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Multidimensional Care 1 Exam 1

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B. A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. - Correct Answer-A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine. A. Frequent sexual intercourse D. Location of the urethra closer to the anus E. Frequent catheterization - Correct Answer-A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization B. Decrease or avoid caffeine. D. Avoid drinking alcohol. - Correct Answer-A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) A. Limit total daily fluid intake. B. Decrease or avoid caffeine. C. Take calcium supplements. D. Avoid drinking alcohol. E. Use the Credé maneuver A. Guided imagery C. Meditation D. Music therapy - Correct Answer-A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (Select all that apply.) A. Guided imagery B. Massage therapy C. Meditation D. Music therapy E. Therapeutic touch A. Art therapy C. Yoga E. Biofeedback - Correct Answer-A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies? (Select all that apply.) A. Art therapy B. Acupressure C. Yoga D. Therapeutic touch E. Biofeedback C. Make sure that the client's call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment - Correct Answer-A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment. C. Move clients who are nearby - Correct Answer-A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit. A. Complete a fall-risk assessment - Correct Answer-A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession. D. Place wet towels along the base of the door to the client's room - Correct Answer-A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room. -R- Rescue and remove all patients in immediate danger. -A- Activate the alarm. -C- Confine the fire by closing doors and windows and turning off oxygen and electrical equipment; ventilate patients who are on life support with a bag-valve mask -E- Extinguish the fire using an appropriate extinguisher - Correct Answer-Fire response follows the RACE sequence, what does each letter stand for? P - pull the pin A - aim at the base of the fire S - squeeze the handle S - sweep the extinguisher from side to side covering the area of the fire - Correct Answer-To use a fire extinguisher, use the PASS sequence, what does each letter stand for? 1. complete a fall-risk assessment at admission & regular intervals 2. ensure patient has and knows how to use the call light 3. use fall-risk alerts (color-coded wristbands) 4. provide regular toileting and orientation of clients who have cognitive impairment 5. provide adequate lighting 6. place clients at risk for falls near a nurses station 7. provide hourly rounding 8. make sure personal items are within reach 9. keep bed low, lock the breaks 10. side rails up (for unconscious patients, sedated, etc.) 11. non-skid footwear 12. use gait belts and other assistive equipment when moving patients 13. keep floor clean (no clutter, cords, scatter rugs, etc.) 14. electronic safety monitors (chair or bed sensors) - Correct Answer-Name some nursing interventions of PREVENTING FALLS That nurses respond in a timely manner...otherwise the patient may become impatient and attempt to move themselves - Correct Answer-What is a nurse's concern with patients using their call lights? primary survey - Correct Answer-What must be completed before performing first aid? - apply pressure to wound site (home) - DO NOT remove impaling objects, stabilize the object (home) - IV volume replacement with blood or volume replacement (hospital) - Correct Answer-Name the nursing interventions for BLEEDING

Content preview

Care



Multidimensional Care I Exam 1
B. A nurse is preparing to initiate a bladder-retraining
program for a client who has incontinence.
Which of the following actions should the
nurse take? (Select all that apply.)

A. Restrict the client's intake of
fluids during the daytime.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. Remind the client to hold urine until the
next scheduled urination time.
E. Provide a sterile container for urine.
Have the client record urination times.
C. Gradually increase the urination intervals.
D. Remind the client to hold urine until the
next scheduled urination time. - Correct Answer-A nurse is preparing to initiate a
bladder-retraining
program for a client who has incontinence.
Which of the following actions should the
nurse take? (Select all that apply.)

A. Restrict the client's intake of
fluids during the daytime.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. Remind the client to hold urine until the
next scheduled urination time.
E. Provide a sterile container for urine.

A. Frequent sexual intercourse
D. Location of the urethra closer to the anus
E. Frequent catheterization - Correct Answer-A nurse is reviewing factors that increase
the risk
of urinary tract infections (UTIs) with a client who
has recurrent UTIs. Which of the following factors
should the nurse include? (Select all that apply.)

A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back to clean the perineum
D. Location of the urethra closer to the anus
E. Frequent catheterization

Care

,Care



B. Decrease or avoid caffeine.
D. Avoid drinking alcohol. - Correct Answer-A nurse is teaching a client who reports
stress urinary
incontinence. Which of the following instructions
should the nurse include? (Select all that apply.)

A. Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
E. Use the Credé maneuver

A. Guided imagery
C. Meditation
D. Music therapy - Correct Answer-A nurse is teaching a group of newly licensed
nurses on complementary and alternative
therapies they can incorporate into their practice
without the need for specialized licensing or
certification. Which of the following should the nurse
encourage them to use? (Select all that apply.)

A. Guided imagery
B. Massage therapy
C. Meditation
D. Music therapy
E. Therapeutic touch

A. Art therapy
C. Yoga
E. Biofeedback - Correct Answer-A nurse is reviewing complementary and
alternative therapies with a group of newly licensed
nurses. Which of the following interventions are
mind-body therapies? (Select all that apply.)

A. Art therapy
B. Acupressure
C. Yoga
D. Therapeutic touch
E. Biofeedback

C. Make sure that the client's call light is within reach
D. Provide the client with nonskid footwear
E. Complete a fall-risk assessment - Correct Answer-A nurse is caring for a client who
fell at a nursing
home. The client is oriented to person, place,

Care

, Care


and time and can follow directions. Which of the
following actions should the nurse take to decrease
the risk of another fall? (Select all that apply.)

A. Place a belt restraint on the client when they
are sitting on the bedside commode.
B. Keep the bed in its lowest position
with all side rails up.
C. Make sure that the client's call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall-risk assessment.

C. Move clients who are nearby - Correct Answer-A nurse observes smoke coming from
under
the door of the staff's lounge. Which of the
following actions is the nurse's priority?

A. Extinguish the fire.
B. Activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors on the unit.

A. Complete a fall-risk assessment - Correct Answer-A nurse is caring for a client who
has a history of falls.
Which of the following actions is the nurse's priority?

A. Complete a fall-risk assessment.
B. Educate the client and family about fall risks.
C. Eliminate safety hazards from
the client's environment.
D. Make sure the client uses assistive
aids in their possession.

D. Place wet towels along the base of the door to the client's room - Correct Answer-A
nurse discovers a small paper fire in a trash can
in a client's bathroom. The client has been taken
to safety and the alarm has been activated. Which
of the following actions should the nurse take?

A. Open the windows in the client's
room to allow smoke to escape.
B. Obtain a class C fire extinguisher
to extinguish the fire.
C. Remove all electrical equipment
from the client's room.
D. Place wet towels along the base of

Care

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