Question 1

Which nursing action is inappropriate when providing the client with a hygienic and comfortable environment? A)Speaking softly in the hall of the facility B)Obtaining a bed extender for the client who is very tall C)Placing a room deodorizer in the room of the client with asthma who complains of the odor in the room D)Maintaining room temperature between 68^°F and 74^°F

Accepted Answer

Placing a room deodorizer in the room of a client with asthma who complains of the odor in the room is not appropriate as it can trigger an asthmatic attack. It is important to address the source of the odor and find a solution that is safe for the client's health. Speaking softly in the hall is respectful of the client's privacy, obtaining a bed extender for a client who is very tall is necessary for their comfort, and maintaining room temperature between 68-74°F is important for the client's comfort and well-being.

Question 2

The nurse is caring for a client in respiratory distress.Which bed position is the most appropriate for this client?&#10;A)Semi-Fowler's position&#10;B)Trendelenburg position&#10;C)Flat position&#10;D)Fowler's position&#10;

Accepted Answer

Fowler's position, where the head of the bed is elevated to 45-60 degrees, is most appropriate for clients in respiratory distress as it promotes lung expansion and improves breathing.

Question 3

The nurse delegates bed making to the unlicensed assistive personnel (UAP).Which client's bed should be made by the nurse and not the UAP?&#10;A)The postoperative client diagnosed with dementia on complete bed rest&#10;B)The client who is diagnosed with myocardial infarction who has bathroom privileges&#10;C)The client with increased intracranial pressure on complete bed rest&#10;D)The postoperative client&#10;

Accepted Answer

The client with increased intracranial pressure on complete bed rest requires specialized care and monitoring that the nurse is trained to provide, making it inappropriate for delegation to unlicensed assistive personnel (UAP).

Question 4

The nurse is instructing the unlicensed assistive personnel (UAP)about the different bed positions available.Which statement by the UAP indicates the understanding of the different bed positions?&#10;A)&#34;Fowler's is used when assisting clients to bed for sleeping.&#34;&#10;B)&#34;Supine is used when assisting the client with eating.&#34;&#10;C)&#34;Trendelenburg is used to promote decreased gastric emptying.&#34;&#10;D)&#34;Semi-Fowler's is used for clients receiving gastric feedings.&#34;&#10;

Accepted Answer

Semi-Fowler's position is commonly used for clients receiving gastric feedings to allow for proper digestion and to prevent aspiration. Fowler's position is an upright sitting position and is often used for activities like reading or watching television. Supine position is lying flat on the back and is not typically used for eating. Trendelenburg position is when the head of the bed is lowered and the feet are elevated, and is used for certain medical procedures or to improve circulation in some conditions.

Question 5

The nurse delegates the making of an occupied bed to the unlicensed assistive personnel (UAP).Which statement made by the UAP would indicate the need for further instruction prior to this assignment?&#10;A)&#34;I will be sure to inform you of any wound drainage.&#34;&#10;B)&#34;I will inform you if any of the client's tubes are loose.&#34;&#10;C)&#34;I will assess the client's IV tubing.&#34;&#10;D)&#34;I will inform you of any problems.&#34;&#10;

Accepted Answer

The task of assessing the client's IV tubing involves a skill that is beyond the scope of practice of UAPs, and requires the expertise of licensed nurses. Therefore, the UAP should not be delegated this task and instead, the nurse should perform this task themselves.

Question 6

When delegating bed-making to the unlicensed assistive personnel (UAP),the nurse would instruct the UAP on which items?&#10;A)Proper disposal of linens that contain drainage&#10;B)What tubes or dressings the client might have&#10;C)How to make hospital corners&#10;D)Whom to inform if they notice anything unusual&#10;E)Placing the call bell in a specific location for a client with mobility concerns&#10;

Accepted Answer

The answer of When delegating bed-making to the unlicensed assistive...

Question 7

The nurse is providing care to a client who is confused and recently suffered a fall.The family is at the bedside and the nurse is discussing the use of side rails with them.Which statement made by the family indicates the need for additional instruction?

A)"We can leave one side rail up."
B)"We can leave all of the side rails down."
C)"We should not put all four side rails up."
D)"We can leave up the bottom two side rails."

Accepted Answer

Leaving all side rails down would not provide any protection to the client and may increase the risk of falls. At least one side rail should be up to provide some level of safety for the confused client. The other options indicate some understanding of the need for side rails, but may require further discussion and clarification with the family.

Question 8

The nurse caring for an older adult client diagnosed with dementia bathes the client and changes the wound dressing.Prior to leaving the room,which action by the nurse is the most appropriate?&#10;A)Raise the side rails.&#10;B)Place the head of the bed in the semi-Fowler's position.&#10;C)Place the bed in the low position.&#10;D)Remove the footboard from the bed.&#10;

Accepted Answer

Placing the bed in the low position is the most appropriate action as an older adult diagnosed with dementia and wound dressing has an increased risk for falls. Lowering the bed decreases the risk of injury if the client falls out of bed. Raising the side rails, placing the head of the bed in semi-Fowler's position, or removing the footboard may not directly address fall prevention and could potentially restrict client mobility or cause discomfort.

Question 9

The nurse is caring for a client who is on bed rest with bathroom privileges.While the client is in the bathroom,the nurse changes the client's bed and makes the bed in what way?&#10;A)Unoccupied open bed&#10;B)Occupied open bed&#10;C)Unoccupied closed bed&#10;D)Surgical bed&#10;

Accepted Answer

An unoccupied open bed is made when the client is out of the bed, such as when they are in the bathroom. This type of bed making allows for easier access for the client when they return.

Question 10

The nurse is instructing the unlicensed assistive personnel (UAP)on positioning the client in the Fowler's position.Which statement by the UAP indicates appropriate understanding of Fowler's position?&#10;A)&#34;I will put the client's head completely flat.&#34;&#10;B)&#34;I will elevate the client's head.&#34;&#10;C)&#34;I will only raise the head of the bed 30&#176;.&#34;&#10;D)&#34;I will place the bed in the Trendelenburg position.&#34;&#10;

Accepted Answer

Fowler's position involves elevating the head of the bed to a 45-60 degree angle. Option A is incorrect as the head should not be completely flat. Option C is incorrect as a 30-degree angle is not high enough for Fowler's position. Option D is incorrect as the Trendelenburg position involves the bed being tilted with the feet higher than the head, which is not the same as Fowler's position.

Question 11

The nurse caring for a client with a fractured third cervical vertebrae determines the client is in spinal shock.Which bed position is the most appropriate for this client?&#10;A)Flat&#10;B)Semi-Fowler's&#10;C)Trendelenburg&#10;D)Reverse Trendelenburg&#10;

Accepted Answer

The answer of The nurse caring for a client with...

Question 12

The nurse is making an occupied bed for a client who is required to maintain complete bed rest.Place the steps of making an occupied bed in the appropriate order to be performed.&#10;A)Loosen the bottom soiled linens behind the side-lying client and fan-fold them close to the client.Response&#10;B)Pull linens from the center of the bed and make that side of the bed.Response&#10;C)Make the side of the bed behind the client and tuck sheets under the client.Response&#10;D)Position the client supine and place the clean top linen on the bed.Response&#10;E)Remove the soiled linen from the bed.&#10;

Accepted Answer

The answer of The nurse is making an occupied bed...

Question 13

The nurse is caring for a client in shock,and places the bed at an angle with the head lower than the feet.Which term will the nurse use when documenting this position in the medical record?&#10;A)Reverse Trendelenburg position&#10;B)Trendelenburg position&#10;C)Fowler's position&#10;D)Semi-Fowler's position&#10;

Accepted Answer

The answer of The nurse is caring for a client...

Question 14

The nurse is making beds on the medical-surgical unit.What would the nurse do differently when making a surgical bed versus an open unoccupied bed?&#10;A)Strip the bed.&#10;B)Do not tuck,miter,or toe-pleat the top covers.&#10;C)Fold top sheets into a triangle at the side of the bed.&#10;D)Place pillows on the chair beside the bed.&#10;E)Raise the bed to a comfortable working height.&#10;

Accepted Answer

The answer of The nurse is making beds on the...

Deck 6: Bed-Making