Quiz 3

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?

• partial care

• as-needed care

• self-care

• complete care

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart?

• "Client normally bathes and washes hair every other day; applies moisturizer to dry areas on elbows and forearms."

• "Client prioritizes personal hygiene in daily routines and is proactive with skin care."

• "Client bathes more often than necessary and consequently experiences dry skin."

•  "Client's level of personal hygiene is acceptable and age-appropriate."

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

• document the assessments and intervention

• reinforce the dressing with additional layers

• administer pain medications intramuscularly

• notify the physician and prepare for surgery

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage?

• under the skin

• under the client

• on the output sheet

• in the axilla

A nurse is developing a plan for repositioning a client who has physical limitations due to recent back surgery. Which action would the nurse do?

• Adhere to a strict every 2-hour turning schedule.

• Tailor the frequency of turning to the patient's needs and responses.

• Allow the patient to determine when repositioning is needed.

• Maintain the patient in proper alignment in the supine position.

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position?

• To prevent hyperextension of the neck

• To prevent pressure on the arms

• To lower the client's center of gravity

• To decrease the effort needed to move the client

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure?

• to lift the client off the bed

• to slide the board with the client onto the stretcher

• to reduce friction as the client is pulled laterally onto the stretcher

• to protect the client's head from hitting the headboard

Which postural deformity might be assessed in a teenager?

• Kyphosis

• Rickets

• Osteoporosis

• Scoliosis

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to:

• allow the client privacy

• assess the client's safety

• assess the client's pain

• allow sufficient time

What type of bath is preferred to decrease the inflammation after rectal surgery?

• bed bath

• tub bath

• whirlpool bath

• sitz bath