A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
"I can detect the presence of carbon monoxide by a metallic odor."
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?
teach the client to use the call light
keep the clients' bed at
the lowest position
place an at-risk fall I'd band on the client wrist
A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I will place a bath seat in the shower to use when I bath"
A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Selected all that apply)
Teach about balance and strengthening exercises
Providing
information about home safety checks
Locking beds and
wheelchairs during transfers
Placing a bedside table within the
client's reach
a nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in the client?
conjunctivae
A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Assess the apical pulse for a full minute
A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?
Prior to percussing the abdomen
A nurse is assessing a clients circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
carotid
A nurse is assessing a client's abdomen who reports "stomach pain". which of the following actions should the nurse do first?
inspect
A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy?
51 yo who is being seen for an annual physical exam
A nurse is talking with a client who is beginning a program of moderate exercise. The client asks the nurse why warm-up exercises are necessary. Which of the following responses should the nurse make?
Warm-up exercises reduce the risk of injury
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?
"Do you have difficulty staying awake when you are driving?"
A nurse is teaching a class about the effects of bathing in warm water. Which of the following information should the nurse include?
decreases stress
A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take?
Use soap and water to clean the client's perineum.
A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?
turn the client to the side
a nurse is planning to perform foot care for a client . which of the following actions should the nurse plan to take
use warm water to wash the client's feet
A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?
Disease prevention
A charge nurse is providing an in-service to a group of nurses about self care. Which of the following information should the nurse include in the teaching?
bring your own food for lunch
A charge nurse is teaching a newly licensed nurse about fall prevention strategies when caring for clients. Which of the following information should the nurse include in the reaching?
provide under-bed lighting at night
lock the wheels on the bed
place break on the clients wheelchairs
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method to transfer, which of the following is most important for the nurse to determine
The client's current weight-bearing status
A school nurse is teaching a group of nurses newly hired to work in the school system about pediculosis capitis (head lice). Which of the following information is appropriate to include in the teaching?
Nits that are shed into the environment are capable of hatching for up to 10 days.
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve Ill?
Checking the pupillary response to light
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?
Move the client to a room closer to the nurses station