c50

25問 • 1年前

問題一覧

A nurse is teaching a client about good oral hygiene. What information should the nurse provide the client regarding oral hygiene and mouth care?

Practice oral hygiene to improve appetite and taste of food.

A nurse is caring for an unresponsive client. Which therapeutic nursing intervention is appropriate when providing mouth care to this client?

Have a suction catheter available, if ordered.

nurse is caring for an unresponsive client. Which position is best for the nurse to place the unresponsive client in to encourage the fluid to drain out of the mouth and prevent choking when providing oral care?

Side-lying

A nurse is caring for an unresponsive client. The client is breathing through the mouth. The client's mouth is frequently dry because of medications the client is receiving. What is the anticipated time frame that the nurse needs to perform oral hygiene for this client?

60 minutes

The student nurse is reviewing the electronic medical record and notices that the client has listed sordes as a condition under personal hygiene. The student nurse is aware that frequent mouth care is necessary for this condition. Based on this information, what is the best response by the student nurse to the nurse educator of the cause of the condition that requires frequent mouth care?

Brownish deposits on the tongue

The student nurse is preparing a nursing care plan for a client who wears dentures. The student nurse should make sure that the dentures are removed in which clinical situations? 1.Unresponsive client 2.Out of control client 3. Client having a documented history of seizures 4. Client going to surgery

1, 2, 4

The student nurse is preparing a nursing care plan for a client who wears dentures. The student nurse has to remove the client's dentures because of a change in medical condition. Which steps have to be completed after removal of the client's dentures? 1.Document that the dentures were removed 2. Label the denture container carefully 3. Store the client's dentures safely 4.Send the dentures home when the client's family visits

1, 2, 3

A nurse is caring for a client who is using a hearing aid. Which instruction should the nurse provide the client with regard to care of the hearing aid?

Avoid exposing the hearing aid to heat and moisture.

The nurse is teaching a client never to insert objects such as cotton swabs, toothpicks, or matches into the ears to clean them. Based on this information, what are the rationales for not placing these objects in the ear that the nurse needs to review with the client? 1. Injure the ear canal 2.Cotton swab frequently becomes lodged in ear 3.Puncture the eardrum 4.Push earwax further into the ear canal

1,3,4

During a bed bath a client complains of drainage from the eye. Which guideline should the nurse follow when removing secretions from the eye?

Moisten a clean washcloth and cleanse from the inner canthus to the outer.

During a bed bath a client complains of drainage from the eye. What would be the best rationale for using separate supplies for each eye?

Help to prevent spreading infection between the eyes

A client removes dentures each night. What is a nursing consideration when providing denture care?

Remove dentures by gently moving them up and down.

A nurse is providing fingernail care to a client. Which is an appropriate nursing intervention when caring for fingernails?

Remove nail polish from the client's nails.

The nurse is using a sterile nail clipper to repair a client's torn nails. What is the best rationale for using the sterile nail clippers to complete the procedure?

Prevents the nails from snagging on clothing or bed linens

A nurse is assisting a client with shaving. Which step is appropriate when assisting the client in shaving?

Apply shaving cream if the client wishes.

The nurse is reviewing with a student nurse that special orders are required to cut the toenails of clients with certain diseases. The nurse asks the student nurse to identify those diseases. Which are the best responses by the nurse for diseases that require special orders before cutting nails? 1. Diabetes 2. Peripheral vascular disease 3. Hemophilia 4. Very thickened nails

1, 3, 4

A healthcare facility uses disposable blade razors. The nurse knows that extra precautions must be considered in the care of the clients with disposable blade razors. Which clients should be closely supervised by the nurse with disposable blade razors? Client with unsteady hands 2. Client with poor eyesight 3. Client who is depressed 4. Client who is suicidal

3, 4

A nurse in a long-term care facility is caring for a client with long hair. Which procedure should the nurse follow when providing hair care to the client?

Wash client's comb and brush regularly.

The nurse is taking care of the nails of a client. What is the correct sequence in caring for fingernails? 1.Shape the fingernails with an emery board. 2.Clip hangnails with manicure scissors or cuticle snippers. 3.Trim the client's fingernails straight across with nail clippers. 4.Soak the client's fingers in a basin or warm water and mild soap.

4, 3, 1,2

The nurse is assessing a client's skin. The nurse asks a student nurse about body fluids that are generally acidic and very irritating to the skin. Based on this information, what are the best responses by the student nurse of which body fluids are generally acidic and very irritating to the skin? 1. Sputum 2. Perspiration 3. Urine 4. Vomitus

2, 3, 4

A nurse is providing perineal care to a client who has delivered a baby. Which intervention should a nurse provide during perineal care?

Place a towel under the client's hips.

A nurse is assisting a client to wash his face and hands. Which nursing consideration is indicated during the procedure?

Allow the client to make a choice about using soap on the face.

A nurse is required to give a backrub to a client who has been admitted to a healthcare facility after a stroke. Based on this information, what is the primary reason for the back rub for this client?

Prevents breakdown of the skin owing to prolonged bed rest

A client has edema and tenderness of the feet. The nurse prepares a warm water foot soak for the client. What is the primary reason for the nurse to use warm water for the foot soak?

It helps the blood vessels to dilate.

The nurse is giving a backrub to a client. The nurse uses a variety of patterns when giving the back rub. What pattern is being used by the nurse when giving effleurage?

Stroking the large surfaces of the client's back in long, smooth strokes, with the palms of the hands