Prep Taylor fundamental of nursing questions and answers, 2022/2023 update.

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Prep Taylor fundamental of nursing questions and answers, 2022/2023 update. Mrs. Jimenez, age 79, became a widow earlier this year and now resides alone in the house that she and her husband sh... ared for 30 years. Her children have encouraged her to move, but she expresses a desire to remain in her home, despite some slight mobility challenges. The nurse who provides occasional home healthcare for Mrs. Jimenez should first propose which of the following? a. Home modification b. Assisted living c. A nursing home d. Homesharing - ✔✔A. Home modifications An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for: a. sleep problems. b. suicidal thoughts. c. poor cognitive performance. d. lack of initiative. - ✔✔B. suicidal thought they are all manifestations of depression but suicide is a serious consequence When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that: a. hair should be washed as often as necessary. b. lubricants or oils should not be used. c. braids should be undone every day. d. combs should be washed as often as necessary. - ✔✔A. hair should be washed as often as possible A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? a. Cut the nail straight across. b. Remove ingrown toenails. c. Soak the foot in witch hazel. d. Protect the foot from blisters - ✔✔A. cut the nail straight across When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should: A. encourage the client to bathe daily as part of protection from infection. B. understand that his culture may influence his hygiene and ask him his preference. C. give the client a bath pan and tell him she will return when he has finished. D. ask another nurse to assist in giving the client a complete bath every other day. - ✔✔B. understand that his culture may influence his hygiene and ask him his preferences A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: A. a rash related to immobility. B. an allergic reaction to medications. C. a rash related to a yeast infection. D. an allergic reaction to detergent. - ✔✔C. a rash related to yeast infection An 85-year-old client's daughter calls the nurse and states her father is recently having periods of confusion, is unable to dress himself, and is having periods of incontinence. Which of the following should the nurse do first? A. Perform a SPICES assessment B. Teach the daughter how to use reminiscence as a therapy C. Make arrangements for the client to move to an extended-care facility D. Schedule an appointment for a physical examination - ✔✔D. schedule an appointment for a physical examination The wound care nurse is performing assessment of clients. Which wound complications does the nurse report to the health care provider? Select all that apply. A. fistula formation B. a wound with a pink wound bed and no drainage present C. a wound with approximated edges 3 days after a surgical procedure D. partial disruption of wound layers E. viscera protruding through the incisional area F. a wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5 - ✔✔A,D,E,F A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals? A. She has motivation to participate in self-care. B. She has good mobility around her home. C. She has hot water to bathe in. D. She has family and friends who help her with self-care. - ✔✔A. she has motivation to participate in self-care A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: A. emotional abuse. B. neglect. C. exploitation. D. abandonment. - ✔✔D abandonment An older adult client being cared for at home has developed a decubitus injury. The nurse would instruct the family caregiver to institute measures to: A. promote bowel elimination. B. improve nutrition. C. control incontinence. D. relieve sustained pressure. - ✔✔D. relieve sustained pressure The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide? A. Buy a hard-bristled toothbrush to ensure proper oral hygiene. B. Reassure the client that prolonged bleeding of wounds and gums is normal. C. Take aspirin for headaches that develop. D. Use an electric razor for shaving purposes - ✔✔D. use an electric razor for shaving purposes The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? A. "You are seeing undermining, a type of tissue erosion." B. "This is normal tissue." C. "Necrotic tissue is devitalized tissue that must be removed to promote healing." D. "That is called slough, and it will usually fall off." - ✔✔C. necrotic tissue is devitalized tissue that must be removed to promote healing The nurse is observing a student who is using a safety razor to shave a client. Which action would require intervention by the nurse? A. washing the skin with soap and water prior to shaving B. pulling the razor against the direction of hair growth C. rinsing the razor after each stroke of the razor D. applying direct pressure to an area that is bleeding - ✔✔B. pulling the razor against the direction of the hair growth. (it should go with the growth of hair) A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? A. autolytic debridement B. enzymatic debridement C. biosurgical debridement D. mechanical debridement - ✔✔C. bio surgical An adult child accompanies an older adult client to the clinic and states, "I am not sure what is going on with my parent but I think it is depression." What questions should the nurse ask the client to determine if he or she is depressed? Select all that apply. A. "Have you lost interest in things you previously found pleasurable?" B. "What foods do you like to eat?" C. "Can you tell me what your sleep patterns are?" D. "Have you had any changes in weight recently such as a gain or loss?" E. "Have you been seeing things that no one else seems to see?" - ✔✔A, C, D The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? A. Apply a skin protectant to the incision site. B. Apply a transparent dressing over the incision site. C. Apply a sterile gauze sponge over the incision site. D. Apply a skin protectant to the skin around the incision - ✔✔D. apply skin protectant to the skin around the incision What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A. To turn the head away from the area whenever coughing B. To remain in bed for the next 4 hours C. To splint the area when engaging in activity D. To ambulate using a cane or walker - ✔✔C. to point the area when engaging in activity The nurse is caring for an older adult postsurgical client who will be immobile for several weeks. Which evidence prompts the nurse to monitor for a risk for infection? A. Decreased red blood cell count on laboratory results B. SpO2 reading of 89 C. Increased white blood cell count on laboratory results D. Incentive spirometry reading of less than70% - ✔✔C. increasing white blood cell count on lab results An 84-year-old client has returned from the postanesthesia care unit. The client is oriented to name only. The client's family is very upset because before having surgery the client knew the family. The client is diagnosed with delirium. Which action should the nurse take to help the family with their emotions? A. Coordinate a family meeting to make sure everyone has the same information. B. Explain that delirium is a state of confused thinking and usually lasts only a short time. C. Refer the family to the health care provider for support. D. Introduce the family to the hospital chaplain for religious counseling - ✔✔B. explain that delirium is a state of confused thinking and usually lasts only a short time An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition? A. Delirium B. Dementia C. Disorientation D. Depression - ✔✔A. delirium The nurse is evaluating a 42-year-old client who says that he is feeling stressed. Which of the following does the nurse know that could be a cause of stress for this age group? A. Being caught in the sandwich generation B. Retirement C. Social isolation D. Losing driving privileges - ✔✔A. Being caught in the sandwich generation Based on an understanding of the cognitive changes that normally occur with aging, what might the nurse expect a newly hospitalized older adult to do? A. talk rapidly but be confused B. take longer to respond and react C. interrupt with frequent questions D. withdraw from strangers - ✔✔B. take longer to respond and react Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? A. Providing entertainment for a client on bedrest B. Arranging for social services to assist with meals for a homebound client C. Counseling a client who complains of being depressed D. Encouraging a client to have regular checkups - ✔✔D. encouraging a client to have regular checkups An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? A. Stress B. Urge C. Overflow D. Functional - ✔✔A. Stress A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? A. Discard the swab and inform the health care provider that the wound is too infected to culture B. Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab C. Obtain the swab as prescribed and send it to the lab for culture D. Obtain the swab and then clean the wound - ✔✔B. discard the swab, clean the wound with a nonatimicrobrial cleanser, and contain another swab A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A. to divert drainage to the peritoneal cavity. B. to provide drainage for bile. C. to decrease dead space by decreasing drainage. D. to provide a sinus tract for drainage. - ✔✔B. to provide drainage for the bile The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? A. The nurse works outward from the wound in lines parallel to it. B. The nurse swabs the wound with povidone-iodine to fight infection in the wound. C. The nurse swabs the wound from the bottom to the top. D. The nurse uses friction when cleaning the wound to loosen dead cells. - ✔✔A. the nurse works outward from the wound in lines parallel to it The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? A. a client with cardiovascular disease B. a critical care client C. a newborn D. an older client with arthritis - ✔✔B. critical care client A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. A. Place the swab in the culture tube when done. B. Tap the outside of the culture tube with the swab before placing it in the tube. C. Press and rotate the swab several times over the wound surfaces. D. Insert a swab into the wound. Use the same swab for both wound sites. E. Touch the swab to the intact skin at the wound edges. - ✔✔A, C, D The nurse has provided instruction to the client concerning the use of the sitz bath. After the instruction the nurse is evaluating the client's understanding of the education. Which findings indicate the need for further instruction? Select all that apply. a. The client uses cool water for the treatment. b. The client reports the treatment will promote circulation to the problem area. c. The client heats the water to a temperature between 115°F (46°C) and 120°F (49°C). d. The client explains to the nurse that the treatment will result in a reduction of discomfort for her hemorrhoids as a result of vessel constriction. e. The client reports that the treatment will take approximately 20 minutes. - ✔✔A, C, D The nurse is preparing to delegate a bath for a 90-year-old client who is nonresponsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel (UAP)? A. tub bath B. bag bath C. traditional bed bath with linen change D. shower with assist - ✔✔C. traditional bed bath with linen The nurse has delegated oral care for an unconscious client to an unlicensed assistive personnel (UAP). Which UAP action requires immediate nursing intervention? A. applying petroleum jelly to lips B. placing the client supine to perform mouth care C. moistening oral swabs before inserting them into the mouth D. mixing equal parts baking soda and table salt in warm water to be used to remove accumulated secretions - ✔✔B. placing the client in supine position to preform mouth care A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)? A. Shaving the face of a resident who has worn a beard for several years B. Using a tool to remove a contact lens that has adhered to the resident's eye C. Providing oral care to a client who has cognitive deficits and a decreased level of consciousness D. Providing a tub bath to a resident who is unable to mobilize independently - ✔✔B. using a tool to remove a contact lens that has adhered to the resident's eye A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? - ✔✔the client should be placed in side-lying position to prevent aspiration A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. B. A Penrose drain promotes passive drainage into a dressing. C. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. D. A Penrose drain is a closed drainage system that is connected to an electronic suction device. - ✔✔B. Penrose drain promotes drainage into dressing A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. A. a wound that takes approximately 2 weeks for the edges to appear approximated and heal together B. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. C. a wound with increased swelling and drainage that may occur during the first 5 days of wound healing D. a wound that forms exudate due to the inflammatory response E. a wound that does not feel hot and tender upon palpation F. incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes - ✔✔E, D, B Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative [Show More]

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