from her uniform

b. The nurse washes her hands before donning gloves

c. The nurse moves from the cleanest to less clean areas d. The nurse checks the temperature of the water before providing care

e. The nurse identifies the client with two identifiers

f. The nurse cleans from the outer to inner canthus of the client’s eye

a. The nurse holds dirty linens away from her uniform

b. The nurse washes her hands before donning gloves

c. The nurse moves from the cleanest to less clean areas

A nurse is providing perineal care for an uncircumcised client. What action is imperative for the nurse to perform?

a. The foreskin should be retracted, pulling it gently away from the body before cleaning

b. The foreskin should not be touched c. The foreskin should be allowed to return to its natural position after care d. The foreskin should be retracted and returned to position after cleaning

d. The foreskin should be retracted and returned to position after cleaning

The nurse is performing diet teaching for a client wanting to better their nutritional intake Which types of foods should the client add to their diet?

a. High density, high calorie

b. Low density, low calorie

c. High density, low calorie

d. Low density, high calorie

c. High density, low calorie

True or False: “I must walk behind my walker so I do not fall”

False

You must walk in your walker

True or False: Identifying risk factors for complications of immobility can be delegated to an AP

False

True or False: Ambulation is an ADL

False

True or False: Those with pressure injury risks should be repositioned Q2H

True

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.)

A fluoride mouthwash should be used to promote oral health.

The teeth should be brushed twice daily for 2 min.

Poor oral hygiene can lead to gingivitis.

Teeth should be flossed every other day.

Use a soft-bristled toothbrush for brushing the teeth.

A fluoride mouthwash should be used to promote oral health.
The teeth should be brushed twice daily for 2 min.
Poor oral hygiene can lead to gingivitis.
Use a soft-bristled toothbrush for brushing the teeth.

Teeth should be flossed every other day is incorrect. Teeth should be flossed once daily to remove bacteria from the close spaces between the teeth and beneath the gum line.

A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?

"A standard toothbrush is more effective than a battery-operated toothbrush in decreasing plaque."

"Clean the tongue with the toothbrush or tongue scraper during oral hygiene."

"Floss the teeth at least three times each day."

"Have the client use mouthwash after brushing their teeth."

The tongue should be cleaned during oral hygiene to remove bacteria that can be found on the tongue.

A battery-operated toothbrush is more effective in decreasing plaque and mild gum disease than a standard toothbrush.

A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis?

The epidermis acts as a cushion against physical trauma.

The epidermis separates the dermis from the underlying organs.

The epidermis consists of squamous epithelial cells.

The epidermis contains blood vessels and blood.

The epidermis is made of squamous epithelial cells that form four layers, providing strength to the skin.

The hypodermis, not the epidermis, acts as a cushion against physical trauma.

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

The most common oral hygiene problem is gingivitis.

The client's ability to obtain dental care is unaffected by their visual impairment.

The visually impaired client has better oral hygiene than those clients without visual impairment.

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.

It is essential for the nurse to educate the client and caregivers regarding the need for routine dental visits to decrease the risk of developing oral health problems.

The most common oral hygiene problem is cavities caused by plaque and calculus.

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take?

Ensure the nurse caring for the client is of the same sex.

Leave the water running while the client takes a bath.

Allow the client time for prayer immediately following bath time.

Discuss with the client their individual perspective on health and illness.

It is important for the nurse to discuss religious preferences with the client because there are various religions with differing perspectives.

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

Nails, made of pterygium, protect the fingers and toes.

The cuticle is a form of keratin that connects the skin and nail plate together.

The cuticle of the nail forms a barrier to prevent infections.

The nail consists of layers of pterygium that protect against pathogens.

The cuticle of the nail connects the skin on the finger and nail plate, forming a barrier to prevent infections.

The nail consists of layers of keratin that serve as protection for the distal ends of the finger and toes. Pterygium is a membrane found under the cuticle that provides additional skin protection against pathogens.

The cuticle is a form of epidermis that protects the skin and nail plate.

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?

"That is unusual. As clients age, they are typically more receptive to bathing."

"It is fine if the client does not bathe regularly at home."

"Give the client choices regarding their bathing preferences to encourage them to bathe."

"Provide the client with the reasons why they need to bathe."

Giving the client choices about bathing preferences may persuade them to bathe or shower.

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?

"The skin contains Langerhans cells that kill pathogens."

"The skin is the smallest organ of the body."

"The skin is the second line of defense against micro-organisms."

"The dermis is the outermost layer of the skin."

Langerhans cells within the skin sense the presence of disease-causing pathogens and destroy them, decreasing the risk of developing infection in the body.

A nurse is performing foot care for a client. Which of the following actions should the nurse take?

Soak the feet prior to washing the feet.

Use hot water when performing foot care.

Use a towel to completely dry between the toes.

File the nail edges straight across with a file.

It is important to completely dry between the toes because infections are more likely to develop in moist areas.

Rounding the nail edges with a file reduces the risk of ingrown toenails and decreases the risk of infection.

The nurse should avoid soaking the client's feet because this can lead to drying out the skin on the feet.

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?

Changes in skin integrity decrease the risk of infection.

Urinary incontinence can cause a yeast infection.

Mild soap is contraindicated for cleansing the skin.

A pH-balanced cleanser increases skin irritation.

Urinary incontinence can cause a yeast infection because of excessive moisture.

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?

Enamel protects the teeth from pathogens.

Enamel is a substance that cannot be dissolved.

Enamel is a soft material that protects the teeth.

Enamel covers the pulp.

Enamel protects the teeth from pathogens by providing a coating that covers the teeth.

The dentin layer of the tooth, beneath the enamel, covers the pulp of the tooth

A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply the amount of soap recommended by the manufacturer.

Wet hands with warm water.

Rub hands together vigorously for at least 15 seconds.

Use a towel to turn off the faucet.

Use a disposable towel to dry.

Rinse hands with water.

Wet hands with warm water.

Apply the amount of soap recommended by the manufacturer.

Rub hands together vigorously for at least 15 seconds.

Rinse hands with water.

Use a disposable towel to dry.

Use a towel to turn off the faucet.

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

"The mucous membranes secrete a thin, salty liquid that traps pathogens and particles."

"The mucous membranes provide a chemical barrier against pathogens."

"The mucous membranes of the auditory tube contain cilia that move particles toward the front of the nose."

"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

Cilia in the nose trap particles as a person inhales, preventing particles from invading the body.

Mucous membranes act as a physical barrier against pathogens because they block pathogens from invading the body.

The mucous membranes secrete mucous, which is a thick, viscous liquid that traps pathogens and small particles.

ia in the auditory tube move the particles towards the back of the throat, where the particles are swallowed.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.)

The nurse's hands become visibly soiled.

The nurse removes the meal tray of a client who has infectious diarrhea.

The nurse moves the cell phone of a client who has pneumococcal pneumonia from the bedside table.

The nurse empties the urinal of a client who has Clostridium difficile.

The nurse is preparing to insert an intravenous catheter.

The nurse's hands become visibly soiled.

The nurse removes the meal tray of a client who has infectious diarrhea.

The nurse empties the urinal of a client who has Clostridium difficile.

Before inserting an intravenous catheter, the nurse should use an alcohol-based sanitizer. 

A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take?

Assist the client as needed to ensure proper hygiene is performed.

Aggressively rub the skinfolds dry to manage moisture.

Use a lye soap bar to cleanse the skinfolds and the rash area.

Apply moisturizer to the skinfolds and rash area.

The nurse should assist the client as needed because it might be difficult for the client to reach some areas on their body.

The nurse should use a pH-balanced liquid soap to cleanse the skinfolds and rash area.

The nurse should keep the skinfold areas dry to prevent further breakdown and infection.

A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take?

Trim the nails to a length that reaches beyond the edge of the finger.

Perform hand hygiene once nail hygiene is complete.

Avoid the use of wooden orange sticks.

Trim the nails straight across.

Nails should be trimmed straight across and then a file can be used to smooth any rough nail edges.

An orangewood stick should be used to remove any dirt from beneath the nail.

Nails should be trimmed to a short length near the nailbed. Longer nails have been shown to harbor a greater number of germs as compared to shorter nails.

A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?

The nurse should perform personal hygiene tasks for the client.

The client has a minor loss of strength on the right side of the body.

The nurse should have the client remove clothing from the unaffected side first.

Oral care is much easier for the client to perform than bathing.

When assisting the client with dressing, the unaffected arm is used first to place clothing on the affected side. When undressing, the clothing is removed from the unaffected side first, then the affected side.

A client who has experienced a stroke often has difficulty performing oral care due to physical limitations and loss of function.

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

Bathing the client completely in bed preserves the client's dignity.

Washing the client in bed is less effective than taking a shower.

A complete bed bath should be performed using a basin, soap, and water.

Perform this type of bath early in the morning.

Washing a client in bed is less effective than taking a shower and should only be used when there is no other option available.

Basins have been shown to contain pathogens and soap and water can cause skin deterioration. A complete bed bath can be performed using disposable wipes that do not require water and are equally effective for the client.

The nurse should ask the client about their preferences regarding the time they prefer to bathe.

A nurse should allow the client to complete as much of their bath as possible to maintain their dignity.

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles store calcium and magnesium.

Muscles produce red blood cells and platelets.

Muscles assist with thermoregulation in the body.

Muscles provide protection of internal organs.

Contracting muscles generate heat that assists in maintaining body temperature. Shivering is an example of the muscles working to produce heat.

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Center of gravity

Bones

Muscles

Synovial joints

Skeletal muscles are attached to the skeleton. They maintain body posture and position.

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Twisting the torso when transferring the client

Bending at the waist when transferring the client

Placing the bed in the high position before transferring the client

Looking at the client face-to-face when transferring the client

The nurse should look at the client face-to-face when transferring. This prevents twisting or turning of the torso, which can cause back injuries.

A nurse is reviewing the importance of skin care with a client who has bariatric needs. Which information should the nurse review with the client?

Clients who have excessive weight can experience overheating, leading to sweating, which can remain in the skin folds.

Rubbing of skin folds against each other and excessive moisture can cause a rash between the folds, leading to an infection. Proper hygiene is the fundamental treatment for the rash

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Gait belt

Mechanical lift

Cane

Sit-to-stand lift

The nurse should identify that, according to the MAT, a client who requires total assistance requires the use of a mechanical lift or slide board, along with assistance from one to two personnel, to transfer the client.

A nurse is bathing a client with a basin, soap, water, and towels. Which of the following is a risk associated with using a basin to bathe the client?

A Skin deterioration

B Contamination with pathogens

C Protection of skin integrity

D Decreased client independence

B. Contamination with pathogens

Bath basins are contaminated with pathogens, and using bath basins could lead to the transfer of pathogens in the hospital setting.

The nurse should allow the client to participate as much as possible in this procedure to encourage client independence.

The use of soap and water increases the risk of skin deterioration.

Other methods of bathing that omit soap and water decrease this risk and preserve skin integrity (Martin et al., 2017).

True or False: When assisting with dressing, use the unaffected arm first to place clothing on the affected side., then clothing is removed from the unaffected side first.

True

True or False: Encourage the client to take tub baths rather than showers because there is less risk of falling.

False

True or False: Offer the client a large washcloth to use for cleansing.

False

True or False: Ensure the availability of a shower chair or tub bench (adaptive bathroom equipment).

True

What is the correct washing order from clean to dirty?

Proceed in a cephalocaudal (head to toe) fashion beginning with the forehead.

Dry each eye gently after washing.

Proceed to wash the client’s cheeks, nose, ears and neck and gently dry each area after washing.

Wash the eyes from the inner canthus to the outer canthus to avoid pulling debris or micro-organisms into the eye area.

Use a clean area of the washcloth for each eye.

Wash the eyes from the inner canthus to the outer canthus to avoid pulling debris or micro-organisms into the eye area.

Use a clean area of the washcloth for each eye.

Dry each eye gently after washing.

Proceed in a cephalocaudal (head to toe) fashion beginning with the forehead.

Proceed to wash the client’s cheeks, nose, ears and neck and gently dry each area after washing.

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Atrophy

Foot drop

Joint contracture

Disuse osteoporosis

The nurse should suspect the client is experiencing foot drop.

Foot drop occurs when the joint of the foot becomes contracted and results in the inability to perform dorsiflexion, or pulling the toes upward. This is due to nerve damage that causes shortening of the muscle. The foot is left with the toes pointing downward and in a dropped position.

A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

Reduced depth perception

Narrower stance when standing

Quick steps when ambulating

The nurse should identify that an increased curvature of the thoracic spine, along with protrusion of the neck, indicates an age-related change to the client's musculoskeletal system. This occurs due to bone loss and degeneration of vertebral discs. This can cause the client to lean forward when standing and have an unsteady gait when walking.

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics improves blood circulation in the body.

The use of ergonomics eliminates costs related to workers' compensation.

The use of ergonomics increases job satisfaction.

The use of ergonomics maintains the body's balance and a lower center of gravity.

The use of ergonomics increases job satisfaction along with productivity of staff members. When staff members can work safely and effectively, they can perform at a higher level.

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? (Select all that apply.)

A stable center of gravity increases stability and balance.

A wide base lowers the center of gravity.

Proper body alignment involves tightening the abdomen.

Leaning slightly back while carrying an object equalizes the center of gravity.

Bending at the waist when picking up objects stabilizes the spine.

Center of gravity is the central point of weight of an object. While standing, center of gravity is an imaginary line that begins at the umbilicus and intersects with the line of gravity. This increases the body's stability and balance.

A wide base lowers the center of gravity, which increases stability and balance and prevents the body from falling over.

When transferring clients or lifting objects, the nurse should keep the back straight, the chin level, and tighten abdominal muscles to maintain alignment.

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Gait belt

Sit-to-stand lift

Mechanical lift

Pivot disc

The nurse should use a mechanical lift, along with assistance from two or more health care staff, to transfer a client who is unable to assist. The use of a mechanical lift decreases the risk of injury to both the staff and the client.

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Restricted movement due to abnormal fixation of a joint

A drop in blood pressure that occurs with a change in position

Altered gait with dragging of the toes while ambulating

Diminished awareness of body position and balance

Diminished awareness of body position and balance

Proprioception, or kinesthesia, is a sense of self-awareness and body position. It is the result of feedback from nerve sensory receptors that alert the brain to fine-tune muscle movement in order to regulate balance, coordination, and movement.

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min

Stand in place for 5 seconds

Walk in place

Step forward and backward

Sit on the edge of the bed for 1 min

The nurse should identify that the client who is at Level 1 Mobility of the MAT requires maximum assistance. The client should be able to sit on the edge of the bed for 2 min and extend their arms across their chest to shake hands with the nurse before advancing to the next level. If the client is unable to complete both tasks, they remain at Level 1 Mobility of the MAT.

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

Synovial joints contain sensory receptors that trigger flexion.

The contraction of a muscle results in flexion of a joint.

Neurotransmitters coordinate with cartilage to initiate flexion.

Ligaments extend to enable flexion of a joint.

The contraction of a muscle results in flexion of a joint.

When muscles contract, they shorten and pull against the bone they are attached to. This results in flexion at the joint.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is NPO for surgery and is receiving IV fluids.

A  client who has a lower extremity fracture and uses the overhead bed trapeze to move.

A client who is incontinent and is taking a prescribed diuretic.

A client who has lung cancer and will be receiving their first radiation treatment.

Clients who are incontinent have an increased risk for developing alterations in tissue integrity, such as maceration, due to prolonged exposure to moisture.

Clients who are malnourished and dehydrated are also at risk for developing pressure injuries.

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Decrease the drainage suction force.

Place the bulb on a flat surface and measure the amount of drainage.

Empty and measure the drainage.

Kink the tubing to prevent further drainage.

The bulb of the portable wound bulb suction device should be emptied at least every 8 hr or when it is more than half full.

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should expect a small separation along the incision line."

"If I feel like something popped, I should sit up in bed."

"I should report pain at my wound site."

"Recurrent vomiting is expected after surgery."

The client should report pain at the incision site to the nurse. This can be an indication of infection, which can lead to the client's incision to dehisce.

The client should notify the nurse immediately if they feel like something "popped" or "gave way." This can be an indication that the client's wound has dehisced due to the layers of the tissues not healing properly following surgery. The client should be placed in bed in the supine position with their knees bent to alleviate pressure to the abdomen.

The client should notify the nurse immediately if they notice a partial or complete separation along the incision line. This can be an indication the client's wound has dehisced due to the layers of the tissues not healing properly following surgery.

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?

A wet gauze dressing

A hydrogel dressing

A transparent film

An alginate dressing

Due to their reduced ability to absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate.

A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Firmly massage lotion into the client's skin.

Tilt the client on their side at 30°.

Slide the client to the edge of the bed to transfer.

Keep the head of the bed at 45° when in the supine position.

The nurse should include in the client's plan of care to tilt the client on their side at 20° to 30°. This prevents the client from sliding down in bed, which can cause shearing of the skin, while also relieving pressure to the client's hip.

Vigorously massaging and rubbing lotion into the client's skin can cause skin breakdown or further damage to the client's skin. The client's skin should be cleansed and patted dry.

The head of the client's bed should be kept lower than 30° at all times to prevent the client from sliding down in bed, which can cause shearing of the skin, and alleviate pressure from the sacrum.

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

"Stage 3 pressure injury to the coccyx observed with a non-blanchable area of erythema."

"Stage 3 pressure injury to the coccyx observed with partial-thickness skin loss, wound bed pink and moist."

"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss, muscle and bones visible."

A stage 3 pressure injury is characterized by full-thickness skin loss and visible adipose tissue. The fascia, muscles, tendons, bone, ligament, and cartilage are not visible in this stage.

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A red incision site with a small amount of exudate

A bright pink incision site that is absent of exudate

A pale pink incision site with moderate amounts of exudate

A white to silver incision site absent of exudate

By the seventh postoperative day, the incision site should appear bright pink and drainage should have subsided.

Days 1 through 4 post op: A red incision site with a small amount of exudate

Day 15 through 1 year post op: A pale pink incision site 

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Obtain the culture using a clean cotton applicator.

Clean the wound with 0.9% sodium chloride.

Collect drainage from the area surrounding the wound.

Place the applicator in a dry vial until cultures are complete.

To collect a wound culture using a sterile cotton applicator, the nurse should first clean the wound with 0.9% sodium chloride to rinse away any resident bacteria that may be present.

The nurse should use a sterile, rather than clean, cotton applicator to obtain the culture.

After collection of the wound drainage, the applicator should be placed in a vial containing a solution that keeps the swab moist until lab cultures are complete.

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

Evisceration

Hematoma

Fistula

Dehiscence is a separation of part or all of the wound edges. This is a common complication after abdominal surgery, where the client experiences a ripping sensation at the wound site.

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?

"The dressing will need to be changed every 24 hours."

"This type of dressing is used in small wounds with small amounts of drainage."

"This dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped."

"This type of dressing will need a secondary dressing for reinforcement."

An alginate dressing is not self-adhesive and needs a secondary dressing for reinforcement.

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Hypertension

Increased blood glucose

Decreased WBC count

Increased BUN

Increased blood glucose

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

"Your staples will dissolve in about 4 weeks."

"You will need to be placed under general anesthesia for the staples to be removed."

"Staples are unlikely to become embedded in the skin, making removal simple."

"Your staples will be removed in about 2 weeks."

In general, wounds that are closed with staples heal faster than wounds that are sutured. Staples can be removed within 7 to 14 days.

Caring for a client with dysphagia and is feeding her with a pureed chicken diet. She begins to cough. What do you do first?

Stop feeding them and keep them NPO

When beginning enteral tube feedings, what is the priority action?

Verify tube placement

At least fowlers (30 degrees)

How do you verify enteral tube feedings?

X-Ray!

Verify pH (acidic for stomach, less than 5)

Inspecting stomach fluid

A nurse is caring for a client to receive a bolus enteral feeding several times daily. Which nursing prevention is vital to prevent aspiration?

Elevate the HOB

True or False: Give the client water after every feeding when adding formula to prevent tube clogging

True

Client is receiving continuous nutritional support via NGT regulated by enteral feeding pump. They have difficulty breathing and are restless (aspirating). What should the nurse do first?

Push the hold button on the feeding

What should be limited in a renal diet?

Potassium

Phosphorous

Oranges

Spinach

Cantaloupe

Hash browns

Broccoli

Sparkling water (sodium)

True or False: Garlic does not reduce the effectiveness of Warfarin

False

The nurse is providing an oral care for unconscious patient. What is the primary concern?

Aspiration

What will the nurse do first in caring for the client’s hair?

Ask about client’s hair care preferences

NOT assess for injuries to the client’s skin

True or False: After cleaning an uncircumcised male, you can let the skin retract itself.

False

You must return the skin

True or False: When cleaning a female, always wipe from the pubis (front) to anus (back)

True

A nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

Asthma

Hernia

Hypertension

The nurse should identify that the client is at risk for developing deep vein thrombosis. Blood clots can develop when a client is immobile due to an increase in blood viscosity and atrophy of the muscles. This can then result in decreased blood circulation, which can lead to blood clots and deep vein thrombosis.

15. A client who has dementia and displays aggressive behavior requires hygiene care. Which techniques should the nurse implement to make the bathing experience less stressful for both the nurse and patient? (Select all that apply).

A. Use restraints to prevent the client from injuring themself or the nurse.

B. Try an alternative to traditional bathing such as a bag bath.

C. Allow the client to perform as much of the care as possible.

D. Start by washing the client’s face.

Alternate to traditional bag bath

Allow the client as much control as possible

13. The nurse is caring for a patient who has reduced sensation in both feet. Which of the following actions should the nurse take? (Select all that apply).

A. Avoid cleaning the feet until an order from the health care provider is received.

B. Wash the feet with lukewarm water then dry well.

C. Apply moisturizing lotions to the feet, especially between the toes.

D. Trim/cut the toenails straight across

Trim/cut the toe nails straight across

Wash the feet with lukewarm water then dry well

The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to cough. What will the nurse do first?

A. Stop feeding them and keep them NPO

B. Apply oxygen at 2L nasal cannula

C. Suction their throat

D. Turn them on her side

A. Stop feeding them and keep them NPO

The nurse receives an order to begin enteral tube feedings. What will the priority action of the nurse?

A. Place the client in a prone position.

B. Irrigate the tube with normal saline.

C. Verify tube placement.

D. Introduce a small amount of fluid into the tube before feeding.

C. Verify tube placement.

A nurse is caring for a client who is receiving continuous nutritional support via NGT that is regulated by an enteral feeding pump. The nurse identifies that the client is having difficulty breathing and is restless. What should the nurse do first?

A. Prepare to have the provider intubate

B. Push the hold button on the feeding

C. Raise the bed to the high-Fowler position

D. Immediately notify the respiratory therapist

B. Push the hold button on the feeding

6. A nurse is teaching a client about foods that should be limited on a renal diet. Which food selected by the client reflects an understanding of the teaching? (Select all that apply).

A. Oranges

B. Spinach

C. Apples

D. Cantaloupe

E. Honey

F. Hashbrowns

G. Broccoli

H. Sparkling water

C. Apples

E. Honey

7. A nurse is caring for client on a full liquid diet following abdominal surgery. What food should the nurse remove from the client’s dinner tray?

A. Vanilla yogurt

B. Protein smoothie

C. Mashed potatoes

D. Custard

E. Strawberry Jell-O

F. Herbal tea with milk

C. Mashed potatoes

8. A patient is taking warfarin following a myocardial infarction along with several herbal supplements. Which supplement will the nurse suggest the client stop taking?

A. Vitamin B

B. Garlic

C. Vitamin C

D. Ginger

B. Garlic

A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide?

"You should eat white bread."

"You can drink 2 cups of milk per day."

"You should limit broccoli to 3 cups per week."

"You can have four servings of oatmeal per week."

The nurse should instruct the client to eat white bread instead whole-grain bread. Whole grains are high in phosphorus.

The nurse should instruct the client to limit milk intake to 1 cup per day because of the level of phosphorus.

The nurse should instruct the client to limit broccoli intake to 1 cup per week because of the level of phosphorus.

The nurse should instruct the client to limit oatmeal, granola, bran, and wheat cereals to one serving per week because of the level of phosphorus.

A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription for the client. Which of the following should the nurse identify as the rationale for the provider's prescription?

The client is at risk for aspiration due to the upcoming surgery.

The client is at risk for dysphagia due to the upcoming surgery.

The nutrients consumed as a part of the regular diet will interact with the sedation used in the procedure.

The client reports having to drink a few sips of water before the procedure.

The client is at risk for aspiration due to their upcoming surgery with sedation. To decrease the risk of aspiration, the client should remain NPO prior to the surgery.

A nurse is preparing to assist with feeding a client who is at risk for aspiration. Which of the following actions should the nurse take?

Position the client upright at a 45° angle.

Turn on the television per the client's request.

Avoid allowing the client to drink until meal is finished.

Cut the client's food into small bites.

To prevent aspiration, the nurse should cut food into small bites.

The nurse should provide the client sips of their drink in between bites after they have completely swallowed their food.

The client should be positioned at a 90° angle to prevent complications during feeding.

A nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the client's blood glucose and it is 67 mg/dL. Which of the following actions should the nurse take next?

Document the client's blood glucose level.

Report the client's blood glucose level to the provider.

Provide the client with a 15-g carbohydrate snack.

Recheck the blood sugar in 15 min.

According to evidence-based practice, the nurse should first provide the client with a 15-g carbohydrate snack to help bring up their blood glucose level to the expected reference range. The client's glucose level is low, less than 70 mg/dL, which means the client is hypoglycemic.

A nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I don't understand what this means." Which of the following responses should the nurse make? (Select all that apply.)

"The glycemic index of a food relates to its ability to increase the blood glucose level."

"You should eat foods such as whole grains, fruits, and vegetables."

"Consuming white bread will increase your blood glucose level slowly."

"Try to limit or avoid potatoes due to their high glycemic index."

"Foods with a high glycemic index will cause your blood glucose to increase rapidly."

"The glycemic index of a food relates to its ability to increase the blood glucose level."

"You should eat foods such as whole grains, fruits, and vegetables."

"Try to limit or avoid potatoes due to their high glycemic index."

"Foods with a high glycemic index will cause your blood glucose to increase rapidly."

A nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72 g of carbohydrates and 9 g of fiber. How many net carbohydrates did the client consume?

81

63

8

72

63

To calculate net carbohydrates, use the following equation: Total Carbohydrates – (Fiber + Sugar Alcohols if applicable) = Net Carbohydrates. In this case, 72 g carbohydrates – 9 g fiber = 63 net carbohydrates.

A nurse is a caring for a client who has a new prescription for a clear liquid diet. The client asks the nurse, "How long will I have to be on this type of diet?" Which of the following responses should the nurse make?

"You will be on this diet as long as the provider feels you need to be."

"You might be on this diet for a week or two."

"You should not be on this diet for more than a few days."

"You should speak with the provider about your concern."

The nurse should identify that a clear liquid diet should be limited to a few days because this type of diet has inadequate nutritional value.

A nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make?

"If taken four or more days a week, a multivitamin provides all the nutrients you need."

"As long as you take a multivitamin daily, you do not need to eat a varied diet each day."

"A multivitamin should not be used in place of a nutritious diet."

"As long as the multivitamin isn't generic, it can replace unhealthy dietary choices."

The nurse should tell the client that supplemental vitamins should not be used as a substitute for a nutritious diet. The client should eat a varied, nutritious diet daily even while taking a multivitamin.

A nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (Select all that apply.)

Increasing daily fiber intake can help alleviate the issue of constipation.

Eating more whole grains can promote regular bowel movements.

Consume 10 g of fiber per day.

Foods such as white rice increase fiber intake.

Decreasing daily fiber intake can help alleviate digestive discomfort.

Increasing daily fiber intake can help alleviate the issue of constipation.

Eating more whole grains can promote regular bowel movements.

The nurse should identify that the daily fiber recommendation is 25 g per day for women and 38 g per day for men. Therefore, 10 g of fiber per day is an inadequate amount of daily dietary fiber.

A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium? (Select all that apply).

Apples

Bananas

Dried beans

Spinach

Tomatoes

Bananas

Dried beans

Spinach

Tomatoes

A nurse is preparing to measure a nasogastric tube for insertion. The nurse recalls that the client's xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process?

Measure from the bottom of the ear.

Measure from the tip of the chin.

Measure from the bottom of the jaw line.

Measure from the tip of the nose to the earlobe.

The NG tube is measured from the tip of the nose to the earlobe, then from the earlobe to the xyphoid process. This would give an accurate measurement for tube insertion, allowing appropriate tube placement.