A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care? 

a) Having the client shift his or her weight every hour
b) Massaging any reddened areas of the skin
c) Placing the client in a semi-reclining position
d) Lubricating the skin with a non-irritating lotion

Answer: D

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

a) 45 degree flexion
b) 15 degree flexion
c) 25 degree flexion
d) 0 degree flexion

Answer: C

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

a) toilet incontinence.
b) reflex (neurogenic) incontinence.
c) functional incontinence.
d) stress incontinence.

Answer: B

A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension?

A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension? 

a) Nausea
b) Flushing
c) Dry skin
d) Bradycardia

Answer: A

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first?

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first? 

a) Place the cane on the lower step.
b) Step down with the affected leg.
c) Step down with the unaffected leg.
d) Place cane and affected leg on step simultaneously.

Answer: C

Which intervention has the highest priority when providing skin care to a bedridden client?

Which intervention has the highest priority when providing skin care to a bedridden client?

a) Changing the client's position frequently
b) Keeping the skin clean and dry without using harsh soaps
c) Rubbing moisturizing lotion over the pressure areas
d) Gently massaging the skin around the pressure areas

Answer: B

A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following?

A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following? 

a) Thumb opposition
b) Supination
c) Wrist flexion
d) Ulnar deviation

Answer: D

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

a) Constipation
b) Edema
c) Sensory overload
d) Diaphoresis
e) Anemia

Answer: B, E & D.

Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?

Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?

a) Barthel index
b) Braden scale
c) FIM
d) PULSES profile

Answer: B

A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length?

A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length? 

a) 66 inches
b) 60 inches
c) 54 inches
d) 48 inches

Answer: C

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

a) Stage I
b) Stage III
c) Deep tissue injury
d) Stage IV
e) Stage II

Answer: B & D.

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?

a) Fowler's
b) Prone
c) Lateral
d) Recumbent

Answer: D

A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position?

A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position? 

a) Side-lying
b) Prone
c) Semi-Fowler's
d) Supine

Answer: B

The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene?

The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene? 

a) Client keeps the cane fairly close to the body when ambulating.
b) Client bears down on the cane when he begins to swing the unaffected leg.
c) Client advances the cane at the same time he moves the affected leg forward.
d) Client moves the arm and leg on the same side together at the same time.

Answer: D

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

a) "Keep feet 12? (30 cm) apart to provide stability and a wide base of support."
b) "Use the axillae to help carry the weight."
c) "Take long strides to maintain maximum mobility."
d) "All weight should be on the hands."

Answer: D

The nurse is helping a patient who experiences frequent constipation select his meal choices for the day. Which of the following should the nurse encourage the patient to order?

The nurse is helping a patient who experiences frequent constipation select his meal choices for the day. Which of the following should the nurse encourage the patient to order?

a) Applesauce
b) Bananas
c) Bran cereal
d) Pop tart

Answer: C

The nurse is completing an initial assessment on an elderly patient. When asked about her urinary patterns, the patient states that she can "never get to the bathroom in time." The nurse documents this as which of the following?

The nurse is completing an initial assessment on an elderly patient. When asked about her urinary patterns, the patient states that she can "never get to the bathroom in time." The nurse documents this as which of the following?

a) Functional incontinence
b) Urge incontinence
c) Reflex incontinence
d) Stress incontinence

Answer: A

A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use?

A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use?

a) Adjusting the height of the walker so the arms aren't bent when the hands rest on the walker grips
b) Moving the walker, stepping with the affected leg, then stepping with the unaffected leg
c) Using the walker for support while rising from a chair
d) Moving the walker, stepping with the unaffected leg, then stepping with the affected leg

Answer: B

A nurse is developing a plan of care for a patient experiencing urinary incontinence and identifies a nursing diagnosis of risk for infection related to urinary incontinence and inadequate bladder emptying. Which of the following would the nurse most likely include as an appropriate fluid to encourage?

A nurse is developing a plan of care for a patient experiencing urinary incontinence and identifies a nursing diagnosis of risk for infection related to urinary incontinence and inadequate bladder emptying. Which of the following would the nurse most likely include as an appropriate fluid to encourage? 

a) Carbonated cola
b) Cranberry juice
c) Tomato juice
d) Milk shakes

Answer: B

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

a) Hyperextending the client's legs
b) Performing shoulder range-of-motion (ROM) exercises
c) Applying knee splints
d) Elevating the foot of the bed

Answer: C