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Question 10.05 pts

 

An 80-year-old client has limited mobility following a stroke. Which nursing intervention will help prevent skin breakdown?

Group of answer choices

Applying moist packs to the skin every shift

 

Decreasing calories consumed; avoiding weight gain

 

Turning and repositioning at least every 4 hours

 

Ensuring the client’s skin remains dry and clean

 

 

Flag question: Question 2Question 20.05 pts

 

A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement indicates the need for further education?

Group of answer choices

“Before I catheterize myself, I will try to urinate.”

 

“I will catch myself at 9 a.m. and 9 p.m.”

 

“I will use the Valsalva and Credé maneuvers before trying to urinate.”

 

“You can teach my son to help me with the catheterizations.”

 

 

Flag question: Question 3Question 30.05 pts

 

The nurse has been effectively using digital stimulation in older adult clients with constipation problems. For which client is this practice unsafe?

Group of answer choices

A 70 year old with recently diagnosed atrial fibrillation

 

A 68 year old with a long history of multiple sclerosis (MS)

 

A 74 year old who is 4 months poststroke

 

An 84 year old with progressive dementia and confusion

 

 

Flag question: Question 4Question 40.05 pts

 

Which client does the RN in the rehabilitation unit plan to assess first?

Group of answer choices

A 63 year old who had a myocardial infarction (MI) and expresses anxiety about walking

 

A 56 year old with a spinal cord injury and new-onset redness over the sacral area

 

A 70 year old with a joint replacement who needs medication before exercising

 

A 45 year old with multiple sclerosis (MS) reporting constipation

 

 

Flag question: Question 5Question 50.05 pts

 

A client with right-sided weakness is receiving antihypertensive medications. What does the RN communicate to the physical therapist (PT), who is planning to help the client walk?

Group of answer choices

“Move the client from lying to standing slowly.”

 

“Monitor the client for weakness and fatigue during exercise.”

 

“Use a gait belt when ambulating the client.”

 

“Remind the client to use the left side to grip.”

 

 

Flag question: Question 6Question 60.05 pts

 

A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client’s bladder training plan, what action does the staff RN advise a new graduate nurse to take first with this client?

Group of answer choices

Remind the client to try the Valsalva maneuver.

 

Insert a straight catheter to empty the bladder.

 

Reassess the client’s bladder volume in 2 hours.

 

Administer a dose of oxybutynin chloride (Ditropan).

 

 

Flag question: Question 7Question 70.05 pts

 

A client has just received a bisacodyl suppository. How soon after administration does the nurse expect results to be evident?

Group of answer choices

5 to 10 minutes

 

10 to 15 minutes

 

15 to 30 minutes

 

30 to 45 minutes

 

 

Flag question: Question 8Question 80.05 pts

 

The nurse is in the room while the assistive personnel (AP) is providing incontinence care to a client. Which action by the AP would require the nurse to intervene? (Select all that apply.)

Group of answer choices

Allowing the client to remain in the same position.

 

Applying moisture barrier cream to the perineal area.

 

Using soap and water to clean soiled areas on the perineum.

 

Rubbing areas on the sacrum that are slightly red.

 

Drying the sacral area carefully with a towel.

 

Placing a bed pillow between the client’s knees.

 

 

Flag question: Question 9Question 90.05 pts

 

The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements will the nurse include? (Select all that apply.)

Group of answer choices

Protecting clients from embarrassment (e.g., bowel training)

 

Making the inpatient unit a more homelike environment

 

Allowing time for clients to practice self-management skills

 

Keeping to a structured hospital schedule (e.g., medication administration)

 

Carefully monitoring fluid and dietary intake

 

Encouraging clients and providing emotional support

 

 

Flag question: Question 10Question 100.05 pts

 

The nurse is caring for a client in a bowel retraining program. Which nursing actions will facilitate consistent defecation patterns? (Select all that apply.)

Group of answer choices

Use digital stimulation inserting the finger into the anus for one minute.

 

Administer bisacodyl suppository daily.

 

Administer the bisacodyl suppository after the client eats a meal.

 

Encourage consumption of a high-fiber diet.

 

nsert the bisacodyl suppository just inside the anal sphincter.

 

 

SCIENCE
HEALTH SCIENCE
NURSING
GNRS 558