Fundamentals Part 2 (all right)

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:

Put all four side rails up on the bed

Ask the unlicensed assistive personnel to place restraints on the client's upper extremities

Request that the client's roommate put the call light on when the client is attempting to get out of bed.

Check on the client at regular intervals to ascertain the need to use the bathrooms.

Check on the client at regular intervals to ascertain the need to use the bathrooms.

The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?

Hand hygiene

Contact precautions

Droplet precautions

Airborne precautions

Airborne precautions

The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate?

Drink hot tea at frequent intervals

Gargle with antiseptic mouthwash

Use an electric toothbrush

Eat a soft, bland diet

Eat a soft, bland diet

A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet? The client:

Is hungry

Has not requested pain medication for 8 hours

Has frequent bowel sounds

Has had a bowel movement

Has frequent bowel sounds

A client has returned from surgery during which the jaws were wired as treatment

for a fractured mandible. The client is in stable condition. The nurse in instructing the unlicensed assistive personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give to the UAP?

A. Keep the client in a side-lying position with the head slightly elevated

B. Do not reposition the client without the assistance of a registered nurse

C. The client can assume any position that is comfortable

D. Keep the client's head elevated on two pillows at all times

Keep the client in a side-lying position with the head slightly elevated

The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:

To the client from sources outside the client's environment

From the client to healthcare personnel, visitors and other clients

By using special techniques to handle the client's linens and personal

items

By using special techniques to dispose of contaminated materials

To the client from sources outside the client's environment

Which statement indicated to the nurse that a client has understood the discharge instructions provided after nasal surgery?

"I should not shower until my packing is removed."

"I will take stool softeners and modify my diet to prevent constipation."

"Coughing every 2 hours is important to prevent respiratory complications."

"It is important to blow my nose each day to remove the dried secretions."

"I will take stool softeners and modify my diet to prevent constipation."

The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?

10 seconds

20 seconds

25 seconds

30 seconds

10 seconds

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?

A. Initiate oxygen therapy as prescribed, and reassess the client in 10 mintues

B. Draw blood for arterial blood gas

C. Encourage the client to relax and breath slowly through the mouth

D. Administer bronchodilators as prescribed

Administer bronchodilators as prescribed

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:

Put all four side rails up on the bed

Ask the unlicensed assistive personnel to place restraints on the client's upper extremities

Request that the client's roommate put the call light on when the client is attempting to get out of bed

Check on the client at regular intervals to ascertain the need to use the bathrooms

Check on the client at regular intervals to ascertain the need to use the bathrooms

The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?

Hand hygiene

Contact precautions

Droplet precautions

Airborne precautions

Airborne precautions

The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate?

Drink hot tea at frequent intervals

Gargle with antiseptic mouthwash

Use an electric toothbrush

Eat a soft, bland diet

Eat a soft, bland diet

A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet? The client:

Is hungry

Has not requested pain medication for 8 hours

Has frequent bowel sounds

Has had a bowel movement

Has frequent bowel sounds

A client has returned from surgery during which the jaws were wired as treatment

for a fractured mandible. The client is in stable condition. The nurse in instructing the unlicensed assistive personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give to the UAP?

A. Keep the client in a side-lying position with the head slightly elevated

B. Do not reposition the client without the assistance of a registered nurse

C. The client can assume any position that is comfortable

D. Keep the client's head elevated on two pillows at all times

Keep the client in a side-lying position with the head slightly elevated

The nurse is caring for an older adult with mild dementia with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.

Reorient frequently to time, place and situation.

B. Put the client in a quiet room furthest from the nursing station.

C. Perform the necessary procedures quickly.

D. Arrange for familiar pictures or special items at bedside.

E. Limit the client's visitors.

F. Spend time with the client, establishing a trusting relationship.

Reorient frequently to time, place and situation.

Arrange for familiar pictures or special items at bedside.

Spend time with the client, establishing a trusting relationship.

Which would be most helpful when coaching a client to stop smoking?

Review the negative effects of smoking on the body.

Discuss the effects of passive smoking on environmental pollution.

Establish the client's daily smoking pattern.

Explain how smoking worsens high blood pressure.

Establish the client's daily smoking pattern.

A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim:

Starts to become cyanotic

Cannot speak due to airway obstruction

Can make only minimal vocal noises

Is coughing vigorously

Cannot speak due to airway obstruction

While the nurse is providing preoperative teaching for a client with peripheral vascular disease who is to have a below-the-knee amputation, the client says. "I hate the idea of being an invalid after they cut off my leg." The nurse's most therapeutic response should be:

A. "Focusing on using your one good leg will make your recovery easier."

B. "Tell me more about how you are feeling."

C. "We will talk more about this after your surgery."

D. "You are fortunate to have a wife who can take care of you."

"Tell me more about how you are feeling."

Which indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client:

Breathes in through the nose and out through the mouth

Breathes in through the mouth and out through the nose

Uses diaphraphragmatic breathing in the lying, sitting, and standing

positions.

Takes a deep breath in through the nose, holds it for seconds, and blows it out through pursed lips

Takes a deep breath in through the nose, holds it for seconds, and blows it out through pursed lips

Which nursing action is most important in preventing cross-contamination?

Changing gloves immediately after use

Standing 2 feet (61cm) from the client

Speaking minimally when in the room

Wearing protective coverings

Changing gloves immediately after use