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The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspirati...

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A.High Fowler's position without a pillow behind the head B.Semi-Fowler's position with a single pillow behind the head C.Right side-lying position with the head of the bed elevated 45 degrees D.Sitting upright and forward with both arms supported on an over the bed table D Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to in...

1. A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: A. Put all four side rails up on the bed B. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities C. Request that the client’s roommate put the call light on when the client is attempting to get out of bed D. Check on the client at regular intervals to ascertain the need to use the bathrooms 2. The nurse should use which t...

1. A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record? a. Nursing process form b. Step-by-step skills manual c. A list of possible procedures d. Reports to third-party payers ANS: D Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. An interprofessional plan...

A married couple lives in a single-family house with their new-born son and the husband’s daughter from a previous marriage. On the basis of the information given, what family form best describes this family? a. Married-blended family c. Nuclear family b. Extended family d. Same-sex family ANS: A Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join together to create a new household. Members of an extended family are kin, or...

1. Which interventions would help alleviate the problems associated with access to health care for maternity patients (Select all that apply)? a. Provide transportation to prenatal visits. b. Provide childcare so that a pregnant woman may keep prenatal visits. c. Mandate that physicians make house calls. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 13 d. Provide low-cost or no-cost health care insurance. e. Provide job training. ANS: A, B, D Lack of transportatio...

1. A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assess first? A. A client who has a hip fracture and is in Buck’s traction B. A client who has aspiration pneumonia and a respiratory rate of 28/min C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot D. A client who has a C diff infection and needs a stool specimen collected 2. A nurse is caring for a client who fell and is reporting pain in the le...

7. A nurse is providing education to a troop of local Boy Scouts regarding first aid for venomous snake bites in the event that transport to the hospital is delayed. Which of the following would be appropriate information to include in teaching about bites to an extremity Apply a constricting band above the bite while maintaining circulation below the bite 8. In reviewing goals of “healthy people” nurse determines the community has a significant problem preventing dental caries in children...

Aging Process Newborn Assessment: Expected Findings ● Normal Assessment Findings for Head: Should be 2-3 cm larger than chest. ● Anterior fontanel should be palpated and approximately 5 cm on average and diamond shaped. ● Posterior fontanel is smaller and triangle-shaped. Should be soft and flat. Molding of sutures is normal. Psychosocial Integrity Crisis Intervention Sexual Assault: Priority Intervention ● Provide a private environment and limit personnel who examine t...

A patient had abdominal surgery and states that after coughing it feels like his guts has spilled out. What should the nurse do first? Visualize the abdominal area A patient has been taking Kenalog (corticosteroid) with increase redness... Schedule an appointment A patient hd a BDP. What warrants further intervention? Positive gastro occult emesis A patient who has been taking B12 says he's fatigue. What lab to monitor? CBC A patient with Parkinson is walking ? C...