Basic Care and Comfort 2

Which of the following devices would be most beneficial for a client with aphasia?

The nurse reviewing the client’s chart notes that the client has a history of urinary retention. Which of the following assessment findings would the nurse watch for in this client?

Select the appropriate personal protective equipment (PPE) when performing an ear irrigation:
Select all that apply.

A. gown
B. gloves
C. shoe covers
D. goggles
E. N95 mask

A client presents to the medical surgical floor following spinal surgery. The client is instructed to remain on strict bed rest for 48 hours but is turned with assistance every two hours. The nurse understands that this client will be at highest risk for which of the following conditions?
Select all that apply.

A. orthostatic hypotension
B. contractures
C. venous thromboembolism
D. dependent edema
E. hypovolemia

A nurse is performing a home health walkthrough with a client’s son. The client is planning on returning home following prolonged hospitalization and has foot drop. Which of the following accommodations need to be made before the client returns home?

The nurse is caring for a client in a halo traction device. Which of the following demonstrates proper management of the device?

A client asks the nurse what document he needs to complete to ensure that his wishes are carried out in the event he cannot make those decisions himself due to his illness. Which of the following documents would best meet this client’s needs?

A client and nurse are discussing complementary therapies to help promote healing. The client states that she would be interested in cupping. Which of the following would be a contraindication to this therapy?

The nurse is preparing to ambulate a client for the first time after prolonged intensive care admission for pneumonia with respiratory failure and 14 days on a mechanical ventilator. Which of the following actions should the nurse perform prior to ambulation?

A client is admitted from a long-term care facility following a fall. The client has not used assistive devices before, but now requires the use of a walker to help stabilize her when ambulating. Which of the following actions demonstrates appropriate use of the walker?

Which of the following pain assessment methods would best assess the pain in a 21-year-old client?

The nurse is caring for a client with nighttime agitation. The client regularly wakes up at night, is disruptive, irritable, and states he cannot sleep. During the day, he is tired and difficult to arouse at times. Which of the following interventions would be least helpful for this client?

The nurse records the following intake and output volumes from the client. What is the client’s total output for the nurse’s shift?

• 0800: 1000 ml IV fluid bolus, 25 ml JP wound drainage, 100 ml voided urine
• 1000: 50 ml JP wound drainage
• 1200: 500 ml PO fluid intake, 200 ml voided urine
• 1400: 25 ml JP wound drainage, bowel movement
• 1600: 500 ml IV fluid bolus, 600 ml voided urine, 10 ml JP wound drainage
• 1800: 300 ml PO fluid intake, 350 ml voided urine

A client in the neuro rehab unit following a left cerebral hemorrhage receives orders to advance his diet from NPO to liquid diet. The nurse should ensure that which of the following specialists evaluates the client prior to advancing his diet?

The nurse is preparing to insert a nasogastric (NG) tube in a client requiring enteral nutrition. Which of the following demonstrates the appropriate nursing actions when measuring the length for NG insertion?