Faculty assigment 4 Flashcards
When caring for a client with extensive burns, the nurse anticipates that pain medication will be administered via which route? A. \_\_\_Oral B. \_\_\_\_ Intravenous C. \_\_\_\_ Intramuscular D. \_\_\_\_ Subcutaneous
Intravenous
The evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?
A. ____ Intact skin
B. ____ Full-thickness skin loss
C. ____ Exposed bone, tendon, or muscle
D. ___ Partial-thickness skin loss of the dermis
D. Partial-thickness skin loss of the dermis
The nurse employed in a long-term care facility is caring for an older male client. Which nursing action contributes to encouraging autonomy in the client?
A. ____ Planning his meals
B. ____ Decorating his room
C. ____ Scheduling his barber appointments
D. ___ Allowing him to choose social activities
D. Allowing him to choose social activities
The nurse is teaching an older client about measures to prevent constipation. Which statement, if made by the client, indicates that further teaching about bowel elimination is necessary?
A. ____ “I walk 1 to 2 miles every day.”
B. ____ “I need to decrease fiber in my diet.”
C. ____ “I have a bowel movement every other day.”
D. ____ “I drink six to eight glasses of water every day.”
B. “I need to decrease fiber in my diet.”
The home care nurse is performing an environmental assessment in the home of an older client. Which of the following, if observed by the nurse, requires immediate attention?
A. ____ Unsecured scatter rugs
B. ____ Clear exit passageways
C. ____ An operable smoke detector
D. ____ A prefilled medication cassette (pill minder)
A. unsecured scatter rugs
The home health nurse is visiting a client for the first time. While assessing the client’s medication, it is noted that there are at least 19 prescription and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?
A. ____ Check for drug-drug interactions.
B. ____ Determine whether there are any adverse side effects.
C. ____ Determine whether there are medication duplications.
D. ____ Call the prescribing physician and report any polypharmacy.
C. Determine whether there are medication duplications.
The nurse who volunteers at a senior citizens’ center is planning activities for the members who attend the center. Which activity would best promote health and maintenance for these senior citizens?
A. ____ Gardening every day for an hour
B. ____ Sculpting once a week for 40 minutes
C. ____ Cycling three times a week for 20 minutes
D. ____ Walking three to five times a week for 30 minutes
D. walking three to five times a week for 30 minutes
A nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse:
A. ____ immediately inflates the balloon.
B. ____ Inserts the catheter 2.5 to 5 cm and inflates the balloon.
C. ____ withdraws the catheter about 1 inch and inflates the balloon.
D. ____ Inserts the catheter until resistance is met and inflates the balloon
A. immediately inflates the balloon
A nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates the balloon, the client complains of discomfort. The appropriate nursing action is to:
A. ____ Aspirate the fluid, remove the catheter and insert a new catheter.
B. ____ Aspirate the fluid, advance the catheter farther, and inflate the balloon.
C. ____ Remove the syringe from the balloon; discomfort is normal and temporary.
D. ____ Aspirate the fluid, withdraw the catheter slightly, and inflate the balloon.
B. Aspirate the fluid, advance the catheter farther, and inflate the balloon.
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the appropriate action for the nurse to take?
A. ____ Hold the feeding.
B. ____ Reinstill the amount and continue with administering the feeding
C. ____ Elevate the client’s head at least 45 degrees and administer the feeding.
D. ____ Discard the residual amount and proceed with administering the feeding.
D. Discard the residual amount and proceed with administering the feeding.
A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in which position for insertion? A. \_\_\_\_ Right side B. \_\_\_\_ Low Fowler's C. \_\_\_\_ High Fowler's D. \_\_\_\_ Supine with the head flat
C. High Fowler’s
A nurse obtains an order from a physician to restrain a client by using a jacket restraint and instructs a nursing assistant to apply the restraint to the client. Which observation by the nurse indicates inappropriate application of the restraint by the nursing assistant?
A. ____ A safety knot in the restraint straps
B. ____ Restraint straps that are safely secured to the side rails
C. ____ Jacket restraint straps that do not tighten when force is applied against them
D. ____ Jacket restraint secured so that two fingers can slide easily between the restraint and the client’s skin
B. Restraint straps that are safely secured to the side rails
A nurse enters a client’s room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. The next nursing action would be to:
A. ____ Call for help.
B. ____ Extinguish the fire.
C. ____ Activate the fire alarm.
D. ____ Confine the fire by closing the room door.
C. Activate the fire alarm.
A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse would offer which full liquid item to the client? A. \_\_\_\_ Tea B. \_\_\_\_ Gelatin C. \_\_\_\_ Custard D. \_\_\_\_ Popsicle
C. custard
The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which action should the nurse take?
A. ____ Contact the nursing supervisor.
B. ____ Administer the dose prescribed.
C. ____ Hold the medication until the physician can be contacted.
D. ____ Administer the recommended dose until the physician can be located.
A. Contact the nursing supervisor.
