Online NCLEX Practice Test about
Basic Care and Comfort I
1. A 36-year-old female with multiple sclerosis (MS) complains that she is constantly dribbling urine and requests that a permanent Foley catheter be inserted. The nurse is most correct to respond:
a. “There are several types of bladder dysfunction associated with MS, so the specific cause must be found first.”
b. “Permanent catheters always cause infections.”
c. “It is better to use an absorbent pad.”
d. “The bladder problem will not get worse.”
2. Which of the following menus is most appropriate for a client on a low-cholesterol diet?
a. Chicken fried in hydrogenated oil, baked potato, fruit, and coffee
b. Chicken salad sandwich, yellow cake, 2% milk
c. Broiled shrimp, fresh broccoli, baked potato, diet soda
d. Flounder filet, baked potato, angel food cake, tea
3. The nurse instructs a pregnant woman about the importance of increasing her calcium intake during pregnancy. Which of the following foods is highest in calcium content?
a. ½ cup vanilla ice cream
b. 1 cup skim milk
c. ½ cup spinach
d. 1 cup broccoli
4. The nurse is performing discharge teaching with an elderly client following surgery for an ileal conduit. The nurse should instruct the client to:
a. Change the appliance several times each day
b. Drink at least 2,000 cc of fluid every day
c. Abstain from sexual intercourse for 2 weeks while the incision heals
d. Dilate the stoma daily with the small finger
5. Which information should be included in the teaching plan for a client with a short leg cast who is learning crutch-walking?
a. Use the bedside trapeze to strengthen the bicep muscles
b. Keep the affected limb in extension and abduction
c. Sit upright in a chair to develop the back muscles
d. Perform resistance exercises of the upper extremities
6. The nurse is developing a dietary teaching plan for a child with Duchenne’s muscular dystrophy. Which elements are most important for the nurse to include in the child’s diet?
a. low-calorie, high-protein, and high-fiber
b. low-calorie, high-protein, and low-fiber
c. high-calorie, high-protein, and restricted fluids
d. high-calorie, high protein, and high-fiber
7. Several days after a client has had a total laryngectomy, the physician orders a progressive diet as tolerated. The nurse should:
a. Keep a suction apparatus readily available in case aspiration occurs
b. Administer the diet through a nasogastric tube until the suture line heals
c. Encourage intake of pureed foods because they promote the swallowing reflex
d. Administer pain medication as ordered 30 minutes before meals to limit discomfort
8. Irradiation to the chest wall on an outpatient basis is prescribed for a client following removal of a tumor in the right lung. When teaching skin care to the client the nurse should emphasize:
a. Massaging the area 4 times a day to increase circulation
b. Frequent washing to remove desquamated cells
c. Keeping the skin dry and protected from abrasions
d. Using skin lotion twice daily to keep the skin supple
9. A female client with scleroderma tells the nurse that she often has numbness and tingling by the hands followed by blanching of her fingers. The nurse recognizes that the client has Raynaud’s phenomenon, a condition commonly associated with scleroderma. The nurse should advise the client to:
a. Bathe her hands frequently in hot water
b. Keep her hands warm by wearing gloves
c. Briskly rub her hands to increase circulation
d. Take the anticoagulants that will be prescribed to prevent attacks
10. After a long leg cast is removed, the client should be instructed to:
a. Report any discomfort or stiffness of the ankle
b. Cleanse the legs by scrubbing with a brisk motion
c. Elevate the leg when sitting for long periods of time
d. Put the leg through a full range of motion once daily
11. A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. The nurse should suggest
a. Wearing loose but warm clothing
b. Avoiding excessive physical stress and fatigue
c. Taking a hot tub bath or shower in the morning
d. Planning a rest break periodically for about 15 minutes
12. When assisting a client who has myasthenia gravis with a bath, the notices that the client’s arms become weaker with sustained movement. The nurse should:
a. Continue the bath while supporting the client’s arms
b. Encourage the client to rest for short periods of time
c. Gradually increase the client’s activity level each day
d. Administer a dose of pyridostigmine bromide
13. Drug therapy for duodenal ulcers includes antacids. Antacids should be taken:
a. 1 hour before meals
b. with meals
c. 1-2 hours after meals
d. at bedtime
14. Which of the following reflects the principle on which a client’s diet will most likely be based the acute phase of MI?
a. Liquids as desired
b. Small, easily digested meals
c. Three regular meals
d. Nothing by mouth
15. Which of the following outcome criteria would be appropriate for a client with COPD who ha been discharged to home?
a. The client promises to do pursed-lip breathing at home
b. The client states actions to reduce pain
c. The client states that he will use oxygen via a nasal cannula at 5 L/ minute
d. The client agrees to call the physician if dyspnea on exertion increases
16. When teaching a client with COPD to conserve energy, the nurse should teach the client to lift objects:
a. While inhaling through an open mouth
b. While exhaling through pursed lips
c. After exhaling but before inhaling
d. While taking a deep breath and holding it
17. Which one of the following assessments would be most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
a. Assessing the client’s skin color
b. Monitoring the respiratory rate
c. Verifying the amount of inflation
d. Auscultating lung sounds bilaterally
18. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care?
a. Assess the oral cavity each time mouth care is given and record observations
b. Use a soft toothbrush to brush the client’s teeth after each meal
c. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours
d. Rinse the client’s mouth with mouthwash several times a day.
19. A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer?
a. Discharge planning
b. Correction of nutritional deficits
c. Prevention of deep vein thrombosis (DVT)
d. Instruction regarding radiation treatment
20. A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and mother develop a plan of care to stimulate the child’s appetite. Which of the following suggestions made by the mother would indicate that she needs additional teaching?
a. Deciding that the mother will feed the child
b. Withholding dessert and treats unless meals are eaten
c. Offering the child finger foods that the child likes
d. Serving smaller and more frequent meals
21. After the nurse counsels a primipara who is breastfeeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for further teaching?
a. “I need to increase my intake of vitamin D.”
b. “I should drink at least five glasses of fluid daily.”
c. “I need to get an extra 650 calories per day.”
d. “I need to make sure I have enough calcium in my diet.”
22. A 64-year-old patient is placed in balanced suspension traction for a compound fracture of the femur. Which of the following symptoms, if exhibited by the patient, should the nurse investigate first?
a. The patient has been having small hard bowel movements for the past 3 days
b. The patient eats only half of the food on his dinner tray
c. The patient states that his hands, feet and nose feel cold
d. The patient complains that he has had trouble falling asleep the past 2 nights
23. A 1-day-old was born with a myelomeningocele. The nurse caring for the neonate should place the infant in which position?
a. On her abdomen with her face turned to the side
b. Sitting upright in an infant seat
c. On her back with the head of the crib elevated
d. On the left side with a pillow on her back.
24. A 55-year-old client is seen in the outpatient clinic for complaints of perineal irritation due to frequent incontinence. Which of the following measures if suggested to the client by the nurse, is best?
a. Apply Betadine ointment to the perineum
b. Gently cleanse the perineum with warm water 2-3 times/ day
c. Use extra large adult incontinence briefs during the day
d. Expose the perineum to the air for 20 minutes each day
25. The nurse utilizes a trochanter roll to position an unconscious patient. Which of the following most accurately describes the correct location for a trochanter roll?
a. From the iliac crest to the knee
b. From the lateral aspect of the hip to mid-thigh
c. From the mid-thigh to the ankle
d. From the medial aspect to the ankle
26. The nurse is teaching a 76-year-old man how to ambulate using a walker. Which of the following behaviors, if observed by the nurse, would indicate that teaching has been successful?
a. The man grasps the front bar of the walker and stands in the middle of the walker
b. The man tips the walker towards himself, and then takes several steps
c. The man grasps the side handles of the walker and stands between the back legs
d. The man tips the walker away from himself, and then takes several steps
27. The nurse is aware that the priority intervention for a client who has experienced burn injuries involving the face, neck, and upper chest is:
a. Tetanus immunization
b. Pain management
c. Dry sterile dressings
d. Endotracheal intubation
28. A 39-year-old client has been diagnosed with iron-deficiency anemia. The clinic nurse would know the client understood the discharge teaching concerning diet therapy when the client states, “I will increase the amount of
a. fresh fruits in my diet.”
b. milk products I drink.”
c. white meat in my diet.”
d. whole grain breads I eat.’
29. When teaching your client about pursed-lip breathing, the nurse would instruct the client to inhale slowly
a. Through the mouth, then breath normally
b. Through the nose, then exhale slowly
c. Through the mouth, then exhale slowly
d. Through the nose, then exhale quickly
30. A client who has had a continent urostomy created complains of postoperative pain. Initially, the nurse should:
a. Interview the client for more data
b. Tell the client to take deep breaths
c. Measure the client’s current vital signs
d. Administer the prescribed analgesic to the client
31. A slightly overweight client is to be discharged from the hospital after a cholecystectomy. When teaching the client about nutrition, the priority intervention should be:
a. Listing those fatty foods that may included in the diet
b. Explaining that fatty foods may not be tolerated for several weeks
c. Teaching the importance of a low-calorie diet to promote weight reduction
d. Encouraging the client to join a weight reduction program in the local community
32. The mother of a preschooler with acute glomerulonephritis asks the nurse whether her child will have to stay in bed. The nurse should tell the mother that bed rest:
a. Is not part of the usual treatment unless the child is seriously ill
b. Will be necessary for 3 to 4 weeks, regardless of the response to therapy
c. Is limited to 72 hours after the institution of anti-hypertensive drug therapy
d. Will be necessary until the child’s blood pressure is normal and the urine is clear
33. Considering the anticholinergic-like side effects of many of the psychotropic drugs, the nurse should encourage clients taking these drugs to:
a. Suck on hard candy
b. Restrict their fluid intake
c. Eat a diet high in carbohydrates
d. Avoid products that contain aspirin
34. The nipples of a client who is breastfeeding her baby becomes sore and cracked. The nurse should instruct the client to:
a. Apply continuous ice packs to her nipples
b. Take analgesics medication as ordered
c. Remove the baby from the breast for a few days
d. Expose her nipples to the air several times a day
35. The nurse is providing care to a child who had cardiac catheterization. Which of the following interventions should the nurse provide?
a. Offer the child liquids immediately on awakening
b. Allow the child to sleep as much as possible
c. Assess the peripheral pulses for symmetry
d. Change the dressing over the catheter site
36. A 10-year-old child is admitted to the pediatric unit in sickle cell crisis. What should the nurse do first?
a. Assess vital signs, including temperature
b. Assess the degree of pain using pain scale
c. Determine the rate of the IVF
d. Obtain pertinent history information from the parents
37. The nurse is teaching the mother of a toddler with iron deficiency anemia about dietary modifications. Which of the following statements by the mother indicates that she understands the teaching?
a. “I can let my child have 4 glasses of milk everyday.”
b. “I will feed my child fortified cereal and lots of vegetables.”
c. “I plan to offer my child juices and cereal for snacks.”
d. “I think my child will drink milk and juices easily.”
38. The nurse is caring for a client who is hypertensive. To facilitate the client’s ability to lower his blood pressure to a normal range, the nurse should teach him to avoid which of the following foods?
a. Cooked cereal
39. The hypertonicity of the muscles in an infant with cerebral palsy cause scissoring of the legs. The nurse should suggest to the infant’s mother that the best way to carry the baby in a sitting position:
a. Astride one of her hips
b. Strapped in an infant seat
c. Wrapped tightly in a blanket
d. Under the arm using a football hold
40. To help manage the client’s pain during burn dressing changes, the nurse can teach the client to:
a. Deep breathing exercises
b. The importance of wound care
c. Active range-of-motion exercises
d. To alternately contract and relax muscles
41. A client has had a cesarean delivery because of fetal heart rate tracing abnormalities. When doing post-operative coughing and deep breathing, she complains of localized pain in the incision, which subsides in a few moments. The nurse should:
a. Place her in the supine position and inspect the wound site
b. Instruct her to splint the wound with a pillow when coughing
c. Assess the intensity of the pain and give her the ordered analgesic
d. Call her physician immediately and then check for wound dehiscence
42. A client has undergone gastrointestinal surgery. Following the surgery, a client’s condition improves and a regular diet is ordered. The food that will most likely be tolerated with little discomfort is:
a. Fresh fruit
b. Baked fish
c. Whole milk
d. Bran cereal
43. A client has a below-the-knee amputation of the right leg. The nurse should understand that after this surgery:
a. Strict bed rest is usually maintained for a least several days
b. The stump dressing is usually changed daily by the physician
c. Hemorrhage rarely occurs during the early post-operative period
d. The client is usually positioned with the stump elevated for the first 24 hours
44. To prevent the development of pressure ulcers, which of these measures should be included in the care of a client on bed rest:
a. Massage red areas on bony prominences regularly
b. Wash skin with soap and water frequently
c. Use a donut-shaped cushion on the sacral area
d. Establish an individualized turning schedule
45. A nurse is aware that to prevent corneal abrasions in a client who has myasthenia gravis and is unable to close her eyes, the nurse care plan should include which of these measures during the day?
a. Placing sunglasses on the client to avoid having the eyes come in direct contact with ultraviolet light
b. Keeping the client’s room dimly lit to prevent over stimulation of the nerves of the eyes
c. Taping gauze sponges loosely over the client’s eyelids to protect the eyes from foreign objects
d. Applying artificial tears to the client’s eyes to keep them moist
46. A client who is receiving chemotherapy for leukemia develops stomatitis. To manage stomatitis, which of these measures would be appropriate?
a. Having the client floss the teeth before and after meals
b. Encouraging the client to rinse mouth with saline q 1-2 hours while awake
c. Keeping the client on a clear liquid diet
d. Offering the client a citrus fruit juice, high in ascorbic acid q 4 hours
47. The client with acute renal failure asks the nurse for snack. Because the client’s potassium level is elevated, which of the following snacks would be most appropriate?
a. A gelatin dessert
c. An orange
48. The nursing assessment of a client’s functional status and after CVA is essential. Why is it so important?
a. The rehabilitation plan will be guided by it
b. Functional status before the CVA will help predict outcomes
c. It will help the client recognize his physical limitations
d. The client can be expected to regain much of his functioning
49. A 66-year-old female client has arthritis and experiencing increased alterations in mobility. In planning her care, which of the following measures would be the best approach for the nurse to safeguard the client?
a. Using a vest restraint at all time
b. Teaching crutch walking
c. Removing excess room furniture and clutter
d. Placing the bedside table away from the client
50. The nurse is speaking to the mother of a 5-year-old child with a burn on the arm from hot soup. What advice should the nurse give to the child’s mother?
a. Wash the area with soap and water
b. Spray the area with a pain reliever
c. Flush the area with tepid water
d. Bring the child immediately to the clinic
51. A 30-year-old former aerobics instructor is 8 weeks pregnant and wants to know if a low-impact aerobics program can be continued. Which of the following would be the nurse’s best response?
a. “Yes. If you are already involved in a physical in a physical fitness regimen, it may be continued within certain limits.”
b. “No. If you moderate your food intake, you shouldn’t gain that much weight.”
c. “Walking is allowed, but an aerobic program can be dangerous to the baby.”
d. “No, but since you’re already fit, it won’t take long for you to get back in shape after the baby is born.”
52. A client with cholecystitis is placed on a low-fat, high protein diet. The nurse should teach the client that this diet can include:
a. Boiled beef
b. Skimmed milk
c. Poached eggs
d. Steamed broccoli
53. The nurse is preparing a presentation on nutrition to a group of pregnant adolescents. Which of the following would important for the nurse to include in the teaching plan?
a. Spinach is an excellent source of calcium in the diet
b. Two to four servings of whole-grain products is recommended
c. Three or more serving of dairy products meets the calcium requirement
d. Vitamin A supplement may be necessary for clients who are vegetarian
54. A child’s plan of care lists increasing protein intake as a goal. Which of the following foods that the child likes would the nurse encourage the child to eat?
a. Bacon, lettuce and tomato sandwich
b. fruit-flavored yogurt
c. Nacho chips and salsa
d. Crackers with butter and jelly
ANSWERS AND RATIONALE
- there can be an increased or decreased tone of the detrusor muscle, sphincter or bladder neck, or a combination of these three.
- Option D is the most appropriate diet for this client. It’s the diet with the least cholesterol.
- one cup skim milk provides the highest amount of calcium.
- a sufficient fluid intake prevents complications such as infection, calculi, and obstruction. The appliance needs to be changed as needed, which is usually every 3-5 days. There is a not limitation on sexual activity. Dilatation is not done with ileal conduit but rather with a colostomy stoma before irrigation.
- preparatory exercises are aimed at strengthening the shoulder girdle and upper extremity muscles.
- a child with muscular dystrophy is prone to constipation and obesity, so dietary intake should include a diet low in calories. High in protein and high in fiber. Adequate fluid intake should also encourage.
- initial attempts at oral feeding may cause a choking feeling that may produce severe coughing and raise secretions. Swallowing does not have an adverse effect on the suture line; a nasogastric tube would not be used because it could traumatize the suture line. A progressive diet is started with liquids, not pureed foods. The pain medication may cause in client’s respiratory effort and may also depress cough reflex
- the skin is the first line of defense; keeping it dry and safe from injury promotes skin integrity. Irradiated skin is fragile and subject to blistering and sloughing. Skin should be free of emollients because they change the angle or degree of radiation.
- Raynaud’s phenomenon is caused by vasospasm, precipitated by exposure to cold or emotional stress. Raynaud’s is commonly associated with scleroderma, a connective tissue disease.
- elevation will help control the swelling that normally occurs. Because the ankle has been at rest, discomfort and stiffness are expected after the cast is removed and because the skin has been exposed, it needs gentle washing to prevent breaking the tissue. The leg should be put through full range of motion mote than once daily.
- moist heat increases circulation and decreases muscle tension, which helps relieve chronic stiffness.
- rest will decrease the demands at the synoptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins.
- antacids should be given 1-2 hours after a meal to extend buffering action. if antacids is given prior to the meal, buffering of acid may not occur. Antacids timing should be correlated with meal times
- recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
- an increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD, and therefore the physician should be notified. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Client with COPD use a low-flow oxygen supplementation (1 to 2L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia
- exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing of lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac dysrhythmias.
- auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetric rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the ET tube.
- a soft toothbrush should be used to brush the client’s teeth after every meal and more often as needed. Mechanical cleansing is necessary to maintain oral health, stimulate gingival, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not nursing assistant. Swabbing with a safe foam applicator does not provide enough friction to cleanse the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.
- clients with gastric cancer often have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutritional deficit is a higher priority. At present, radiation therapy hasn’t been proven effective for gastric cancer, and teaching about it preoperatively wouldn’t be appropriate. Prevention of DVT also isn’t a high priority prior to surgery, though it assumes greater importance after surgery.
- allowing the mother to feed the child, serving smaller and more frequent meals, and offering finger foods are all acceptable interventions for a 5-year-old child. This is true whether the child is well or ill. Withholding certain foods until the child complies is punitive and rarely successful.
- for the breastfeeding client, drinking at least 8 to 10 glasses of fluid per day is recommended. Breastfeeding women need an increased intake of vitamin D for calcium absorption. A breastfeeding woman requires an extra 650 calories per day to produce quality breast milk. Breastfeeding women need adequate calcium for blood clotting and strong bones and teeth.
- when the heart is unable to tolerate the increased cardiac workload imposed by immobility, the peripheral areas of the body will be colder than the central region, and cardiac failure may develop.
- this prevents pressure on the sac-like protrusion on back; the pressure would result in increased intracranial pressure, or may rupture sac leading to infection.
- warm water and gentle stroking stimulate good circulation, promote good hygiene; barrier creams may be used.
- the hip joints lie between the lateral aspects of the hip to mid-thigh; hips tend to rotate externally when the patient is positioned on his back.
- walker is placed in front of the body with the open side toward the patient; patient’s arms must rest on the hand grips of the walker with the elbows flexed 20-30 degrees; patient lifts the walker, place it forward so he is between its back legs and walks into it.
- although the client may need dressings and pain management, endotracheal intubation is the priority for a client with airway injury.
- cereals, grains, organ meats, and dried fruit are high in iron.
- clients inhale through their nose and exhale through pursed lips. The client should not inhale through the mouth.
- the nurse should determine the location, intensity, and other characteristics of the pain before initiating intervention. Assessment should occur before nursing intervention.
- bile, which aids fat digestion, is not as concentrated as before surgery; once the body adapts to the absence of the gall bladder, the client should be able to tolerate a regular diet that contains fat.
- bed rest promotes decreased cardiac output; it also decreases tissue catabolism, which lowers the workload of the kidneys, eventually increasing filtration by the renal glomeruli; limiting activity also helps lower the blood pressure.
- hard candy may produce salivation, which helps alleviate the anti-cholinergic-like side effect of dry mouth that is experienced with phenothiazines
- air drying the nipples several times a day hardens the nipples and reduces soreness; changing the position of the neonate while nursing will also relieve sore nipples.
- the most important nursing intervention after cardiac catheterization is to assess peripheral pulses, especially those distal to the catheter site. The pulse may be weaker initially but typically becomes stronger in a short period of time. The dressing should be assessed and the child may want liquids after the procedure. Allowing the child to sleep as much as possible may be appropriate but isn’t the most important intervention
- all options are important, but the nurse should assess vital signs first to determine the patient baseline. Children with sickle cell disease are prone to developing infections as a result of necrosis of body areas where vaso-occlusive crisis occurs; this crisis also is associated with localized pain at the site of infection. It’s important for the child to receive adequate fluids to help prevent dehydration and increase blood volume. History will help determine other coexisting conditions.
- for the child with iron deficiency anemia, iron-rich foods such as fortified cereal, green leafy vegetables, and red meat need to be offered in larger amounts. Foods that contain less iron, such as milk, juices, yellow vegetables, and non fortified cereals should be offered in smaller amounts.
- catsup, like all canned tomato products, is very high in sodium.
- straddling the hip would help prevent scissoring by keeping the infant’s legs abducted. An infant seat would not prevent scissoring. Tight wrapping would maintain the infant’s legs in scissored position. When the football hold is used, the infant is carried in supine position with the legs adducted, which promotes scissoring.
- deep breathing provides an active role in controlling pain; this is a positive coping skills. Understanding the importance of wound care will not reduce severe pain; health teaching should be initiated before, not during, a procedure. Distraction techniques are usually ineffectual in the presence of severe pain; contraction may increase the pain
- this relieves some of the pain because it provides support to the incised abdominal wall. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved
- baked fish is a low-residue, low-fat, high-protein, and non-gas-producing food that is usually well tolerated. Other options irritate the GI tract.
- elevation in the first 24 hours helps prevent edema; continued elevation may lead to hip contractures. The client is usually out of bed on the second day post-op. the stump dressing is usually a pressure dressing and it is not changed daily. Hemorrhage and infection are two most common complications.
- establish an individualized turning schedule. Turning and positioning interventions, tailored to the client’s needs, are designed to reduce pressure and shearing force to the skin. Massage applied directly to a reddened are promotes further skin breakdown. Soap and water cause drying of the skin, which contributes to breaks in skin integrity. A donut-shaped cushion interferes with the oxygenation of the tissue of the sacrum in the center of the donut.
- inability to close eyelids, loss of protective mechanism, places the client at risk for corneal abrasions because foreign objects (e.g., dust, dirt) are not removed from the corneas. In addition, the eyes tend to dry out, which dries the cornea. To keep the eyes moist, artificial tears should be applied several times during the day. A lubricant gel and shield may be applied to the eyes during the night for greater protection
- rinsing the mouth with plain water, or saline, frequently helps to relieve stomatitis (mouth sores). Commercial mouth washes that contain alcohol or other drying agents should be avoided.
- gelatin desserts contain little or no potassium and can be served to a client on a potassium-restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.
- primary reason for the nursing assessment of a client’s functional status before and after a CVA is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client recover from the residual effects of the CVA; only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client’s functional status is not a motivating factor.
- removing excess room furniture and clutter is the best way to safeguard the client because this measure can reduce the chance of injury by ensuring clearer access for walking and movement.
- when a child has a scald type burn, it’s important to immediately flush the area with tepid water to cool the skin and prevent the burn from progressing. Soap shouldn’t be used until the area had been flushed well. The child shouldn’t be taken to the clinic until the area has been flushed. Spraying the area with pain reliever won’t stop the burning process.
- Continuance of an existing exercise program is allowed and encouraged during pregnancy. Restrictions on exercise include keeping the pulse less than 140 bpm, keeping the core temperature less than 38C (100.4F), drinking plenty of fluids and avoiding both jarring movements and the supine position.
- during acute cholecystitis, low-fat liquids are permitted; skim milk is low in fat and contains protein, which will eventually promote healing. Beef, even if it is lean, contains fat and egg yolks contain fat and should be avoided. Gas-forming vegetables should be avoided.
- three or more servings of dairy products meet the calcium requirement. This can be obtained through milk, cheese, yogurt and foods such as tofu. Spinach contains oxalates, which decrease the availability of calcium. Six to eleven servings of whole grains are recommended. Vitamin A supplements are not necessary in vegetarian diets because most vegetarian diets are rich in vitamin A. vitamin A supplements can lead to anorexia, irritability, hair loss and damage to fetus.
- yogurt is high in protein because it is made from milk. The other choices are much higher in carbohydrates than protein except for bacon, which is higher in fat.