D. Keep client on complete bed rest during TPN therapy. An obese client who uses a wheelchair A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Particularly in the elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. 16. The first step in pain assessment is for the nurse to, A. have the client identify coping methods 12. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg, Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg. Hopefully this helps someone else out later on down the line. Answer: A. exercise doing weight bearing activities. C. monitor glucose levels. Which statement best describes the effects of immobility in children? An 85-year-old male patient has been bedridden for two weeks. Spend your time wisely! This preview shows page 8 - 10 out of 27 pages. The excess fluid will back flow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids. The nurse is observing a newly licenced nurse who is preparing a sterile field for a dressing change. 50+ Tips & Techniques on IV... IV Fluids and Solutions Guide & Cheat Sheet (2020 Update), Cranial Nerves Assessment Chart and Cheat Sheet, Diabetes Mellitus Reviewer and NCLEX Questions (100 Items), Drug Dosage Calculations NCLEX Practice Questions (100+ Items). Drug related hearing losses have a typically abrupt and sudden onset when the medication is begun. Which of the following actions should the nurse identify as. Any items you have not completed will be marked incorrect. 2. The handle of the cane is even with the client's waist. Nurses must assess and reassess the client's safe and appropriate use of all assistive devices, as discussed above and immediately below. A. Which of the following actions is the appropriate manner for handling infectious waste? The client's weight is sustained by the hands; there should not be any weight or pressure on the arm pits when the person is walking with their crutches. The whole wheat bread has some fiber. Assistive devices facilitate the clients' communication abilities, their performance of the activities of daily living, their highest possible level of independence, the prevention of the complications associated with immobility, and it also enhances the patient's feelings of self-esteem and self-worth. Option 1 is incorrect; elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Weight bearing exercises are beneficial in the treatment of osteoporosis. B. Immobility in children has similar physical effects to those found in adults Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet? Properly fitting crutches should have the client's hands firmly placed on the grips. Skin blanching, edema, and coolness at the IV site indicate infiltration, A nurse is providing care to four clients. As she moves the weak leg, the cane and the strong leg provide support. If you leave this page, your progress will be lost. The client holds the cane with his right hand, moves the cane forward followed by the right leg, and then moves the left leg. Thanks so much, I haven't had much experience with this and may actually have some later today. B. Soreness of the gums B. The client’s dietary habits include foods high in bulk. Which of the following actions is the appropriate manner for handling infectious waste? Answer: A. Elevate the head of the bed on 4-6 inch blocks. 12. The need for an artificial limb can occur as the result of some congenital anomaly, as the result of an accidental traumatic amputation of a limb, and also as a planned process when the client has a limb that has to be amputated, as often occurs among clients with diabetes. Which factor indicates further information is needed by the nurse? Lie down after eating. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple b. When Mrs. Kennedy. For example, the nurse may refer the client to an ophthalmologist or optician when an actual or potential visual deficit is present; an audiologist or hearing aid professional may be referred for the client when they have an actual or potential auditory deficit; and a speech and language therapist may be contacted in order to evaluate and assess clients with a speech and oral communication deficit. Which of the following actions is the appropriate manner for handling infectious waste? A nurse is assessing several clients in a long term health care facility. The top of the cane is parallel to the client’s waist. In most health care facilities, a physical therapist, in collaboration with nurses and other health care professionals, assess the client for these assistive devices and the physical therapist and/or the nurse instructs the client about their proper use and maintenance. This choice shows a low-fat soup (which would have been higher in fat if made with chicken or beef stock) and high-fiber bread and soup contents (both the vegetables and the legumes). B. Nasogastric Enteral Ostomy Lab Day Topics.doc, Fluid balance, IV therapy and bld transfusion.docx, Health Career Institute • NURSING NURSING II. The client holds the cane on the stronger side of her body. D. Children are likely to have prolonged immobility with subsequent complications. trachea and prevent the tube's passage into the trachea. to help damaged tissue in a diabetic to heal. C. to help damaged tissue in a diabetic to heal. Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)? Walkers can be with or without wheels, with or without brakes, and with or without a seat that the client can use when they need to rest during a long walk. Decreased appetite is unlikely to be related to immobility. Drink small amounts of milk on an empty stomach. 1. broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk Real quick, when you're instructing a client on the proper use of walking with a cane, do they hold the cane on their weak side or strong side? Answer: D. encouraging the use of an overhead trapeze. 8. Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)? Vegetable soup made with vegetable stock, carrots, celery, and legumes served with toasted oat bread, Chef’s salad with hard boiled eggs and fat-free dressing, Broiled chicken stuffed with chopped apples and walnuts. Cutaneous stimulation increases movement and decreases pain. Which of the following should be included in a plan of care for a client who is lactose intolerant? 15. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol. Therapeutic Communication Techniques Quiz. Battery powered wheelchairs and scooters require some manual dexterity and close attention to safety. A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Since we started in 2010, Nurseslabs has become one of the most trusted nursing sites helping thousands of aspiring nurses achieve their goals. The nurse is evaluating a client's use of a cane for left-sided weakness. The first step in pain assessment is for the nurse to, get the description of the location and intensity of the pain. Short-term memory loss is not related to immobility. Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. D. The client’s bowel habits were not discussed. Fluid does not flow uphill. Change TPN solution every 24 hours. Thanks so much, I haven't had much experience with this and may actually have some later today. A. B. asking her family to visit 1. The nurse teaches an elderly client with right-sided weakness how to use a cane. Which of the. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. Please visit using a browser with javascript enabled. Which of the following food choices, if selected by the client, indicate an understanding of a low-fat, high-fiber diet? For example, a client may be completely deaf at birth because of some genetic disorder, an elderly client may have a hearing loss as the result of the aging process, and a client can have a hearing loss as the result of some trauma, and some medication such as loop diuretics like furosemide, cancer chemotherapy agents like cisplatin, aspirin, nonsteroidal anti-inflammatory medications like ibuprofen, and some aminoglycoside antimicrobial medications like neomycin, gentamicin and streptomycin. Which of the following reflects correct use of the cane? The nurse is planning to teach a preschool child how to properly use a metered dose inhaler. B. Topics or concepts included in this exam are: To make the most out of this exam, follow the guidelines below: In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be given after you’ve finished the quiz. Daily dietary intake is much more related to the diagnosis of iron deficiency anemia than is sociocultural, economic, and educational background of the family. 1. A nurse caring for a 40-year-old man after a femur fracture. The nurse collects data about the client’s pain. B. Are lizards from the same family as dinosaurs? For more questions, visit our NCLEX Exam page. This question is part of basic physical care (part 2). Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy. Nurses dispense comfort, compassion, and caring without even a prescription. following actions should the nurse take when inserting the NG tube? 7. Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. Which type of dressing should the nurse apply until a wound specialist can be contacted? Answer: A. Stiffness of the right ankle joint. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. Because iron deficiency anemia is suspected, which of the following is the most important information to obtain from the infant’s parents? The provider orders wrist restraints after the client attempts to assault the admitting nurse. A routine for bowel elimination should be based on the client’s previous bowel habits and alterations in bowel habits that have occurred because of illness or trauma. Which of the following actions should the nurse take next? And which do they step with first? Answer: D. The client’s bowel habits were not discussed. A nurse is providing discharge instructions to a client who will be using a walker. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. C. Chef’s salad with hard boiled eggs and fat-free dressing Which of the following actions by the client indicates correct usage? The tympanic thermometer reads 36.8 (98.2f). What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding? Crutches are used most often for younger clients who have good upper arm strength who have been affected with an acute musculoskeletal injury such as a sprain, strain or fracture. D. Butterscotch. To walk, they move the cane forward first, then the weak leg, then the strong leg. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

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