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Question
A client with paranoid schizophrenia is threatening the staff and believes the staff is trying to harm him. When the nurse enters the client's room, the client is agitated, and attempts to slap the nurse. The nurse gets assistance from other staff members and restrains the client. Which nursing action is the priority at this time?1. Requesting a psychiatric referral
2. Notifying the health care provider of the need to see the client
3. Padding the side rails
4. Obtaining consent from the client for use of restraints
Answer
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Related questions
Q:
A client is recovering from hip arthroplasty using the anterolateral approach. What should the nurse ensure to maintain the integrity of the joint?
1. Place needed items on operative side
2. Keep needed items on the non-operative side
3. Instruct to avoid bending at the waist to put on shoes
4. Instruct to avoid crossing the operative leg past the body's midline
Q:
A client's x-ray report shows a fractured leg where one part of fractured bone is driven into another. How should the nurse document this client's fracture?
1. Impacted
2. Greenstick
3. Comminuted
4. Compression
Q:
The nurse caring for a client in traction inspects the apparatus and determines all is well when noting which finding?
1. The weight is sitting on the floor.
2. The rope is on the side of the pulley.
3. The knots are positioned 5 inches from the pulley.
4. All ropes are intact and connected with slipknots, and short ends are taped.
Q:
Which task could be safely delegated by the nurse to the unlicensed assistive personnel (UAP)?
1. Caring of the client with the newly placed cast
2. Explaining to the client how to respond to itching under the cast
3. Caring of the insertion site for Crutchfield tongs
4. Caring of the client with a stable cast
Q:
An adolescent client newly placed in traction says, "Lying in this bed all the time is going to turn my body into mush. Is there any way I could exercise while I'm in traction?" Which response by the nurse is the most appropriate?
1. "Many people worry about muscle weakness when they are confined to bed. You could perform range of motion, isometric, and specific exercises."
2. "Don't worry about your muscles, because you can get them back after you get out of traction."
3. "You're young and in great shape. Your muscles won't weaken with a few weeks in bed."
4. "I'll put a referral in for physical therapy to come and work with you."
Q:
For which client should the nurse anticipate a plaster cast would be used?
1. The client with a diagnosis of amyotrophic lateral sclerosis (ALS)
2. The client who had a compound fracture and multiple lacerations
3. The older adult client with muscle wasting secondary to cancer
4. The client with a fractured femur who plans to return to construction work before cast removal
Q:
The nurse is performing a damp-to-damp dressing change, and is removing the old dressing. Part of the dressing is adhered to the tissue. Which action by the nurse is the most appropriate?
1. Removing that part of the dressing quickly, to reduce the pain
2. Wetting the dressing with alcohol to release the section adhered to the wound
3. Wetting the dressing with tap water to release the section adhered to the wound
4. Wetting the dressing with sterile saline to release the section adhered to the wound
Q:
The nurse is applying a hydrocolloid dressing to a client's wound, which measures 2 inches by 3 inches. The nurse should cut the dressing to which dimensions?
1. 3.25 inches by 4.55 inches
2. 2 inches by 3 inches
3. 1 1/2 inches by 2 1/2 inches
4. 1 inch by 1 1/2 inches
Q:
The nurse changes the client's IV dressing and removes the existing transparent wound barrier. Prior to applying the new barrier, which action by the nurse is the most appropriate?
1. Applying benzoin to make the dressing stick firmly
2. Placing a sterile piece of gauze over the insertion site before placing a new transparent barrier over the wound
3. Cleansing the site with normal saline or a mild cleansing agent
4. Applying sterile gloves
Q:
The nurse is caring for a client with induced hypothermia for major thoracic surgery. For which potential health problems should the nurse assess this client? Select all that apply.
1. Acidosis
2. Afterdrop
3. Hypotension
4. Hypertension
5. Rebound fever
Q:
The nurse receives a call from a client who reports a deep, long cut to the left hand sustained while slicing a bagel and asks the nurse what to do. Which action should the nurse direct the client to take?
1. Elevate the arm above the head and apply ice and pressure while en route to the emergency department.
2. Apply heat and pressure en route to the emergency department.
3. Apply ice and elevate the arm.
4. Apply pressure and elevate the arm.
Q:
The nurse is providing ostomy care for a client with a colostomy. Which assessment findings should the nurse report to the health care provider if noted during the procedure?
Standard Text: Select all that apply.
1. No change in stoma size
2. A stoma that appears dry and grey in color
3. The presence of skin irritation
4. The amount of drainage
5. The odor of the drainage
Q:
The nurse is working with unlicensed assistive personnel (UAP) in a long-term care facility. Which tasks can the nurse delegate to the UAP?
Standard Text: Select all that apply.
1. Administering an enema to a stable client
2. Removing a fecal impaction for an unstable client
3. Assisting a client to perform ostomy care after hand surgery
4. Helping a client onto a bedpan
5. Assessing skin during an ostomy appliance change
Q:
The nurse is changing the ostomy appliance for a client with a new loop colostomy. Which action by the nurse is the most appropriate?
1. Remove the plastic bridge in order to create a tight fit with the ostomy appliance.
2. Cut two holes in the skin barrier for each loop.
3. Cut an opening in the skin barrier for only the afferent or proximal end of the stoma.
4. Place a piece of tissue or gauze over the stoma, and use a guide to measure the size of the stoma.
Q:
The nurse is administering a cleansing enema. Which action would indicate the need for further instruction on the process?
1. Enema solution is warmed to 40C (105F).
2. The solution container is held 12 inches above the rectum.
3. The client is in the Fowler's position.
4. The client is encouraged to retain the enema for 5"10 minutes.
Q:
A client with chronic renal failure is being discharged after surgery to create an arteriovenous fistula for hemodialysis. Which client statements indicate that teaching provided about the care of this fistula have been effective? Select all that apply.
1. "I will not lie on the arm with the fistula."
2. "I will not wear clothing with tight sleeves."
3. "I will contact the doctor if my hand feels cold."
4. "I will tell people to use the fistula arm for blood pressures."
5. "I will not carry anything heavy with my arm with the fistula."
Q:
A client with a closed urinary drainage system is demonstrating signs of a urinary tract infection. In which order should the nurse obtain a urine specimen from this system?
1. Remove gloves
2. Clamp the tubing
3. Cleans the access port
4. Perform hand hygiene
5. Remove drainage clamp
6. Aspirate a 2 mL sample of urine
7. Transfer urine to a specimen cup
8. Engage Luer-Lok syringe to the port
Q:
The nurse is caring for a client receiving continuous bladder irrigation following transurethral prostatectomy. When emptying the urine collection bag, the nurse notes that 500 mL of irrigant has infused with only 100 mL of drainage returned. Which is the priority action by the nurse?
1. Irrigating the outflow port using an irrigation syringe to determine patency
2. Notifying the health care provider immediately
3. Irrigating the irrigation port to determine patency
4. Continuing to monitor output
Q:
A client is scheduled for a diagnostic test using radioactive isotopes. What should the nurse expect to be provided to this client before the test?
1. A sedative
2. A blocking agent
3. Intravenous fluids
4. A dose of an antibiotic
Q:
A staff nurse position has been posted for the radiology department. Which nurse is the most qualified for this position?
1. Nurse with 10 years of experience in the intensive care unit
2. Nurse with 6 months of experience in the post anesthesia care unit
3. Nurse with 7 years of experience working in the hemodialysis center
4. Nurse with 4 years of experience in the outpatient ambulatory center
Q:
The nurse obtains a specimen from the client's wound. Which items will the nurse include when documenting this procedure in the medical record?
Standard Text: Select all that apply.
1. Source of specimen
2. Type of culture obtained
3. Appearance of wound
4. Dispersal of the specimen
5. Microorganism causing infection
Q:
The nurse is obtaining a throat culture. Which action indicates correct technique?
1. Inserting the swab into the sterile tube without touching the outside of the container
2. Inserting a tongue blade to depress the anterior two-thirds of the tongue
3. Swabbing along the side of the cheek inside the mouth
4. Swabbing the pharynx gently and quickly, avoiding the tonsils
Q:
The nurse is collecting a capillary blood specimen. Which statement demonstrates proper technique for this procedure?
1. Clean the site with alcohol, and puncture the finger quickly, then collect the first drop of blood.
2. If the puncture site is not bleeding, squeeze the finger as firmly as possible without causing pain.
3. Clean the site with alcohol, puncture the finger, wipe the first drop of blood with gauze, and then collect the specimen.
4. Puncture the finger in the center of the pad, which is more vascular.
Q:
The nurse performs a guaiac stool test and gets a positive result. Based on this test result, which diagnosis is least expected for this client?
1. Colon cancer
2. Hemorrhoids
3. Bleeding stomach ulcers
4. HIV/AIDS
Q:
The nurse receives an order to collect a midstream urine specimen from the client. Which is not a part of collecting this specimen?
1. Teaching the client how to clean the genitals prior to collecting the specimen
2. Labeling the specimen and sending it to the lab
3. Assuring that the specimen is collected following sterile technique
4. Documenting that the specimen has been collected and what was done with it
Q:
Which clients should the nurse consider as candidates for an enteral access device?
Standard Text: Select all that apply.
1. The client who is NPO in preparation for surgery
2. The client with an absent cough and gag reflex
3. The postoperative client who returns to the unit following bowel resection who is unconscious secondary to sedation
4. The client who needs stomach contents sent for laboratory analysis
5. The client who overdosed on an oral medication
Q:
When assessing the client's nutritional status and needs, which type of assessment is the most important for the nurse to use?
1. A complete nutritional assessment
2. A nutritional screening
3. A comprehensive nutritional assessment
4. An in-depth nutritional assessment
Q:
The responsibility for nutritional assessment and support in most health care facilities belongs to which individuals?
Standard Text: Select all that apply.
1. The client
2. The primary care provider
3. The nurse
4. The dietitian or nutritionist
5. The food service staff
Q:
The nurse working in an oncology clinic is caring for a client diagnosed with breast cancer. The client reports anorexia and weight loss. The client's serum albumin is low, and there is visible muscle and fat wasting. Which term should the nurse use when documenting this client's appearance?
1. Malnutrition
2. Undernutrition
3. Overnutrition
4. Protein-calorie malnutrition
Q:
The nurse is preparing to provide an intramuscular injection. For which reason should the nurse use the Z-track technique?
1. Takes less time
2. Is an easier method
3. Prevents leakage into subcutaneous tissue
4. Able to use the deltoid muscle for the injection