Q&A Hero

Q: A client with a new case is complaining of itching under the cast. Which should the nurse instruct this client? 1. Use a back scratcher to scratch under the cast. 2. Use a wooden spoon to scratch inside the cast. 3. Blow air from a hair dryer set to cool under the cast, or apply ice. 4. Take an antihistamine to reduce itching.

Q: The nurse working in the emergency department (ED) is providing discharge teaching for a client with a newly applied cast to the left arm. Which statement by the client indicates additional teaching is required? 1. "When I take a shower, I will put a plastic bag over my cast and keep it dry." 2. "When my fingers feel cold, I will cover them with a blanket." 3. "I will go home today and put ice on the cast over the fracture and prop it on pillows." 4. "If I lose sensation in my fingers, I will call my doctor."

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 observes the health care provider apply a cast made of strips of open-weave cotton saturated with powdered calcium sulfate crystals. When documenting this procedure, which term should the nurse use for this type of cast? 1. Plaster cast 2. Synthetic cast 3. Fiberglass cast 4. Thermoplastic cast

Q: The nurse is caring for a client with a fracture of cervical vertebrae 4. Which piece of equipment connects the client to traction for this type of injury? 1. Pearson attachment 2. Buck's extension 3. Thomas splint 4. Crutchfield tongs

Q: A client receiving an opiate for postoperative pain management is experiencing nausea and vomiting. What action would be the most beneficial for the client? 1. Provide an emesis basin 2. Maintain on NPO status 3. Keep Narcan at the bedside 4. Administer an antiemetic as prescribed

Q: The nurse notes that a client is scheduled to receive conscious sedation for a surgical procedure. What should the nurse review prior to preparing the client for this type of anesthesia? 1. Adverse effects 2. Reversal agents 3. State nurse practice act 4. Assignment of a student nurse

Q: The nurse is preparing preoperative medications for a client. Which medication will reduce the amount of respiratory secretions? 1. Opiate 2. Antibiotic 3. Antianxiolytic 4. Anticholinergic

Q: Before beginning a surgical procedure the safety checklist is reviewed. Which information is necessary prior to starting this client's case? 1. Date of birth 2. Known allergies 3. Last urine output 4. Family members' names

Q: The nurse is caring for a client who had surgery a day ago. Which observation indicates that the client was physically prepared for the procedure? 1. Does leg exercises 3 times a day 2. Rates pain as 5 on a scale from 0 to 10 3. Permits staff to reposition in bed every 2 to 4 hours 4. Deep breathes and coughs every 2 hours while awake

Q: A client is highly anxious about an upcoming surgical procedure. What action should the nurse take to reduce this client's anxiety? 1. Answer the client's questions 2. Provide written teaching material 3. Instruct on range of motion exercises 4. Assign to review videotapes prior to teaching

Q: A client scheduled for surgery is demonstrating mild levels of stress. How should this stress level affect the client's recovery? Select all that apply. 1. Increased alertness 2. Increased wound healing 3. Increased ability to learn 4. Increased ability to adjust to stressors 5. Increased adjustment to the environment

Q: The nurse is caring for a client scheduled for surgery the next day. On what should the nurse focus to determine this client's level of stress? Select all that apply. 1. The surgical procedure 2. The client's religious beliefs 3. If the surgery is going to alter the client's life 4. Client's perception of the surgical experience 5. Number of stress-producing events in the client's recent past

Q: The nurse is completing the preoperative checklist on the night shift in preparation for the client's surgery, scheduled for 0800. Which tasks could the nurse complete at this time? 1. Documenting the time of last voiding 2. Checking the medical record for the history, physical, and signed informed consent 3. Administering preoperative medication 4. Removing the prosthesis

Q: The nurse performs preoperative teaching for a client requiring a surgical intervention. Which actions by the client indicate appropriate understanding of the information provided? Standard Text: Select all that apply. 1. Demonstrating proper coughing and deep breathing 2. Asking questions about and voicing understanding of information provided 3. Having no anxiety about the impending surgery 4. Demonstrating proper performance of leg exercises 5. Demonstrating how to turn and get out of bed

Q: A postoperative client displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. Which complication should the nurse suspect is occurring? 1. Pneumonia 2. Atelectasis 3. Hypovolemia 4. Pulmonary embolism

Q: In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital, the need for which provision of care? 1. Type of diet 2. Activity level 3. Assessment intervals 4. Intravenous solutions

Q: Upon receiving the client from the postanesthesia care unit, which nursing action is the priority? 1. Apply clean linens to the bed. 2. Assemble required equipment, such as suction, IV pole, or oxygen equipment. 3. Assess the client. 4. Notify the family of the client's return to the room.

Q: When providing preoperative teaching for the client who is scheduled for coronary artery bypass surgery in the morning, the nurse should include which dimensions? Standard Text: Select all that apply. 1. Information 2. Psychosocial support 3. The role of the client and support people 4. Skills training 5. Coughing and deep breathing

Q: The nurse administers the preoperative medication to the client 1 hour before elective surgery, and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate? 1. Have the client sign the consent quickly, before the medication begins taking effect. 2. Have a family member or medical power of attorney sign the consent. 3. Send the client to the holding area without a signed consent. 4. Notify the health care provider that surgery will need to be canceled.

Q: A client arrives at the surgeon's office 1 week after surgery to have the sutures removed. Which classification should the nurse use when documenting care for this client? 1. Preoperative 2. Postoperative 3. Perioperative 4. Intraoperative

Q: A client is scheduled for surgery the new day. Which type of teaching should the nurse provide? 1. Postoperative 2. Preoperative 3. Perioperative 4. Intraoperative

Q: A client has a deep wound with areas of exudate and eschar. Which would be the fastest way to debride this wound? 1. Surgical 2. Chemical 3. Autolytic 4. Mechanical

Q: The nurse is preparing a care plan for a client with a stage IV pressure ulcer. What should be the goals of care for this client? Select all that apply. 1. Speed healing 2. Absorb drainage 3. Prevent infection 4. Prevent from injury 5. Remove necrotic tissue

Q: The nurse is preparing to assist with the debridement of a client's wounds. In which order should the nurse complete surgical hand antisepsis? 1. Remove all jewelry 2. Wet hands with warm water. 3. Turn on water using foot pedal 4. Completely dry hands and forearms 5. Rub hands together for at least 20 sec 6. Apply 3"5 mL of antimicrobial soap to hands 7. Scrub hands and forearms up to 3 in. above elbows 8. Rinse hands and arms from finger tips to elbows

Q: Prior to beginning a client's intravenous antibiotics the nurse needs to culture the wound. In which order should the nurse perform the steps to obtain this culture? 2. Use non"cotton-tipped swab 6. Place swab in culture medium 3. Rotate swab while obtaining specimen 1. Rinse wound thoroughly with sterile saline 5. Do not take specimen from exudate or eschar 4. Swab edges starting at top, crisscross wound to bottom

Q: The nurse is preparing to assess a wound on a new admission on a medical"surgical unit. Which items should the nurse review in the medical record prior to assessing the client's wound? Standard Text: Select all that apply. 1. The cause of the wound 2. The length of time the wound has been present 3. The previous treatments and client responses 4. The equipment used by other nurses 5. The current medication list

Q: When the nurse documents a client's wound, which is the best means of describing the wound? 1. Measuring the wound and documenting size 2. Comparing the wound to a universally understood object, such as a quarter or cashew 3. Using terms such as small, medium, or large 4. Taking a picture and inserting it into the record

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 irrigating a wound with tracts and crevices. Which piece of equipment should be applied to the syringe in order to irrigate these areas? 1. A 22 gauge needle 2. A small gauge Robinson catheter 3. An IV catheter with the needle removed 4. An IV catheter with the needle in place

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 changing the client's dressing on a postoperative nondraining wound. Which personal protective equipment (PPE) should the nurse apply prior to the dressing change? 1. Sterile gown, mask, and sterile gloves 2. Sterile gown, mask, and goggles 3. Sterile gloves and mask 4. Sterile gloves

Q: Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)? 1. Changing the postoperative dressing on a clean wound 2. Irrigating the client's wound 3. Apply a dry dressing 4. Performing a damp-to-damp dressing change

Q: The nurse is admitting a client with a pressure ulcer to the long-term care facility. When assessing the wound, the nurse finds partial-thickness skin loss free of eschar. In which stage is this client's ulcer? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

Q: A client is assessed as: having no sensory deficits; skin is dry and not exposed to moisture; confined to bed; is completely immobile; requires moderate assistance in moving; and nutritional status is adequate. Which pressure ulcer risk score is the most appropriate based on the assessment data? 1. 14, indicating moderate risk 2. 15, indicating high risk 3. 12, indicating risk 4. 14, indicating high risk

Q: For which client should the nurse consider applying a transparent film for wound care? 1. The client with a postoperative wound held together by sutures 2. A client with a stage I pressure ulcer 3. The client with a venous stasis ulcer 4. A client with a highly exudative wound

Q: The client experiences a burn on the arm that is confined to the skin. How should the nurse describe this burn when documenting this client's care? 1. A clean wound 2. A dirty or infected wound 3. A partial-thickness wound 4. A full-thickness wound

Q: The nurse notes black necrotic tissue on the client's wound. Which term should the nurse use when documenting this finding? 1. Debridement 2. Eschar 3. Alginate 4. Purulence

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 is caring for a client with body temperature instability. What hypothalamic reactions should the nurse consider occurring to help control the client's temperature instability? Select all that apply. 1. Radiation 2. Convection 3. Conduction 4. Evaporation 5. Condensation

Q: The nurse is instructing the unlicensed assistive personnel (UAP) to apply a warm compress to the client's knee. Which statement made by the UAP indicates that further instruction should be given? 1. "I can place the heating pad directly to the client's knee." 2. "I will maintain the proper temperature of the heating pad." 3. "I will inform you of any redness of the skin." 4. "I will report to you when the treatment is over."

Q: The nurse is going to apply a cold compress to a client's lower forearm. What nursing intervention would be indicated? 1. Decrease the length of time the cold compress would normally be applied. 2. Increase the length of time that the compress would be applied. 3. Keep the length of time the same as it would be when applying to other areas of the body. 4. Leave the cold compress in place until it is no longer cool.

Q: Many conditions can increase the risk for injury from heat applications. Which clients would be at the greatest risk for injury? Standard Text: Select all that apply. 1. A client with a lot of body fat 2. A client being treated for anxiety 3. A client with peripheral vascular disease 4. A malnourished client 5. A client prescribed steroids

Q: The nurse applies a warm moist compress to the client's left wrist. Which item should the nurse exclude from the documentation of the intervention for this client? 1. Assessment of site before and after the application 2. Client's response to the compress 3. Assessment of the site every 5"10 minutes 4. Vital signs before, during, and after the treatment

Q: The nurse is applying a warm moist compress to the client's right calf. Prior to putting the compress in place, which action by the nurse is the most appropriate? 1. Turn the client onto the left side. 2. Position the client appropriately. 3. Turn the client onto the right side. 4. Elevate the head of the bed.

Q: The nurse is preparing an ice bag to apply to the client's sprained left ankle. How should the nurse fill the bag? 1. One-third full of ice, and add water to make it more pliable 2. One-half to two-thirds full of crushed ice 3. Completely full to make it last longer 4. One-third to two-thirds full of ice cubes

Q: Which is the most effective way for the nurse to apply an appliance such as a hot water bottle or disposable hot pack to a client? 1. Directly to the client's skin 2. Directly to the client's skin with a towel or blanket wrapped over the appliance to hold it to the leg 3. If possible, have the client lay on top of the appliance 4. Wrap the appliance in a towel and lay it on the site on the client

Q: The nurse is applying an aquathermia pad to a client complaining of arthritic pain in the right knee. Which filler is appropriate for this unit? 1. Sterile water 2. Normal saline 3. Tap water 4. Distilled water

Q: While applying a warm wet soak to the client's left leg, the unlicensed assistive personnel (UAP) notes a small burn on the inside of the calf. The UAP informs the RN. Which response by the nurse is the most appropriate? 1. "Please notify the health care provider." 2. "Describe the burn in detail, please." 3. "I'll go take a look at it." 4. "Make sure you document it and complete an incident form."

Q: Which activity can the nurse safely delegate to unlicensed assistive personnel (UAP)? 1. Sterile warm soak to client's infected postoperative wound 2. Application of warm moist soak to client's left leg 3. Determine effectiveness of cold application to reduce client's pain 4. Responsibilities for the application of a warm pack to client's IV infiltrate

Q: The nurse is providing care to several clients on a medical"surgical unit. Which clients would benefit from the application of heat? Standard Text: Select all that apply. 1. Client with muscle spasms in the lower back 2. Client with traumatic injury and bleeding 3. Client with joint contracture 4. Client in pain 5. Client with inflammation

Q: The nurse is caring for a client diagnosed with osteoarthritis. Which intervention should the nurse advise the client to do in order to reduce discomfort? 1. Apply ice to the painful joint. 2. Immerse the painful joint in cold water. 3. Apply heat pack once a day. 4. Apply heat to the painful joint several times a day.

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 client calls the nurse into the room and says that the heat pack the nurse applied feels cold, and asks the nurse to turn the heat up on the aquathermia unit. Which response by the nurse is the most appropriate? 1. "I'll turn it up a little at a time and you let me know when it feels warm again." 2. "The doctor wants the aquathermia pad maintained at a specific temperature, so there's no need to change it." 3. "The aquathermia pad still feels warm to me." 4. "Your body has adjusted to the warmth, and is making it feel cooler, but it's actually the same temperature as when it was first applied."

Q: The nurse applies an aquathermia heat pack to the client's right leg and removes it after no more than 45 minutes. What is the nurse trying to avoid by completing this action? 1. Vasodilation 2. Rebound phenomenon 3. Heat tolerance 4. Systemic effects

Q: A client with a rectal tube begins to experience diarrhea. What should the nurse do? 1. Clamp the tube 2. Remove the tube 3. Reposition the client 4. Attach a collection bag

Q: A client is considering the placement of a continent ileostomy. What should the nurse explain as an advantage of this type of surgery? 1. Gas may be expelled 2. An appliance is not needed 3. Additional surgery may be required 4. A drainage catheter needs to be inserted several times a day

Q: The nurse notes that the skin around the stoma of a client with an ileostomy is partially denuded. What should the nurse do? 1. Keep the appliance off 2. Apply skin barrier paste 3. Apply Stomahesive powder 4. Increase the size of the stoma opening on the barrier

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 educator is conducting an in-service to a group of new nurses regarding the use of ostomy appliances. When discussing the characteristics of ostomy appliances, which statements are appropriate for the educator to include in the presentation? Standard Text: Select all that apply. 1. The ostomy appliance comes in a three-piece set. 2. The ostomy appliance should protect the skin near the stoma. 3. The ostomy appliance should collect both stool and urine. 4. The ostomy appliance controls odor. 5. All ostomy appliances can only be used once.

Q: The nurse is caring for a client with a newly created ostomy. After changing the ostomy appliance, which items should the nurse include when documenting the procedure? Standard Text: Select all that apply. 1. How the drainage was disposed 2. Quantity of drainage recorded on output record 3. Any client participation in the procedure 4. Assessment of stoma and skin around the stoma 5. The odor of the drainage

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: While the nurse is removing a fecal impaction, the client begins to perspire profusely and complains of shortness of breath. The nurse notes that the client's pulse rate has slowed to 44 beats per minute. Which is the priority action by the nurse? 1. Holding the fingers still until the symptoms stop, and then resuming removal of fecal impaction 2. Stopping the procedure immediately 3. Continuing the procedure, and monitoring the client carefully 4. Stopping the procedure and calling the health care provider immediately

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: The nurse is caring for a client who is on complete bed rest secondary to a deep vein thrombosis in the right leg. When placing the client on the bedpan, which position is most appropriate? 1. Prone 2. Semi-Fowler's 3. Fowler's 4. Supine

Q: Which actions could the nurse safely delegate to the unlicensed assistive personnel (UAP)? Standard Text: Select all that apply. 1. Assist the client to use the bedpan for bowel elimination. 2. Change the ostomy appliance for the new ostomy. 3. Administer a cleansing enema. 4. Remove a fecal impaction. 5. Determine effectiveness of cleansing enema.

Q: The nurse is caring for an older adult client with an ileostomy and hemiplegia secondary to a stroke experienced a few years ago. When changing the client's one-piece appliance, the nurse finds the skin under the skin barrier is ulcerated and erythematous. The client does not empty the pouch until it is completely full because it hurts so much to remove the skin barrier. Which action by the nurse is the priority? 1. Apply a two-piece ostomy appliance. 2. Treat the damaged skin and replace the one-piece pouch. 3. Keep the skin open to air to allow time for healing, and replace the ostomy appliance in a few days. 4. Call the health care provider to report the damaged skin.

Q: The nurse assists the client off the bedpan after defecating. After emptying and cleaning the bedpan, the nurse finds the bedside table is full, and there is no room for storage of the pan. Which action by the nurse is the most appropriate? 1. Store the bedpan under the bed, where it is out of sight. 2. Place the bedpan on the overbed table until creating a space in the bedside table. 3. Place the bedpan on the floor of the bathroom behind or on the side of the toilet, where it is not likely to be tripped over. 4. Remove objects from the bedside stand and return the bedpan to the stand.

Q: The nurse is caring for a client who complains of frequent constipation. Which factor in the client's history is least likely to be the cause of the constipation? 1. Inadequate fluid intake 2. Repeated inhibition of the urge to defecate 3. Inadequate fiber intake 4. The presence of Escherichia coli

Q: The nurse is caring for a client with a colostomy who has continuous liquid drainage with a fecal odor. Which term should the nurse use when documenting the type of colostomy for this client? 1. Ileostomy 2. Ascending colostomy 3. Transverse colostomy 4. Descending colostomy

Q: The nurse is caring for a client with abdominal distention who is unable to expel flatus. Which type of enema should the nurse anticipate administering? 1. Cleansing enema 2. Carminative enema 3. Retention enema 4. Soapsuds enema

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: Prior to applying the condom catheter, which action by the nurse is the most appropriate? 1. Documenting the use of the catheter 2. Inspecting and cleansing the penis 3. Calling the health care provider to obtain an order 4. Attaching the urinary drainage system securely

Q: After applying a condom catheter, what should the nurse document? Standard Text: Select all that apply. 1. Appearance of the penis, such as swelling or discoloration 2. Amount of urine flow 3. Assessment 30 minutes after application and every 8 hours thereafter 4. Any client complaints or concerns 5. Time of application

Q: The nurse is caring for a client with a newly created urinary diversion ostomy appliance. Which is the priority when caring for this client? 1. Increasing fluid intake 2. Limiting fluid intake 3. Administering IV fluids, because the client will be NPO 4. Teaching the client self-care and support persons' care

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: The nurse is caring for a client with an indwelling catheter. When emptying the urine collection bag, the nurse notes the urine is cloudy with moderate amounts of sedimentation and a foul odor. Based on these assessment findings, what should the nurse suspect? 1. Urethral irritation 2. Bladder atrophy 3. Urinary tract infection 4. Kidney infection