Basic Care Assessment

The nurse examines a client who has ankle swelling and pain on movement after a fall while climbing stairs.  What nursing measure is most helpful for relieving the soft tissue swelling?

A hospice nurse makes a visit to the home of a client with acquired immunodeficiency syndrome (AIDS) dementia complex. What nursing approach for communication would be best if the client becomes confused?

Following the eye wash, the nurse reassesses the client’s eye in the health room and irrigates with normal saline. The nurse is preparing to irrigate the student’s eye. What step(s) is appropriate in completing the irrigation? Select all that apply.

The client’s nursing care plan indicates that the client must be weighed each day. When directing the unlicensed assistive personnel to weigh the client, what instruction is most important for obtaining accurate data?

The nurse provides crushed ice chips in an 8-ounce glass to the client who mouth breathes. Which nursing action provides the most accurate intake amount?

The client reports having acute pain in the incisional area after coronary artery bypass graft (CABG) surgery. When the nurse applies antiembolism stockings following cardiac surgery, what measurements are necessary for ensuring an optimum fit? Select all that apply.

A client develops mucositis of the oral cavity while receiving chemotherapy for cancer. Which food item(s) is best for the nurse to withhold from the client’s dietary tray? Select all that apply.

A 45-year-old client is suspected of having cholecystitis. When the dietitian has finished instructing the client about a low-fat diet, the nurse knows that the client requires additional teaching based on which statement?

A stroke victim is admitted to a long-term care facility. The male client has a history of urinary incontinence. A nurse applies an external condom catheter to the client. What nursing action is best for preventing irritation of the urinary meatus?

A 16-year-old client confides to the school nurse that she has cramps that accompany the onset of menstruation. What activity is best for the nurse to recommend to the client who believes she is experiencing premenstrual syndrome (PMS)

The bones are not fractured, but the ankle is severely sprained. The nurse is teaching the client how to use an elastic bandage. Where should the nurse demonstrate applying an elastic bandage to the client’s lower extremity?

The client with Parkinson disease takes levodopa/carbidopa three times a day. Because the client with Parkinson disease is prone to constipation, the nurse should encourage increased consumption of which food?

The client asks the nurse to explain the purpose of preoperative therapy with potassium iodide solution. Preoperatively, what information is most important to teach the client before the thyroidectomy?

The client reports having acute pain in the incisional area after coronary artery bypass graft (CABG) surgery. When initially ambulating the client after surgery, which assistive device is most helpful?

While helping a client onto the examination table, the nurse notes that the client has several large protruding leg veins. What nursing instruction is most beneficial in helping relieve the client’s symptoms caused by varicose veins?

While preparing to return home, the client with emphysema verbalizes concern about continued fatigue and shortness of breath. What discharge instruction is most appropriate for reducing the client’s fatigue and shortness of breath during mealtimes?

A client develops mucositis of the oral cavity while receiving chemotherapy for cancer. The nurse assesses the client’s oral cavity and plans to assist with oral care. What item should the nurse obtain?

The client who had an open cholecystectomy develops postoperative nausea and vomiting. Metoclopramide 10 mg is prescribed. When the nurse assists the client out of bed to ambulate after a cholecystectomy. What is the best nursing action?

The nurse plans to initiate a bladder retraining program for the incontinent client. What nursing assessment is most important before beginning bladder retraining?

A 64-year-old client with uterine cancer is scheduled to undergo an abdominal hysterectomy under general anesthesia. Postoperative prescriptions include applying antiembolism stockings to the client’s legs after the hysterectomy. The client’s urinary catheter can be removed. What nursing action is performed first?

A 29-year-old multiparous client who has had an uneventful, healthy pregnancy is admitted to the hospital. The health care provider informs the client that the active phase of the first stage of labor is in progress. The records also show that the full-term fetus is in the left occipitoposterior (LOP) position. When the fetus is in the left occipitoposterior (LOP) position, what nursing intervention is most appropriate?

A surgical repair of the myelomeningocele is successfully completed. What should the nurse plan to teach the parents as the child gets older to prepare them for managing their child’s urinary incontinence at home?

The health care provider admits the child with extensive partial-thickness and full-thickness burns to the pediatric intensive care unit (PICU) for close assessment and nursing care. Because the burned child is confined to bed, the nurse assesses for footdrop. What nursing action best prevents the development of footdrop?

During the care conference, the parent of the child with an autism spectrum disorder says that the child helps to get dressed but will not eat independently and must be fed by others. What suggestion by the nurse would be most beneficial for the child’s nutrition at this time?

The bones are not fractured, but the ankle is severely sprained. What is the best technique for the nurse to use when applying the elastic bandage to the client’s lower extremity?

A 48-year-old client experiences an exacerbation of multiple sclerosis after being asymptomatic for the past 6 months. When assisting the client with activities of daily living (ADLs), what approach is best?

Following the eye wash, the nurse reassesses the client’s eye in the health room and irrigates with normal saline. When irrigating the client’s eyes, what technique describes the best way to direct the flow of irrigating solution?

The client has three of the four lobes of the parathyroid gland surgically removed. After the client returns from surgery and resumes eating, the nurse should encourage the client to eat foods from what food groups?

Over a period of 10 years, the client’s condition has progressively worsened, and the client is now scheduled to have surgery for a mitral valve replacement. The nurse notes that postoperatively the client experiences shortness of breath during self-care. What nursing action would best reduce the client’s energy expenditure?

Warm, moist compresses are ordered for the affected leg. The nurse is gathering supplies and instructing on the procedure. What nursing action is most appropriate when applying the warm, moist compress to the affected leg?

A nurse is assigned to care for several clients who require total care and is planning oral care for them. The nurse should plan specialized oral care twice a day for the client who:

A liver biopsy is performed to confirm a diagnosis of cirrhosis. The client with cirrhosis has developed pruritus. What nursing measure is most beneficial to implement?

The client in early renal failure is placed on a sodium-restricted diet. When the client expresses dissatisfaction about the bland taste of the food, the nurse appropriately recommends substituting salt with what condiment?

In addition to a mild analgesic, sitz baths are recommended as a comfort measure for the prostatitis. What nursing instruction is correct concerning the sitz bath regimen?

A 26-year-old primigravid client visits the obstetrician for the first prenatal visit. The health care provider confirms that the client is in the 9th week of pregnancy. The nurse and client discuss general health needs during pregnancy. What client statement regarding bathing indicates a need for additional teaching?

Just after the birth of the placenta, the client reports of uncontrollable shaking and of being cold. What actions by the nurse are most appropriate at this time? Select all that apply.

A 1-week-old newborn who was born with hydrocephalus is scheduled for surgery. What measure is most appropriate for the nurse to use to reduce the potential for a pressure injury developing on the head of an infant with hydrocephalus?

The condition stabilizes for the child with extensive partial-thickness and full-thickness burns. The child is now placed on a high-protein diet. If the following foods are available, which snack is best to meet the child’s need for protein?

A client with a malignant eye tumor has consented to undergo enucleation of the eye. When a client with a stye (hordeolum) asks a nurse to suggest measures to relieve the discomfort, what is the best advice the nurse can offer?

While backpacking with a youth group, a 17-year-old falls and sustains an injury to the lower leg. A nurse who is accompanying the group suspects a fracture of the tibia. How should the nurse apply a splint to immobilize the suspected fracture?

During a physical assessment, the nurse notes that the client experiences weakness and numbness in various parts of the body. What nursing measure is appropriate to add to the care plan at this time for preventing impaired skin integrity?

A client who wears a hearing aid is frustrated by the loud and shrill noise (feedback) that is occasionally heard.  What nursing action is most helpful for reducing or eliminating feedback from the client’s hearing aid?

A client diagnosed with Addison’s disease is learning appropriate food choices to help with disease management. If the following foods are available, which one, selected by the client, confirms an understanding of appropriate food selection?

A 75-year-old client in a skilled nursing facility has peripheral arterial disease (PAD). What nursing intervention is most appropriate if the client experiences cold feet as a result of impaired circulation?

A nurse is assigned to care for several clients who require total care and is planning oral care for them. What nursing technique(s) is appropriate when providing oral care for a client’s dentures? Select all that apply.

A 48-year-old client presents to the emergency department because of severe upper abdominal pain. The client reports that the pain came on suddenly a few hours ago and nothing so far has relieved it. The nurse observes that the client is curled in a fetal position and is rocking back and forth. A diagnosis of acute pancreatitis is made. What action would best assist the nurse in further assessing the client’s pain?

Interferon beta-1a given intramuscularly using an injection pen is prescribed for a client with multiple sclerosis. What nursing action is best if the client develops anorexia and nausea while taking interferon beta-1a?

The esophagoscopy reveals that the client has a stricture near the end of the esophagus. To help improve the client’s ability to swallow, what nursing recommendation is most appropriate?

The client in early renal failure is placed on a sodium-restricted diet. What nursing action is most appropriate when the client states being thirsty because of the fluid restrictions?

One of the participants in the prenatal class tells the nurse, “My skin itches so much. What can I do about it?”. What nursing instruction is most appropriate regarding the relief of itchy skin during pregnancy?