A nurse is providing teaching for a client who has a prescription for home oxygen

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?"

Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client uses non-acetone nail polish remover.

The client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter.

The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

The nurse is preparing to administer enoxaparin SC to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45 degree angle.

The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients' safety, health, and rights.

Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear.

Pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system.

The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area.

An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

I will hire someone to trim the trees that hang low over the stairs of my front porch.

Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

position the client's arm in a dependent position.

The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assisstive personnel? Select all that apply.

Assist the client with a partial bed bath is correct. Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function.

Measure the client's BP after the nurse administers an antihypertensive medication is correct. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function.

Test the client's swallowing ability by providing thickened liquids is incorrect. Assessing the client's swallowing ability places the client at risk for aspiration and is not within the AP's range of function. Nurses perform tasks that require assessment.

Use a communication board to ask what the client wants for lunch is correct. Using a communication board poses minimal risk to the client and is within the AP's range of function.

Irrigate the client's indwelling urinary catheter is incorrect. Irrigating the client's indwelling urinary catheter is an invasive procedure and is not within the AP's range of function

A nurse is performing a skin assessment for a client's who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance.

An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping

This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

SBAR

SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is education a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

We would give you oxygen through a tube in your nose.

Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is caring for a client with a NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse in a long-term care facility is caring for a client who dies.

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instruction should the nurse include in the teaching?

Administer the medication into the abdomen.

The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse take?

The indicate the form of treatment a client is willing to accept in the event of a serious illness.

Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs? Select all that apply.

Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge.

Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly.

Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety.

Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall.

Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

calf swelling

Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is administering 1 mL of 0.9% NS to a client who is postoperative and has a fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

Examine personal value about the issue.

Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

A nurse is using an open irrigation technique to irrigate a client's indwelling catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

A nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.