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Basic Care and Comfort Rationale
1 C: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
2 A: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
3 B: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
4 B: Decreased sodium and potassium. Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
5 D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.
6 B: Oozing liquid stool. When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea.
7 D: baked potato. A baked potato contains 610 milligrams of potassium.
1. Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel
(UAP) to help a client ambulate for the first time after a colon resection?
A) Have the client sit on the side of the bed before helping the client to walk."
B) If the client is dizzy ask the client to take some slow, deep breaths."
C) Help the client to walk in the room as often as the client wishes."
D) When you help the client to walk, ask if any pain occurs."
2. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
A) Ask the client and family if they are satisfied with the care given
B) Determine if the home health aide's care is consistent with the plan of care
C) Investigate if the home health aide is prompt and stays an appropriate length of time for care
D) Check the documentation of the aide for appropriateness and comprehensiveness
3. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
A) Assess and document skin turgor and color changes
B) Test stool for occult blood and urine for glucose and report results
C) Suggest foods high in iron and those easily consumed
D) Report mental status changes and the degree of mental clarity
Table of Contents
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Rachell Allen NCLEX Notes PDF Free Download
NCSBN NCLEX Question Bank PDF Free Download
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