The immobile client is in a hospital bed at home. Which information should the home health nurse include when teaching family caregivers how to safely move and reposition the client?

The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse’s assessment supports the presence of foot drop?

The nurse is giving report to the NA on the care of four clients. The nurse should inform the NA to avoid taking a rectal temperature for which client?

The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse’s best response?

The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?

The nurse is taking the client’s temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?

The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse’s best action?

The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse’s best response?

The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?

The nurse is observing the UAP providing oral hygiene to the client Which action by the UAP requires follow-up?

The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?

The client who is Jewish is to receive a kosher meal. Which direction by the nurse to the NA is appropriate?

The client was treated for constipation 1 month earlier. On a return clinic visit, which statement would best assist the nurse to evaluate that the client is no longer constipated?

The client is receiving 2 liters of oxygen by nasal cannula. Which rationale should the nurse use to explain the reason for oxygen being bubbled through a humidifier?

The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hypcrbilirubincmia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?

The client began wearing hearing aids 5 weeks earlier. Which statement to the nurse demonstrates that the client is successfully adapting to the hearing aids?

The client reports pain in the right leg even though it was amputated. Which complementary therapy should the nurse use to control the phantom pain associated with the client’s amputation?

The NA tells the nurse that the unit’s small- adult BP cuff cannot be found and that the client’s arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?

The hospitalized client is at risk for thromboembolism. Which direction should the nurse include when teaching this client about wearing antiembolism hose stockings?

The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?

The client is in skeletal traction with 20 lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals?

The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse’s best action?

The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?

The client uses a walker to ambulate with partial weight-bearing after foot surgery. What should the nurse observe when this client is using the walker correctly?

Before ambulating the client for the first time, the nurse obtains the client’s BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?

The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?

The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?