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- The nurse must assess the temperature and blood pressure of a client on contact precautions every shift. Which is the appropriate nursing action to minimize the spread of microorganisms?
- Keep the equipment in the client’s room.
- Store the equipment in the soiled utility room between uses.
- Cleanse the equipment after each use.
- No special action is required with the equipment.
- The nurse is making a home visit to a 70-year-old client with emphysema. Which assessment finding has the most serious implication for this client's nursing care?
- Increased anterior-posterior diameter of the chest
- Bilateral crackles throughout the lung fields
- Pursed-lip breathing
- Circumoral cyanosis
- While performing an environmental assessment of a 72-year-old client, what hazards should the nurse document and correct?
- Absence of grab bars in the bathroom, and unanchored rugs
- Non-skid tub and shower mats
- Smoke detectors and fire extinguishers
- Night lights in bathrooms and hallways
- A client who is in Stage II of Alzheimer's disease has memory impairment. The nurse should plan to do which of the following at the beginning of the upcoming work shift?
- Check to ensure that the client is wearing an ID badge.
- Place the client in a quiet, calm environment.
- Write a note on the cover of the chart asking for a prn order for restraints.
- Instruct ancillary caregivers to assess the client's level of consciousness hourly.
- Which statement by the client with myasthenia gravis indicates a need for further instruction before discharge?
- "I realize I need to be sure I take my medications at the scheduled times."
- "I won't be drinking anymore gin and tonics!"
- "I am looking forward to taking a really long, hot bubble bath when I get home."
- "I am not going to train for the triathlon this year."
- A client asks the nurse to explain why she is receiving lidocaine (Xylocaine) in her IV when her dentist injects it into her gums to numb the teeth before a filling. The best response by the nurse is:
- "The medication is more effective intravenously, and you will feel no pain anywhere."
- "As an IV medication, it will help you relax and rest, so your heart can heal."
- "When given IV, this medication reduces the irritability of the cells in your heart, and helps reduce dysrhythmias."
- "The medication will increase your urine output, so that you will be less likely to suffer from heart failure."
- Which of the following actions by the nurse comply with core principles of surgical asepsis? Select all that apply.
- Wash hands before and after client care.
- Keep the sterile field in view at all times.
- Wear personal protective equipment.
- Add contents to the sterile field holding the package 6 inches above the field.
- Consider the outer 1.5 inches of the sterile field as contaminated.
- The major focus for nursing care of the client with meningitis will be to:
- Enhance coping skills.
- Provide cognitive stimulation.
- Assess risk for injury and prevent complications.
- Increase cardiac output.
- The nurse is providing home care instructions for a family with a toddler diagnosed with lice. The nurse includes which of the following instructions in the teaching plan? (Select all that apply.)
- Immerse combs and brushes in boiling water for 30 minutes to kill lice.
- Vacuum floor and furniture to remove hair that might have live nits.
- Have the mother use a bright light and magnifying glass to check the hair for lice.
- Launder the child’s bedding and clothing in hot water with detergent and dry in a hot dryer for 20 minutes.
- Teach children to not share combs, brushes, and hats.
- To treat a client with autonomic dysreflexia, the nurse positions the client:
- Prone, head to the side, arms on pillows.
- In a fetal position with a blood pressure cuff on.
- Leaning forward over the bedside table.
- By elevating the head of bed and removing support hose.