Deck 53: Caring Interventions

Question 1

The nurse is making an occupied bed. In which order should the nurse perform when removing the top linens and adding the bath blanket?

A)Spread the bath blanket over the top sheet.
B)Remove the spread and the blanket.
C)Reach under the bath blanket, grasp top edge of sheet.
D)Ask the client to hold the top edge of the bath blanket.
E)Pull the sheet from under the bath blanket.

Answer 1

Spread the bath blanket over the top sheet.
Remove the spread and the blanket.
Reach under the bath blanket, grasp top edge of sheet.
Ask the client to hold the top edge of the bath blanket.
Pull the sheet from under the bath blanket.

Question 2

The nurse is acting as preceptor for a novice nurse. Which action by the novice nurse requires the nurse preceptor to intervene?

A)Labeling medications placed in a medication cup.
B)Removing prepackaged medication and placing in a medication cup.
C)Keeping narcotics separated from other medications that need to be administered.
D)Breaking scored tablets as needed for correct dosage.

Answer 2

Removing prepackaged medication and placing in a medication cup.

Question 3

The nurse determines some client care tasks can be delegated to the UAP. Which task should not be delegated?

A)Performing foot care for a client with diabetes.
B)Changing an occupied bed for a client with multiple intravenous medications infusing.
C)Performing a bath for a newborn with an unhealed umbilical cord.
D)Oral care for an unconscious client.

Answer 3

Performing foot care for a client with diabetes.

Question 4

The nurse delegates soft contact lens care to a UAP. Which action by the UAP requires the nurse to intervene?

A)Placing the client in semi-Fowler's position.
B)Placing the client's removed disposable lenses in the trash.
C)Placing the gloved thumb and forefinger directly on the soft lens on top of the eyeball.
D)Placing the gloved thumb on the client's lower eyelid and gloved index finger on the client's upper lid, pressing lightly on the eyeball.

Question 5

The nurse understands that, in addition to the five client rights of medication administration, there are now more rights for safe medication administration. Which rights are the new rights for safe medication administration? Select all that apply.

A)Right documentation
B)Right dose
C)Right time
D)Right route
E)Right reason

Question 6

The nurse prepares to perform oral care for a client with dentures. Place the steps in correct order for how the nurse will remove the client's dentures.

A)Use gauze to grasp upper plate at the front teeth with the thumb and second finger.
B)Lift the lower plate and remove without stretching the lip.
C)Move the denture up and down slightly.
D)Don gloves
E)Place the upper plate in the denture cup.
F)Place the lower plate in the denture cup.

Question 7

The nurse prepares to administer an intermittent intravenous solution using a secondary administration set. Place the steps of assembling the secondary infusion in correct order.

A)Insert the secondary tubing needleless cannula into the distal primary tubing port located above the infusion pump.
B)Hang the secondary container above the level of the primary bag.
C)Attach the appropriate label to the secondary tubing.
D)Lower medication bag to clear tubing and back-prime tubing.
E)Close the clamp on the secondary infusion tubing and spike the medication infusion bag.

Question 8

A novice nurse instructs a client on the use of sublingual nitroglycerin. Which statement by the novice nurse requires intervention by the nurse preceptor?

A)"Be sure to take the medication prior to the start of your pain."
B)"Do not chew or swallow the tablet."
C)"The tablet may cause burning or tingling as it dissolves."
D)"Be sure to sit down when you decide to take the medication."

Question 9

The nurse is observing a UAP performing a bed bath for a client. Which action by the UAP requires the nurse to intervene?

A)Washing the client's arms from wrists to shoulders.
B)Washing the client's eyes and face first before the rest of the body.
C)Washing, rinsing, and drying the client's leg from thigh to ankle.
D)Washing the client's back and then the perineum.

Question 10

A nurse mixes two insulins in one syringe for a client with diabetes. Which action by the nurse is incorrect?

A)Injecting a volume of air equal to the volume of medication to be withdrawn into the first vial.
B)Drawing up air in the syringe equal to the dose of both insulins.
C)Gently shaking the vials in order to ensure medication has dissolved.
D)Withdrawing the needle from the first vial and injecting the remaining air into the second vial.

Question 11

When teaching the client about foot care, which statement will the nurse include in the teaching?

A)"Use creams or lotions on the feet and in between the toes after showering."
B)"While sitting, cross your legs at the knees instead of the ankles."
C)"Avoid using pumice stones on the feet to decrease callouses."
D)"When your feet are cold, place them on a hot water bottle to warm them."

Question 12

The nurse is performing hearing aid care for a client and notes the hearing aid has "TM" near its on/off switch. What is the nurse's understanding of the meaning of "TM"?

A)Transmitting mode
B)Tympanic membrane
C)Telephone/microphone
D)Tympanic/microphone

Question 13

Prior to delegating hearing aid care to a UAP, what is the nurse's priority?

A)Determine the UAP's knowledge of the procedure.
B)Inform the UAP of what to report back to the nurse.
C)Discuss relevant client health information necessary for the task.
D)Provide the UAP with guidance on where to find supplies necessary for the task.

Question 14

The nurse prepares to mix two medications (vial A and B) in one syringe. Place the steps in correct order for how the nurse will perform the procedure.

A) Inject a volume of air equal to the volume of medication to be withdrawn into vial A.
B) Withdraw the required amount of medication from vial B.
C) Draw up a volume of air equal to the volume of medications to be withdrawn from both vials A and B.
D) Withdraw the needle from vial A and inject the remaining air into vial B.
E) Withdraw the required amount of medication from vial A.

Question 15

The nurse prepares to make an unoccupied bed. Place the steps in correct order of how the nurse will remove the soiled linens.

A)Detach the call bell and any drainage tubes from the bed linens.
B)Loosen all the bedding systematically.
C)Roll all soiled linens inside the bottom sheet.
D)Remove the incontinent pad and discard.
E)Remove the pillowcases and fold reusable linens.

Question 16

The nurse delegates oral care of an unconscious client on supplemental oxygen to the UAP. Which action by the UAP requires the nurse to intervene?

A)Placing a bite block in the client's mouth.
B)Applying petroleum-based moisturizer to the client's lips.
C)Positioning the client in side-lying position with head of bed lowered.
D)Using a separate moistened swab for the inside of each cheek.

Question 17

A nurse cares for a client who receives new hearing aids for the first time. Which statements will the nurse include when teaching the client about the hearing aids? Select all that apply.

A)"Push the earmold slightly backward and pull out to remove it."
B)"Rotate the earmold slightly forward and pull out to remove it."
C)"If the hearing aid is not used for several days, be sure to turn the device off."
D)"If the earmold is detachable, soak it in isopropyl alcohol weekly to disinfect it."
E)"Blow any excess moisture through the opening of the earpiece when cleaning it."

Question 18

The nurse performs a skin assessment while bathing an older adult client. Which lifespan considerations regarding skin characteristics are more common in the older adult? Select all that apply.

A)Dry skin
B)Itchy skin
C)Poor healing
D)Increased risk of water retention
E)Increased risk of trauma

Question 19

A nurse is providing oral care to an older adult. What findings does the nurse recognize are normal findings in this client? Select all that apply.

A)Dry mouth
B)Gingivitis
C)Jaw bone loss
D)Receding gums
E)Tooth root decay

Question 20

A client places one hearing aid in the ear and tells the nurse, "I hear a whistling sound." Which actions will the nurse take in response to the client's statement? Select all that apply.

A)Turn the volume of the hearing aid up.
B)Check the battery inside the hearing aid.
C)Turn the volume of the hearing aid down.
D)Ensure the ear canal is not blocked with wax.
E)Check that the earmold is attached to the receiver.

Question 21

The nurse is caring for an older adult client and performs a bed bath and linen change. Which action by the nurse poses an increase of injury in the client?

A)Washing the client with a washcloth.
B)Pulling linens underneath the client.
C)Assisting the client to turn in bed.
D)Covering the client with warm linens.

Question 22

The nurse cares for a client who wears soft contact lenses for vision correction. Which statement will the nurse include when teaching the client about care of the lenses?

A)"If you do not have saline solution, saliva works to cleanse the lenses."
B)"If you wear disposable lenses, it is acceptable to cleanse them and wear them again."
C)"If you are removing the lens, place your thumb and forefinger directly on the lens."
D)"If you wear disposable lenses, be sure to cleanse the lens container daily."

Question 23

While giving the client a bath, the nurse notes the client has facial acne. What statement by the nurse will not be included when teaching the client about this condition?

A)"Use cool water when cleansing your face to close the pores."
B)"Wash your face frequently to remove oil and dirt."
C)"Avoid using oil-based creams on your face."
D)"Do not squeeze the lesions on your face."

Question 24

The nurse prepares to perform a z-track injection to a client. Place the steps of the procedure in correct order.

A)Maintain displacement and insert needle at a 90-degree angle.
B)Inject medication slowly, keeping skin taut.
C)Pull skin 2.5-3.8 cm (1-1. in.)laterally away from the injection site.
D)Withdraw needle.
E)Release retracted skin.