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TIMBYS FUNDAMENTALS NURSING SKILLS AND CONCEPTS 12TH EDITION TEST BANK
TIMBYS FUNDAMENTALS NURSING SKILLS AND CONCEPTS 12TH EDITION TEST BANK
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By: MEGAMINDS • 7 months ago
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TIMBYS FUNDAMENTALS NURSING SKILLS ANDCONCEPTS 12TH EDITION TEST BANK
1.
, 1.A nurse is assisting a client who has difficulty swallowing. Which of the following
interventions should the nurse use to help prevent aspiration?
o A. Give the client thin liquids.
o B. Instruct the client to tilt their head back when swallowing.
o C. Provide a straw for drinking liquids.
o D. Instruct the client to tuck their chin when swallowing.
Answer: D. Instruct the client to tuck their chin when swallowing.
Rationale: Tucking the chin helps to close off the trachea and prevent aspiration. Thin
liquids increase the risk of aspiration. Tilting the head back may cause liquids to enter the
airway. Using a straw can make it harder to control the flow of liquids.
2. A nurse is providing care for a client who is immobile. Which of the following
interventions should the nurse implement to prevent skin breakdown?
o A. Massage bony prominences.
o B. Use a donut-shaped cushion.
o C. Reposition the client every 4 hours.
o D. Place a pillow between bony surfaces.
Answer: D. Place a pillow between bony surfaces.
Rationale: Placing a pillow between bony surfaces reduces pressure and prevents skin
breakdown. Massaging bony prominences can damage capillaries and tissue. A donut-
shaped cushion can increase pressure around the periphery of the cushion. Repositioning
should occur every 1 to 2 hours.
3. A nurse is reinforcing teaching with a client about the use of a cane. Which of the
following instructions should the nurse include?
o A. "Hold the cane on the stronger side of your body."
o B. "Move the cane forward first, followed by your stronger leg."
o C. "Place the cane 15 inches in front of you before taking a step."
o D. "Keep your elbow straight when holding the cane."
Answer: A. "Hold the cane on the stronger side of your body."
Rationale: Holding the cane on the stronger side provides better support and balance.
The cane should move with the weaker leg. The cane should be placed about 6 to 10
inches in front of the body, and the elbow should be slightly bent.
4. A nurse is measuring the blood pressure of a client who is sitting in a chair. Which
of the following actions should the nurse take?
o A. Place the client's arm above the level of the heart.
o B. Use a cuff that is 40% of the circumference of the client's arm.
o C. Position the client's forearm at heart level.
, o D. Measure the blood pressure after the client has been sitting for 1 minute.
Answer: C. Position the client's forearm at heart level.
Rationale: Positioning the forearm at heart level ensures accurate blood pressure
readings. The arm should be at heart level, and the cuff should be 40% of the
circumference of the arm. The client should sit quietly for 5 minutes before measurement.
5. A nurse is caring for a client who has an indwelling urinary catheter. Which of the
following actions should the nurse take to prevent infection?
o A. Clean the periurethral area with antiseptic solution daily.
o B. Empty the collection bag every 4 hours.
o C. Ensure the catheter is taped to the client's thigh.
o D. Keep the collection bag below the level of the bladder.
Answer: D. Keep the collection bag below the level of the bladder.
Rationale: Keeping the collection bag below the level of the bladder prevents backflow
of urine and reduces the risk of infection. Daily cleaning with soap and water is
recommended, not antiseptic solution. The collection bag should be emptied when it is
half full, and the catheter should be secured to the thigh without tension.
6. A nurse is providing postoperative care for a client who has undergone abdominal
surgery. Which of the following interventions should the nurse implement to
prevent respiratory complications?
o A. Encourage the client to drink fluids.
o B. Place a pillow under the client's knees.
o C. Instruct the client to use an incentive spirometer every hour.
o D. Apply sequential compression devices to the client's legs.
Answer: C. Instruct the client to use an incentive spirometer every hour.
Rationale: Using an incentive spirometer helps to prevent atelectasis and promote lung
expansion. Encouraging fluid intake and applying sequential compression devices are
important, but they do not directly prevent respiratory complications. A pillow under the
knees can impede circulation and should be avoided.
7. A nurse is reinforcing teaching with a client about how to collect a stool specimen
for occult blood testing. Which of the following instructions should the nurse
include?
o A. Collect the first stool specimen in the morning.
o B. Avoid eating red meat for 3 days before the test.
o C. Use a sterile container for the specimen.
o D. Refrigerate the specimen until it is taken to the laboratory.
Answer: B. Avoid eating red meat for 3 days before the test.
, Rationale: Red meat can cause a false positive result for occult blood. The specimen
does not need to be collected first thing in the morning, and a clean container, not sterile,
is sufficient. The specimen should be taken to the lab as soon as possible and does not
need to be refrigerated.
8. A nurse is caring for a client who is at risk for developing deep vein thrombosis
(DVT). Which of the following interventions should the nurse implement?
o A. Encourage the client to cross their legs.
o B. Apply a warm compress to the legs.
o C. Instruct the client to perform leg exercises every hour.
o D. Elevate the client's legs on a pillow.
Answer: C. Instruct the client to perform leg exercises every hour.
Rationale: Leg exercises promote circulation and reduce the risk of DVT. Crossing legs
can impede blood flow, and warm compresses are not effective for preventing DVT.
Elevating the legs is beneficial, but regular leg exercises are more effective in preventing
DVT.
9. A nurse is caring for a client who requires a mechanical restraint. Which of the
following actions should the nurse take?
o A. Attach the restraint to the side rail of the bed.
o B. Remove the restraint every 4 hours.
o C. Secure the restraint with a quick-release tie.
o D. Check the client's circulation every 30 minutes.
Answer: C. Secure the restraint with a quick-release tie.
Rationale: A quick-release tie allows for easy removal in an emergency. Restraints
should never be attached to the side rail, as it poses a risk of injury. Restraints should be
removed every 2 hours for assessment and care, and circulation should be checked every
15 minutes.
10. A nurse is reinforcing teaching with a client who has a new prescription for a
metered-dose inhaler (MDI). Which of the following instructions should the nurse
include?
o A. Shake the inhaler well before use.
o B. Inhale quickly and deeply through the mouthpiece.
o C. Hold the breath for 5 seconds after inhaling.
o D. Wait 15 seconds between puffs.
Answer: A. Shake the inhaler well before use.
Rationale: Shaking the inhaler
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