Basic Care and Comfort

A nurse is performing discharge instructions to a patient who has undergone a left total hip replacement. The nurse is providing instructions on the correct use of a cane following their discharge to home. Which one of the following statements indicates the patient needs further instruction?

A term used to refer to generalized wasting of body tissues and malnutrition is called:

Which of the following clients is at a higher risk of developing oral health problems?

A nurse is providing care for a patient who has undergone a left knee replacement. Upon assessment, she notices that the patient has redness, warmth, and swelling on the right calf. The patient also complains of increased pain in the right leg when ambulating. What would be the priority nursing action?

A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?

Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity?

A patient on a medical-surgical unit who was admitted for chest pain, past medical history includes: DMII, COPD, CHF, and Atrial fibrillation. The following information is obtained upon assessment: VS: T- 99.9, P-62, R-20, BP-100/90, Sp02-91% on RA. Patient has diminished lung sounds in the bases and +3 edema in the lower extremities. The patient is currently receiving 80ml/hr of NS through a peripheral IV. He has a foley catheter that has put out 45 ml in the last two hours, however he had 70ml of urine output the two hours prior. Which of the following is most concerning that the nurse should notify the physician immediately?

A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?

A nurse is assisting a client who uses an intraaural hearing aid. Once the aid has been placed in the ear, it begins to whistle. What is the next action of the nurse?

A nurse is calculating a client’s intake and output. During the last shift, the client has had ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client has urinated 250 cc and has had 2 bowel movements. What is this client’s intake and output for this shift?

A school nurse is providing care for a student who had injured his left ankle on the playground. The student is rating pain a 6/10. The nurse advises the student not to bear weight on his left ankle until he is assessed by a primary care provider. While the student waits for his mother to arrive, the school nurse applies ice to the ankle. This is a correct action by the nurse because cold:

A nurse is caring for a client with ariboflavinosis. Which of the following foods should the nurse serve this client?

A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent?

Which of the following is part of client teaching regarding anti-embolism stockings?

A nurse is providing discharge instructions to a 15 year old female following a left fibula fracture. The physician has written the discharge instructions as ‘partial-weight bearing for 2 weeks and must use crutches for all transferring for one week until walker is fit by physical therapy.’ The patient indicates she has understood the instructions when she states the following:

Which of the following reasons is the most likely cause of constipation in a client?

A nurse is assisting a client with a range of motion exercises. She moves his leg in a pattern of circumduction. Which movement is this nurse performing?

A nurse is assisting a client to lie in the Sims’ position. In what position does the nurse arrange the client?

A nurse is instructing a client about how to use his crutches. Which of the following information should the nurse include in her teaching?

Which of the following is a disadvantage of using a dry heat application?

A nurse is coming onto her shift at 07:00 and is assigned four patients on an orthopedic medical-surgical unit. The first patient is post-op day two from a left-knee replacement and has had uncontrolled pain through the night, rating the pain 9/10. The second patient is post-op day one and ordered an antibiotic IV at 07:30. The third patient has physical therapy at 08:00 and is requesting pain medication one hour before therapy. The fourth patient is complaining of SOB and hematemesis. Which patient would the nurse see first?

Which of the following signs or symptoms indicates a possible nutritional deficiency?

A nurse is preparing to insert a small-bore nasogastric feeding tube for a client’s enteral feedings. In which method does the nurse measure the correct length of the tube?

In which of the following ways can a nurse promote sleep for a client who is experiencing insomnia?

A nurse is preparing to irrigate a client’s colostomy. Which of the following situations is a contraindication for this type of irrigation?

A nurse is providing discharge instructions to a patient who will be discharged to a transitional care unit following a right-sided CVA. The patient is ordered a standard walker for ambulation. Which statement by the nurse is the correct discharge instructions for the patient?

The nurse is assessing a patient at 1900 who has undergone a total knee replacement. The patient was ordered antiembolic stockings by his physician to prevent thrombus formation. The stockings were applied at 1100 and have not yet been removed. The following action taken by the nurse is a priority:

A nurse is preparing to attach a TENS unit to a client who is experiencing pain. Which of the following actions is most appropriate in this situation?

When cleansing the genital area during perineal care, the nurse should _______.

You are ready to wash your patient’s face. You would start by washing what area of the face?

Patients who cannot move in their bed on their own should be turned at least _______.

Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness fluids for her. Water is not a honey thickness fluid. It is much thinner. What should you do?

You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

Mr. Thomas is a well groomed 68 year old male patient. He had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?

The nurse is providing teaching instructions to a group of clients who will have planned orthopedic surgeries next week. She is reviewing methods to reduce the compression of leg veins post-operatively when a client voices concerns of blood clots. Which of the following statements by the client would indicate the need for further teaching?

You are providing mouth care to a patient who is in a coma. You should ___________ to provide good and safe mouth care.

This particular gland of the endocrine system secretes a hormone that is known to assist with the sleep/ wake cycle. What gland is it?

Digestion, elimination and ___________ are the three functions of the digestive system.

Which of the following is an example of restorative care?

Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for: