Exam (elaborations)
Custom: B260 (D&D, CJ, Final Comprehensive) FA23 correctly answered graded A+
- Course
- Nurs-b260
- Institution
- Indiana University
Custom: B260 (D&D, CJ, Final Comprehensive) FA23 correctly answered graded A+
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Custom: B260 (D&D, CJ, Final Comprehensive) FA23A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
"They protect your legs and heels from skin breakdown."
"They help keep you warm after your surgery."
"They improve your circulation to keep blood from pooling in your legs."
"They make it easier for you to do leg exercises after your surgery." - correct answer ✔✔"They improve your circulation to keep blood from pooling in your legs."
-Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis, also known as clot formation, and peripheral edema.
A nurse if providing oral care to a client who is immobile. Which nursing action? - correct answer ✔✔Turn the client on his side before starting oral care.
- Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.
History and Physical
Day 1:
Macular degenerationUses a cane to ambulate
Nurses' Notes Day 3:
Client is discharged to home. Home hazard assessment is performed by a home health nurse.
Home hazard assessment report:
Unsecured throw rugs over tile floor in kitchenGrab bar present in bathroomHot water heater set at 43.3° C (110° F)Nonskid mat in bathtubElectrical cord on floor over walkway
A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall?
Select all that apply.
Grab bar in bathroom
Macular degeneration
Electrical cord on floor over walkway
Uses a cane to ambulate
Throw rugs in kitchen - correct answer ✔✔Grab bar in bathroom
- Macular degeneration
- Electrical cord on floor over walkway
Uses a cane to ambulate
- Throw rugs in kitchen
NG tube removal? nursing first action
Disconnect the tube from the wall suction.
Perform hand hygiene.
Provide mouth care to the client.
Verify the provider's prescription to discontinue the tube. - correct answer ✔✔Verify the provider's prescription to discontinue the tube.
- The first action the nurse should take using the nursing process is to assess the provider's prescription to confirm the NG tube should be removed. Discontinuing an NG tube requires a provider's prescription. Therefore, confirmation of the prescription is a priority before removal of the tube. Nasogastric tubes are used to provide enteral nutrition, to administer medication, and to provide gastric decompression. If the NG tube is still required by the client, removing it can cause injury to the client.
immobile and in cont. mitten restraint. interventions included in care plan?
Document restraint checks and client status every 2 hr.
Educate the client's family about restraint use.
Obtain the provider's prescription renewal every 72 hr.
Implement passive range-of-motion exercises.
Release the restraint and reposition the client every 4 hr. - correct answer ✔✔Document restraint checks
and client status every 2 hr.
Educate the client's family about restraint use.
Obtain the provider's prescription renewal every 72 hr.
Implement passive range-of-motion exercises.
Release the restraint and reposition the client every 4 hr.
Assessing an IV infusion side on an infants left hand. Indicates infiltration?
Blood in the IV tubing
Absence of blanching at the insertion site
Edema in the palm of the hand
Warmth around the insertion site - correct answer ✔✔Edema in the palm of the hand
- Edema, pallor, and coolness around the insertion site indicate a collection of fluid leaking into subcutaneous tissue, also known as an infiltration.
A nurse is caring for a client who is scheduled for a surgical procedure.
1 week before procedure:
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